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
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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. 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)
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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
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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. 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
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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
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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.
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