Original Article

Spatula DD. 2013; 3(4):161-166

A comparative clinical study on the effects of Mehjama
Nariya (fire cupp...
Effect of Hijamah in Irqunnasa (Sciatica)

INTRODUCTION
Irqunnasa is an Arabic term, whose literal
meaning is “name of a n...
Sheeraz, Quamari, Ahmed

Treatment procedure
Patients of Irqunnasa fulfilling the inclusion
criteria were selected and kep...
Effect of Hijamah in Irqunnasa (Sciatica)

Table 1: Objective Parameters
No

Objective
Parameters

Group A

Before or Afte...
Sheeraz, Quamari, Ahmed

for treating persistent nonspecific low back pain
yielded clinically significant improvement with...
Effect of Hijamah in Irqunnasa (Sciatica)

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Rāzi ABMBZ. Kitab ul ...
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A comparative clinical study on the effects of mehjama nariya and hijamat bila shart in irqunnasa (sciatica)

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A comparative clinical study on the effects of mehjama nariya and hijamat bila shart in irqunnasa (sciatica)

  1. 1. Original Article Spatula DD. 2013; 3(4):161-166 A comparative clinical study on the effects of Mehjama Nariya (fire cupping) and Hijamat Bila Shurt (dry cupping) in Irqunnasa (sciatica) Irqunnasa (siyatik)’da ateşli kupa ve kuru kupa tedavilerinin etkileri üzerine karşılaştırmalı klinik bir çalışma Mohammed Sheeraz, Mohd. Aleemuddin Quamari, Zaheer Ahmed Department of Moalajat (Medicine), National Institute of Unani Medicine, Bangalore -560091, India. SUMMARY Aim: Irqunnasa (Sciatica) is one of the commonest neuralgic pains in lower limbs. The overall incidence of this condition is approximately between 13% and 40 % with the malady has the potential to become chronic and intractable with major socioeconomic implications. Several Unani medical regimens are claimed to be effective in its treatment, but are not corroborated. In order to validate scientifically, two different regimens viz; Mehjama Nariya (Fire cupping) and Hijamat Bila Shurt (Dry cupping) were selected to evaluate their effects comparatively in Irqunnasa by an open label, prospective, simple randomized, observational study. Methods: Diagnosed cases of Irqunnasa aged between 18 to 65 years of either gender fulfilling the inclusion criteria were selected and randomly allocated after obtaining voluntary informed consent into two groups of 20 patients each viz; Group A Mehjama Nariya and Group B Hijamat Bila Shurt. Treatment protocol was followed for 15 days in both groups. Results: Mean visual analogue scale (VAS) scores before treatment in Group A was 10 and Group B was 9.4, while after treatment it declined to 6 in Group A and 6.6 in Group B. This reduction was found statistically significant in both groups (p< 0.01). The Oswestry disability index (ODI) scores in both groups revealed significant difference (p<0.05). Conclusion: The study has revealed that both the regimens are equally effective in ameliorating the symptoms of Irqunnasa. Key words: Irqunnasa; Sciatica; Mehjama Nariya; Hijamat Bila Shurt; VAS; ODI. ÖZET Amaç: Irqunnasa (Siyatik) alt ekstremitedeki en sık nöraljik ağrılardan birisidir. Hastalık sosyoekonomik major etkileri ile kronik ve inatçı olma potansiyeline sahip olmakla birlikte, bu durumun tüm insidansı yaklaşık olarak %13-40 arasındadır. Birkaç Unani tıbbi tedavisi rejimimin siyatik tedavisinde etkili olduğu iddia edilmekte, ancak bu doğrulanmamıştır. Bilimsel olarak doğrulama için, iki farklı tedavi rejimi olan Mehjama Nariya (ateşli kupa) ve Hijamat Bila Shurt (kuru kupa), randomize, prospektif ve gözlemsel bir çalışma ile Irqunnasa (siyatalji) için etkilerinin araştırılması amacıyla seçildi. Yöntem: Tanı konmuş 18 ila 65 yaşları arasında her iki cinsiyetten kriterlere uyana vakalar seçildi ve gönüllü bilgilendirme rızaları alındıktan sonra rastgele 20 hastalık iki gruba -Grup A ateşli kupa ve Grup B kuru kupa gruplarına- ayrıldı. Tedavi protokolü her iki gruba da 15 gün boyunca takip edildi. Bulgular: Tedavi öncesi ortalama görsel anolog ölçeği (VAS) skorları, grup A için 10 ve grup B değeri 9,4 iken; tedavi sonrası grup A için 6, grup B için ise 6,6 olarak bulundu. Bu azalma her iki grupta istatistiksel olarak anlamlı bulundu (p< 0,01). Oswestry sakatlık ölçeği (ODI) skorları her iki grup içinde belirgin farklı bulundu (p<0,05). Sonuç: Çalışmamız her iki tedavinin de Irgunnasa (siyatik) semptomlarının iyileşmesinde eşit derecede etkili olduğunu gösterdi. Anahtar kelimeler: Irgunnasa, siyatik, ateşli kupa tedavisi, kuru kupa tedavisi, VAS, ODI. Corresponding Author: Mohammed Sheeraz, Department of Moalajat (Medicine), National Institute of Unani Medicine, Bangalore -560091, India. E-mail: drsheerazmd@gmail.com Spatula DD Received September 17, 2013; accepted November 27, 2013 DOI 10.5455/spatula.20131127023056 Published online in ScopeMed (www.scopemed.org). Spatula DD. 2013; 3(4):161-166. 161
  2. 2. Effect of Hijamah in Irqunnasa (Sciatica) INTRODUCTION Irqunnasa is an Arabic term, whose literal meaning is “name of a nerve” which starts from gluteal region and continues up to the ankle, and pain associated with this nerve is termed as Irqunnasa [1-8]. It is one of the commonest neuralgic pain in the lower limbs,which closely resembles to Sciatica and is clinically defined as “ pain in the sciatic nerve and its component, which may radiates from low back up to leg.”In addition to pain, there may be numbness, muscular weakness, tingling sensation and difficulty in moving or controlling the leg [9-11]. The overall incidence of this condition is approximately between 13% and 40 % with the malady has the potential to become chronic and intractable with major socioeconomic implications. Irqunnasa is usually treated by the conventional therapists either pharmacologically or surgically or sometimes both. Pharmacological therapy includes oral or parenteral administration of non-steroidal anti-inflammatory drugs (NSAID’s) epidural injections of anaesthetics, corticosteroids, and surgical intervention through hemilaminectomy or micro discectomy [10]. According to the principles and philosophy of Unani medicine, maintenance of health, disease and its manifestations are innate process, hence proper and normal functioning of the bodily process must be ensured to maintain health. Any disturbance in the normal humoral balance whether it be excess, diminution or blockage leads to disease. Unani scholars managed certain ailments since antiquity by regulating the metabolic process through various modes of treatment [1]. Regimenal therapy is one such core method of treatment through which the morbid matter is eliminated, its excessive production is checked or its spread is arrested and resolved by certain special techniques and there by restoring humoral equilibrium which is a prerequisite for maintenance of health. Unani scholars advocated various regimens viz; Dalk (Massage), Hijamat Bish Shart (Wet cupping), Mehjama Nariya (Fire cupping), Hijamat Bila Shart (Dry cupping), Fasd (Bloodletting), Takmeed (Fomentation), Taleeq (Leeching), Zimad (Ointment), Tila (Liniment), Nutool (Douching), which are claimed to be effective in the treatment of Irqunnasa [1,12-22]. In order to validate scientifically, two such regimens Mehjama Nariya and Hijamat Bila Shart were selected as effective means for controlling pain of Irqunnasa [5, 17]. Therefore it was hypothesized that these regimens for Irqunnasa should be 162 evaluated in terms of efficacy and a clinical trial entitled “A comparative clinical study on the effects of Mehjama Nariya and Hijamat Bila Shart in Irqunnasa (Sciatica)” was contemplated. Hijamah is an Arabic word derived from a term ‘Hajm’ which stands for volume, but technically used for sucking. It also means “to minimize”, “to restore to basic size” or “to diminish the volume”. The importance of this regimen can be gauged from the noble saying of blessed messenger of Islam Hazrat Mohammed “Indeed the best of remedies you have is Hijamah” [23, 24]. MATERIAL AND METHODS This study was an open label, prospective, simple randomized, observational, comparative clinical study conducted on 46 patients, of which 40 patients completed the trial. They were allocated randomly to two groups of 20 each viz Group A: Mehjama Nariya and Group B: Hijamat Bila Shart (5 cases from group A and 1 case from group B lost to follow up). The study was carried out in OPD/IPD of National Institute of Unani Medicine hospital, Bangalore, India, after obtaining ethical clearance from Institutional ethical committee (IEC) for biomedical research over a period of 11 months from January 2012 to November 2012 with the following criteria. Patients having low back pain radiating to back / buttocks / leg / foot difficulty in movement, of both gender between 18 and 65 years of age were included in the study. Patients below 18 and above 65 years of age, pregnancy and lactation, any systemic illness such as liver, kidney, cardiac, pulmonary disease, diabetes mellitus, hypertension, mental illness, spinal deformity (Congenital / Acquired), radiological evident cases of spinal injury / deformity/ disease, body mass index (BMI) > 32, Rheumatoid Arthritis (RA) positive, on contraceptives / Steroidal therapy, unwillingness or inability to comply the requirements of the protocol were excluded from the study. Subjective parameters include low back pain radiating up to ankle, pain in legs and difficulty in movement and were assessed by visual analogue scale (VAS). Objective parameters include straight leg raising test (SLRT), Femoral stretch test (FST), VAS index (10 points Likert’s Scale), and Oswestry disability index (ODI) Spatula DD
  3. 3. Sheeraz, Quamari, Ahmed Treatment procedure Patients of Irqunnasa fulfilling the inclusion criteria were selected and kept on washout period for one week with no concomitant therapy allowed during the clinical trial. Group A patients were subjected to Mehjama Nariya and Group B to Hijamat Bila Shart regularly for 15 days with follow ups on 3rd, 6th, 9th, 12th and 15th day. Both the groups received the procedure over lumbosacral region along the course of sciatic nerve with 4 cups of 45 mm diameterfor 20 minutes in the affected limb. disc prolapse, and 3 (7%) spondylolisthesis as the likely cause. Before initiating the trial in Group A, all the patients (100%) had severe pain, while after the trial 1 patient had no pain, 4 reduced to mild pain, 8 to moderate pain and only 7 (35%) patients had severe pain. All the Group B patients (100%) had pain of severe grade. At the end of trial 1 patient had no pain, 2 reduced to mild, 7 to moderate, and only 6 (30%) patients remained with severe grade pain (Figure 1). Assessment criteria Response was graded on the basis of the effect on VAS score, ODI, SLRT and FST. Statistical analysis Quantitative analysis of the data was expressed as median with range and differences between two groups were compared by Kruskal-Wallistest for intergroup comparison and Friedman test for intra group comparison of subjective parameters assessment. Chi-square test was applied for assessment of objective parameters using Graph Pad and Vassar stat. RESULTS Out of 40 patients who had completed the trial, 16 patients (40%) were in the age group of 31- 40 years, 9 (22.5%) were between 51-60, 7(17.5%) between 20-30, 6 (15%) between 41-50 and 2 (5%) patients were between 61-70 years. Out of 20 cases treated under Group A, the Mizaj (Temperament) of the patients was found to be Damvi (Sanguine) in 80%, Balghmi (Phlegmatic) in 10%, Safravi (Choleric) and Saudavi (Melancholic) in 5% each. The Mizaj of 20 cases treated with Group B was Damavi in 95% and Safravi in 5% of cases. This study has shown that 47.5% of patients had BMI of 26-30 followed by 21-25 (32.5%), 16-20 (20%). The findings of this study revealed that in terms of incidence of the disease and occupational correlation, out of 40 patients, 14 (35%) were labourers. It was observed that the chronicity of disease was <1 year in 20 (50%) patients followed by 1-2 years in 9 (22.5%), 3-5 years in 5 (12.5%), 6-10 years in 5 (12.5%), and > 10 years in 1 (2.5%) patient. X–ray findings revealed 13 patients (33%) with lumbar spondylosis, 10 (25%) with inter vertebral Spatula DD Figure 1: Distribution of patients according to group and grade wise effect of the study on low back pain radiating to leg with reference to VAS scores The effect of regimen on pain with reference to Mean VAS score before treatment in Group A was 10 and in Group B were 9.4, while after treatment it declined to 6 and 6.6 respectively. This reduction was found to be statistically significant in both groups (p< 0.001) (Figure 2). Figure 2: Comparative effect of Mehjama Nariya and Hijamat Bila Shart on VAS for low back pain radiating to ankle in Irqunnasa 163
  4. 4. Effect of Hijamah in Irqunnasa (Sciatica) Table 1: Objective Parameters No Objective Parameters Group A Before or After treatment Mean Group B Range Mean Range 3 10 8-10 7 1-9 47 20-60 49 30-60 58 30-75 50 30-60 45 18-90 36 8-64 AT ODI 8-10 1-10 AT SLT 10 6 BT VAS 2 BT AT BT 1 38.2 16-90 33.6 6-64 Table 2: Demographic Data No Demographic parameters 1 Statistical unit Group A Group B Age Mean 39 44 Range 20-65 20-65 Male (%) 9 (45%) 9 (45%) 11 (55%) Damvi (%) 80 95 Balghami (%) 10 5 Safravi (%) 5 - Saudavi (%) 3 11(55%) Female (%) 2 5 - Sex Mizaj Mean 20.4 17-30 19.6-30 Mean 557 1080 Range 5 24.59 Range 4 30-3650 20-5110 BMI Chronicity of disease Mean SLRT angle before treatment in Group A was 46.50 and in Group B were 48.50 while after treatment it raised to 57.50 and 49.50 respectively (Table 1). There was no change observed in FST with both groups. A significant improvement (p<0.001) was observed in Group A when the pre and post treatment values of pain, pain in legs and difficulty of movement were compared between both groups. Mean ODI scores before trial in Group A was 45% i.e. severe disability and on completion it decreased to 38.2% with moderate disability and with Group B was 36% on baseline and after trial it reduced to 33.4% i.e. moderate disability. This reduction was statistically found significant with both groups (p< 0.05) (Table 1). 164 DISCUSSION Though Hijamah (cupping) has been in vogue since antiquity to treat various types of pain in Unani medicine, this institutional study which was carried out as part of M.D (U) dissertation work was aimed to scientifically validate the effect of these regimens in cases of Irqunnasa. In a similar open randomized clinical trial with drug treatment control group designed to evaluate the efficacy of Hijamah in patients of Waja-ul-Mafasil (Osteo arthritis), it was observed that the treatment strategy of Hijāmat-BilaShart alongwith drug group was the better in terms of satisfactory treatment when compared with only drug treatment and only Hijāmat-Bila-Shart treatment groups (p<0.01) [25]. In another study which was conducted to determine the efficacy of wet cupping Spatula DD
  5. 5. Sheeraz, Quamari, Ahmed for treating persistent nonspecific low back pain yielded clinically significant improvement with three sittings (0,3 and 6 days) at 3 months follow up. The experimental group had significantly lower levels of pain intensity (95% CI – 1.72-2.60) mean difference = 2.17, p<0.01) than the control group [26]. Clinical trial which was carried out to evaluate the efficacy of bloodletting cupping (BLC) therapy as a complementary therapy in management of rheumatoid arthritis (RA) and to investigate its modulatory effects has revealed the BLC therapy combined with conventional therapy may improve the clinical condition of patients of RA with significant reduction (p<0.001) [27]. The results of above trials are near compatible with our findings. The findings about age substantiate the description by Rāzi in Alhavi Fit Tib [15] and studies of Koes et al. [28], and Ioannis Karampelas et al. [29], as the highest prevalence of Irqunnasa was found among middle aged persons (Table 2) 40 patients belonged equally to both gender [15, 30, 31]. The observation about Mizaj is in accordance to the description given by Rāzi that Irqunnasa is more frequent among the Damvi mizaj people [15] (Table 2). The findings about BMI indicates that greater the BMI higher the risk factor for this disease. The X-ray findings affirms the findings and description of Davidson’s principals and practice of medicine, Koes et al. and Stafford et al. as the 90% cases of sciatica is due to herniated disc of vertebral column [9, 10, 28]. The findings about occupational factors corroborates the claims of Koes et al. and Stafford et al. as occupational factors, such as strenuous physical activity, driving, movements including vibration of whole body may be prone to sciatica [10, 28]. The findings about chronicity of disease coincides with the description that this condition has the potential to become chronic and intractable [10]. Various theories are put forth for the benefits of the Hijamat Bila Shart (cupping therapy); one theory suggests that it is by increasing circulation around the area of cupping and allowing for the elimination of toxins trapped in the tissues. Another theory suggests that it is the process of transferring discomfort and even pathology from one site to another that may cure the original site of any disease process. The psychometric theory also exists that explains the effect of cupping as purely placebo effect. From a biomedical point of view, mechanical stimulation due to negative pressure in the jar activates local tissue metabolism, intensifies Spatula DD phagocytosis and promotes a healing response.It also improves circulation to the area and provides better nutrition to the area where it is applied [30, 31]. Cupping without bloodletting works on the principal of Imalae-mavad i.e. diversion of morbid humours from one site to another. In case of Mehjama Nariya, due to combustion of air inside the cups, the air becomes warm, and helps in retracting the muscular surface, causing pulling of the area beneath the cups immediate after its application and relieves pain [30,32]. CONCLUSION The study has revealed that both Mehjama Nariya and Hijamat Bila Shart were found to be effective in relieving the pain and difficulty in movement in cases of Irqunnasa without producing any adverse effects. This study testifies that both these age old procedures which forms the integral part of Unani principles of treatment, can be adopted due to its feasibility, cost effectiveness with minimal or no side effects in the management of Irqunnasa. However, long term study with larger sample size is warranted or further exploration of the effects of both these regimens with improved methodology. ACKNOWLEDGEMENT This being an institutionally funded study, the author acknowledges all the staff of National Institute of Unani Medicine, Bangalore, India and the trial participants for their support, consent and cooperation. The authors also duly acknowledge the reviewers for highlighting the discrepancies contained in this manuscript. REFERENCES 1. 2. 3. 4. 5. 6. 7. Ibne Sina. Kulliyate Qanoon (Urdu translation by Allama Kabeeruddin). New Delhi, Ejaz publishing house, 2006.p. 335336,344-350. Zuhrawi AQ. Jarahiyate Zuhrawi (Urdu translation by Hakim Nisar Ahmed Alwikakori). New Delhi, CCRUM, 2012. p.26. Qarshi MH. Jameul Hikmat. New Delhi, Idarae kitabushifa, 2011.p.1028. Ibn Iwaz Kirmani AN. Moalajate Nafeesi. Lucknow: Matba Nami Almunshi Navalkishor, 1906. p.427. Arzani A. Tibbe Akbar (Urdu Translation by Hakim HussainM). Deoband, Faisal Publications, YNM. p. 627. Tabri AHAIR. Firdausul Hikmat (Urdu translation by Hakeem MA Shah). Deoband, Faisal publication, 2002.p.291. Ibn Zuhr AMAM. Kitabut taisir. New Delhi: CCRUM; 1986.p. 221. 165
  6. 6. Effect of Hijamah in Irqunnasa (Sciatica) 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Rāzi ABMBZ. Kitab ul Mansoori (Urdu Translation). New Delhi, CCRUM, 1991.p.393. Colledge N, Walker BR, Ralston SH. Davidson’s Principles and Practice of Medicine. Lumbar spondylosis. 21st edition. Churchill Living Stone. Elsevier, 2010.p. 1222. Stafford MA, Peng P, Hill DA. Sciatica. A review of history, epidemiology, pathogenesis, and the role of epidural steroid injection in management. British Journal of Anesthesia 2007; 99(4):461-73. Golwalla ASPIF. Medicine for Students. Sciatica. 21st edition. Express Court: Dr.Golwalla AF, 2005. p. 589. Majusi AHAIA. Kamilussanaa. New Delhi: Idarae kitabushifa, 2010. p. 543-74. Alquamari AMA. Ghina Muna (Urdu translation). New Delhi: CCRUM, 2008.p.339. Baghdadi IH. Kitab ul Mukhtarat fit Tib. Vol.1. New Delhi: CCRUM, 2005.p.278. Rāzi ABMBZ. Al Havi Fit Tib. Vol.11. New Delhi: CCRUM; 2004. p. 75-77, 84, 88, 99, 114, 129, 174. Arzani MA. Ikseer ul Quloob (Urdu translation of Mufarrehul Quloob). New Delhi: CCRUM, YNM .p.743. Jurjani MI. Zakheerae Khuwarizm Shahi (Urdu translation of Hakim Hadi Hussain). New Delhi: Idare kitabushifa, 2010. p. 637, 649 - 650. Ali S. Zakheerae Sabit Ibn Qurra.UP: Fakhruddin Ali Ahmed Memorial Committee, 1987. p.313. Chagmini SH. Qanuncha. Deoband: Faisal Publications, 2004. p. 151. Khan HS. Byaze Khas Almaaroof Ilajul Amraz. New Delhi: Ejaz publishing house, 2006. p. 382, 739, 741-742. Antaki D. Tazkira Oolil Albab. Part III. New Delhi: CCRUM; 2010. p. 32. 166 22. Ibne Sina. Al Qanoon Fit Tib (Urdu translated by Kantoori GH). Vol. 3. New Delhi: Idara Kitabushifa, 2007.p. 1120-21. 23. Ghassan J. Tib-ul-Hijamah. Beirut: Dar-ul-Harf-il-Arabi; 2005.p. 14, 54-55. 24. Bukhari AAMBI. SahihBukhari sheriff (Urdu translation). Vol 3. New Delhi: Farid Book Depot; 1990. 314: 5371. 25. Nayab Md. Clinical study on effects of Hijamat (Cupping therapy) in the management of Wajaul Mafasil [dissertation]. Bangalore: NIUM.RGUHS. 2007.p. 33-57. 26. Farhadi K, Schwebel DC, Saeb M, Choubsaz M, Mohammadi R, Ahmadi AR. The effectiveness of wet-cupping for nonspecific low back pain in Iran - A randomized controlled trial. Complementary Therapies in Medicine 2009; 17:9-15. 27. Ahmed SM, Madbouly NH, Maklad SS, Abu-shady EA. Immunomodulatory effects of bloodletting cupping therapy in patients with rheumatoid arthritis. The Egyptian journal of immunology 2005; 12 (2):39-51. 28. Koes BW, Tulder MWV, Peul WC. Diagnosis and treatment of sciatica. British Medical journal 2007; 334: 1313-17. 29. Karampelas I, Boev AN 3rd, Fountas KN, Robinson JS Jr. Sciatica: a historical perspective on early views of a distinct medical syndrome. Neurosurg Focus. 2004; 16(1):E6. 30. Akhtar J, Siddiqui MK. Utility of cupping therapy Hijamat in Unani medicine. Indian journal of traditional knowledge 2008; 7(4): 572-74. 31. Huang Shixi, Cao Yu. Cupping Therapy. Journal of Chinese Medicine 2006; 82:52-7. 32. Ali M, Shukla VD, Dave AR, Bhatt NN. A clinical study of Nirgunda Ghana Vati and Maatra Basti in the management of Gridhrasi with special reference tosciatica. AYU Journal 2010; 31(4):456. Spatula DD

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