Kshipra Rajoria,Sarvesh Kumar Singh＊,Sanjeev Sharma

National Institute of Ayurveda,Jorawar Singh Gate,Jaipur Rajasthan 302004,India.

Abstract

Keywords:Wet cupping,Principles,Indications,Contraindications,Complications,Comprehensive review

Background

Presently in developing country, like India, there is a need of an economical, safe, preventive and curative modality with wide range of therapeutic benefits.The expectation from Ayurveda, the traditional Indian medicine is at its peak.There are many options present in Ayurveda like following ofPathya Ahara(dietary modifications),Vihar(modified activities) prescribed inDincharya(daily regime) andRitucharya(seasonal regime),Aushadha Chikitsa(treatment through medicines),Panchakarma Chikitsa(specific fivefold therapies),Satvaavajaya Chikitsa(psychotherapy),Rasayana Chikitsa(rejuvenation therapy) etc., but the most economical, relatively safer but unfortunately the most neglected therapy appears to beShringa Karma[wet cupping therapy (WCT) ].A lot of work is being conducted on WCT worldwide.The present work is first effort aiming to revive the therapy for maximum utilization.For this purpose,Ayurveda perspective and global scenario of WCT is explored as an initial step.

Classical Ayurveda texts were scrutinized forShringa Karmawhich akin with WCT and an on-line search of five databases (Pub med, Cochrane Library,Science direct,Google scholar and DHARA databases)was conducted for studies on WCT latest up to April 2020 to explore the global scenario of WCT.184 potential articles were identified, 95 abstracts were screened and 62 full text articles were assessed for eligibility and 36 original articles were included.The method of WCT application, principles, indications,contraindications, complications and probable mode of action from Ayurveda perspective and global scenario were introduced and summarized(Figure 1).

WCT from Ayurveda perspective and global scenario

Ayurveda perspective

In Ayurveda, all preventive and curative aspects are summarized in two basic treatments, theSantarpana(nourishing treatments) andApatarpana(apheresis).TheApatarpanaare categorized inSodhana(purification) andShamana(pacification) therapies.The fiveSodhanaareVamana(therapeutic emesis),Virechana(therapeutic purgation),Sirovirechana(nasal purgation),Niruha Basti(medicated enema) andRaktamokshana(therapeutic phlebotomy) [1].Raktamokshanais the prime treatment ofPitta(metabolic disease) andRakta(disease rooted in components of blood)and a part of regimental therapy for autumn season [2].TheRaktamokshanais performed throughSiravedha(vein puncture) orPracchana(scarification).Modifications are adopted forSiravedhain delicate people, which comprises of three basic modalitiesShringa Avacharan(horn wet cupping) (SA),Alabu Avacharan(gourd wet fire cupping) (AA) andJalauka Avacharan(leech therapy)[3].A modification of AA is also described asGhati Avacharan(wet fire cupping with pitcher shaped instruments) [4].Thus, Ayurveda WCT comprises of the SA,AA andGhati Avacharan.

Global scenario

The concept of WCT roots in many ancient civilizations like Mesopotamian, Egyptian, Chinese,Greek, Persian, Roman,Aztecs and Indus valley.Time line of the history of WCT [5] shows that the first recorded evidences of practice were found from 3,500 B.C.and evidences of textual reference were found from 1,500 B.C..The WCT was actively practiced from 1,000 B.C.till 19th century and then there was decline in the following era.From the year 1973 to 2016 there were few times, when the WCT was discussed as a therapeutic modality again.Presently it is practiced in some parts of Asia and Europe by very few traditional practitioners.

Method of WCT application from Ayurveda perspective and global scenario

Ayurveda perspective

In Ayurveda, the WCT is mostly used for localized curative purpose for minor ailments and it is generally adopted in delicate and fragile individuals.The standard operating procedure as following:(1).Administration done in moderate temperature in morning or noon.(2) Proper assessment of indication and contraindication and counseling done, consent taken.(3) Preoperative procedure like Snehapana,Abhyanga, Swedana, Yavagupana done.(4).Aseptic and precautionary measure adopted during and after puncturing.

Global scenario

Apart from the preparatory procedure likeSnehana(tropical oleation)andSvedana(sudation)the principle methodology of application of the WCT on the operative day adopted in Ayurveda is more or less applied globally.This method is known as five step puncture-cupping method practiced in Eastern Asia.It includes five steps;the first step is demarcation of skin followed by sterilization and puncturing.Puncturing is followed by cupping and sterilization.In Middle East a slight modification is adopted as six step cupping-puncture-cupping and it is claimed to be more effective than the previous one.In this skin demarcation and sterilization is followed by cupping and puncturing.After puncturing, cupping and sterilization is adopted [6].The various sites that are preferred for application of WCT are between the shoulder blades at the level of fourth to eighth thoracic vertebrae(site being close to lymph nodes of the neck,thymus,armpit,chest and abdomen)on waist,on hips,on legs behind knee,on face,shoulder,head and arms.These sites are believed to stimulate the immune system of the body.

Figure 1 Complications and probable mode of action from Ayurveda perspective and global scenario

Principles of WCT from Ayurveda perspective and global scenario

Ayurveda perspective

Although the principle of WCT are same globally, but there are some core principles of Ayurveda which make its distinguishable.The age criteria for bloodletting in Ayurveda is from 16-70 years of age[7].Although it is impossible to control the amount of blood evacuated in WCT but estimate may be made on the basis of number of incisions, numbers and size of devices used.In Ayurveda, the targeted amount of evacuated blood depends on strength of the body andDosha.The maximum targeted amount of the blood removed in multiple bloodletting sessions should not exceed onePrastha(～648 ml),halfPrastha(～324 ml)and one fourthPrastha(～162 ml) in person with maximum, medium and least strength of body andDosharespectively [8].After session of WCT as aftercare the patient is advised to takeLaghu(easily digestible),Snigdha(contains lipids),Sonitavardhana(hematopoietic),Ishadamla-Alavana(slightly sour and without salt) meals [9].Advice is made to avoidKrodha(anger),Ayasa(Physical exertion),Socha(mental exertion),Maithuna(Coitus),Divasvapna(day nap),Uccaibhasya(speaking or hearing loud),Yanayana(excessive travelling),Chirasana-Chirasthana(sitting or standing for long times),Atichankramana(excessive walking),Sheeta-Vata-Atapa(excessive exposure to cold, breeze and sunrays),Viruddha(incompatible meals),Adhyasana(eating before the digestion of previously taken meals is completed),Asatmya Bhojana(toxic or allergic articles),Apramanat Bhojana(inappropriate quantity of meals) [10] for a month or till the strength of the body is regained.The aftercare advised for the healing wound isParisechana(showering of warm Ghee) to subsideSopha(inflammation) andToda(pricking pain) [11].The most reliable criteria for decision making for WCT repetition or discontinuing it,is the appearance of the symptoms ofSuddha Rakta(Pure blood), which isPrasanna Varna(clear complexion indicative of proper biliary system functioning),Indriya-Indriyarthinaschartha(absence of hormone resistance)Avyathapakti Vegam Sukhanvitam(normalization of physiological process),Pushtibalutpanna(normalize nourishment and immune function) [12].If the patient's conditions allow then it could be repeated on the next day or at a gap of 2-3 day in patient in milder forms [13] and in cases of failure of proper administration in previous attempt[14].In weak patients with loads of toxins the procedure is repeated fortnightly with repetition of Snehana.In minor impurities the condition is managed with medications [15].Some concepts of WCT could be utilized by the Ayurveda also like the site of WCT for preventive purposes as interscapular area and sites for other unnamed disease in Ayurveda which are prevalent today[16].

Global scenario

Globally the WCT work on two sets of principle, first set of principle is influenced by the Islamic ideology which treats WCT as a religious duty.It prescribes the age limit from two years to sixty years of age and states that a person of 20 years, 30 years, 40 years and 50 years should adopt bloodletting at every 20th day,30th day, 40th day, 50th day respectively.Females during menstruation are prohibited for WCT.The preferred seasons are autumn and springs.The most suitable time of applications are afternoons or early evenings preferably on Sundays, Mondays, Tuesdays or Thursdays, on 12th to 15th, 17th, 19th or 21st of each lunar month.The patients should be full stomach at the time of therapy and intake of three cubes of sugar, honey syrup, pomegranate or fresh fish is advised prior therapy.Honey syrup, juices (like sweet pomegranate, fleawort, pineapple, cherry etc.) and cooked watery meal with low fat and salt and liver should be used as after therapy diet.The patient is advised for taking bath 12 hours after the treatment.The diets that are avoided after therapy are dairy products, pickles and excessive salt [17].The second set of principle is the based on the traditional Chinese medicine which follows the core principle of Acupuncture therapy.

Indications of WCT from Ayurveda perspective and global scenario

In Ayurveda, the general indication ofRaktamokshana[18], disorders ofRaktaandPittavitiation are considered as the indications of WCT.Both SA and AA are used forTvakasthaorSupta Rakta(superficially present blood, immobile blood) [19].The SA is believed to pull impurities up to 10Angula(～19 cm)and AA sucks impurities up to 12Angula(～22.8 cm)from the body.The specific indications for SA are theVata(Pain)dominated conditions due toUshna(warm),Madhura(sweet),Snigdha(soothing) properties and for AA areKaphadominated conditions (conditions of stasis, autoimmune condition or inflammatory conditions etc.) due toKatu(pungent),Ruksha(roughness),Teekshna(highly penetrating) properties.Ayurvedic indications are compared with the indications from global scenario in Table 1[20-43].

Contraindications of WCT from Ayurveda perspective and global scenario

In Ayurveda, the general contraindications of theRaktamokshanais considered as the contraindications of the WCT [44].The specific contraindications of SA are theKaphadominant disorders, attributed to its incapacity to remove the impurities.The specific contraindications of the AA are thePittadominant disorders because it will further vitiate the conditions due to the fire elements in its procedure.Textual Ayurvedic contraindications are compared with the contraindications from global scenario in Table 2[45].

Complications of WCT from Ayurveda perspective and global scenario

Most of the complications of WCT described in Ayurveda are due to excessive loss of blood and faulty procedure which could be avoided easily [46].A comparison of the Ayurveda complication and complications from global scenario is made in the Table 3.

Table 1 Ayurvedic indications compared with the indications from global scenario

Mode of Action of WCT

Ayurveda perspective

Ayurveda WCT is principally based on the fact that disease causing entitiesRaktaandPitta Dosha(blood or components of circulating blood)are removed in the process of RM.The preparatory stepsPachana(oral metabolic correctors drugs containing certain catalyst or enzyme enhancers),Snehapana,AbhyangaandSvedanaall together causes pouring of the disease-causing entities in the superficial circulations and interstitial spaces.These are expelled from the body through wound created in WCT.In SA the suction pressure alone is responsible for the pulling of the waste containing blood from the body and whereas in AA the warmth due to the fire component also has additive effect.

Global scenario

There are various theories that suggest the probable mode of action of WCT.They are summarized as follows.

Purification theory.

Kidney like function—WCT is believed to have excretory functions like kidneys, for renal glomerular filtration there is pressure difference between the capillary and Bowman's capsule as in WCT.The WCT has better capability than kidney in evacuating both hydrophilic and hydrophobic metabolites of interstitial fluids, fluids from blood capillaries and hemolyzed blood cells under high filtration pressure as per Boylee Marriott law [47].In this process Prostaglandins,inflammatory mediators, Heavy metals like Zinc,Aluminum, cadmium triglycerides, low-density lipoprotein (LDL) cholesterol, total cholesterol, uric acid, and immunoglobulin antibodies (rheumatoid factor)are significantly reduced[48].

Abscess drainage like function-Like in abscess drainage external compression is applied to evacuate the pus similar in WCT artificially skin barrier is opened to enhance the natural excretory functions of the skin.It cleans blood (through fenestrated skin capillaries) and interstitial fluids without adding a metabolic burden.Additionally, the suction force exert pressure on sweat glands, sebaceous gland and dermal cells which attributes to its cleansing function [49].It is interesting that in WCT healthy blood cells are not evacuated due to 100–1,000 times larger size than the 6–100 nm diameter of pores of the skin capillaries and only the cell debris is removed.

Reduction in iron toxicity and achieve benefits of Phlebotomy—In human body there is no active physiological mechanism of removing excess of iron.The excess of iron circulates in non-transferring bond form which is taken up and stored in cells of liver,brain and endocrine glands.This iron cause production of free radical which is beyond the corrective limit of body.Thus, causing development of primary iron overload disease like metabolic syndrome (visceral obesity, hypertension, dyslipidemia, hyperglycemia,glucose intolerance and fatty liver disease,non-alcoholic fatty liver with hyperferritinemia).

Table 2 Textual Ayurvedic contraindications compared with the contraindications from global

Table 3 Ayurvedic complication compared with complications from global scenario

In WCT targeted blood loss in each session is around 50 to 100 ml.After WCT there is reduction in levels of serum ferritin in single session and serum iron in multiple sessions.Thus,WCT can cause depletion in iron reserve of the body.The various disease of secondary iron overloads (Polycythemia Vera,Hemochromatosis, Porphyria cutanea tarda, Sickle cell disease) also are benefitted similarly by Phlebotomy[50].

Pain management.Effect on circulation—In WCT there is decrease in capillary venous return, interstitial fluid pressure, venous pressure and peripheral vascular resistance causing improvement in blood flow for enhanced oxygen supply and tissue perfusion.This relieves congestion and muscle spasm.The enhanced circulations assist in evacuating the toxins which may be responsible for inflammation and pain stimulus[51].

Counter irritant—To understand the WCT functioning a study was conducted on rat model on paralumbar region which showed the elevated levels of heat shock protein 70 (a chaperone protein that prevents stress-induced denaturation), and beta-endorphin (endogenous opioid), which might be the cause of pain relief [52].A study was also conducted to assess the effect of WCT on human cardiac rhythm in terms of heart rate variability.The increased heart rate variability parameters post WCT suggested the cardio protective action through the restoration of sympatho-vagal imbalances by acid, CE (16.1) (9Z), Epiandrosterone,7-Ketocholesterol and increased levels of—L-Arginine,Cholesterol and Aldosterone.The pathway impact was checked and seventeen pathways differentiated between the two samples.Among them Steroidogenesis, Insulin Signaling, Steroid Biosynthesis, Vitamin B6 Metabolism, Betaine Metabolism, Glucose Alanine Cycle, Nicotinate and Nicotinamioe Metabolism were very significant and the rest Bile acid biosynthesis, Protein biosynthesis,Urea cycle, Glycolysis, Methionine metabolism,Galactose metabolism, Arginine and proline metabolism, Gluconeogenesis and Purine metabolism were found differentiated[55].

Immune modulations—The wound created in the process causes changes in vascular tone, mucosal permeability causing accelerate lymphatic circulation,enhance phagocytosis, endogenous opioid release,inflammatory cell migration, altering the skin sensitivity and tolerance.The chronic stimulation of WCT may cause immune modulations[56].

Antioxidant effect—Interestingly, skin wounding enhances the production of endogenous nitric oxide(Anti-oxidant) through up regulating the expression of nitric oxide synthase (NOS).The nitric oxide causes vasodilatation, decrease vascular resistance, lower blood pressure, inhibition of platelet aggregation-adhesion, inhibits leukocyte adhesion-migration, and reduction of smooth muscle proliferation.A study was conducted on before and after venous samples of WCT undergone healthy volunteers to assess serum nitric oxide,malondialdehyde levels, superoxide dismutase and myeloperoxidase activity through Spectrophotometry which relieved higher levels of myeloperoxidase,malondialdehyde and nitric oxide and lower levels of superoxide dismutase suggesting the antioxidant effect of WCT[57].

Thermal stimulations—The warmth due to fire element in fire WCT causes vasodilatation and enhances vascular tone, blood vessel permeability,stimulating the peripheral nervous system [53].Thus,WCT may act as counter irritant by stimulation of acute pain fibers and affect the brain and spinal cord,cause release of b-endorphin, encephalin, activation of the opioid system, inhibition of pain transmission via simultaneous tactile sensory signals, affect the pain gates and alter the pain threshold of the site[54].

Metabolic effects.Alter metabolic pathways—A study was conducted for the metabolic effects of the WCT.A venous sample before and after WCT in healthy volunteers were analyzed for various metabolites.It was observed that the WCT samples had decreased levels of—S-Adenosyl-homocysteine, Pyridoxamine,Nicotinamideribotide, Deoxyadenosine, Cortisone,D-Glucose, 7-Dehydrocholesterol, 1-2Hydroxyglutatic acid,3-Hydroxybutyric acid,CE(16.0),Taurocholic mucosal permeability, phagocytic ability of the cells along with enhanced lymphatic circulation causing an immune modulation.

Alteration in Gut micro biome—The deficit in iron concentration in the body favors growth of iron independent microbial strain like lactobacillus and Enterobacteriaceae,whereas it causes reduction in iron dependent microbial strain like Clostridium and Bacteroides.The levels of iron influence the gut micro biome and thus gut mucosal immunity which plays major role in development and curing of disease like intestinal inflammation, diarrhea, inflammatory bowel disease (IBD), lactose intolerance, allergic diseases(atopic dermatitis,asthma),colorectal cancer[58].

Negative pressure wound healing therapy(NPWT)—Ppresently the most advanced therapy to facilitate the wound healing in acute and chronic wounds is NPWT.In this therapy the negative pressure is used to remove exudates from wound and facilitate healing in granulation tissue.The cupping action of WCT is considered the precursor therapy of NPWT[59].

Effect of hemorrhagic variables of blood—Repeated phlebotomy reduces cytocrit (platelet and leukocyte)and whole blood viscosity.This hemodilution reduces aggregability and enhance deformability of blood cells which reduce chances of thrombosis and have cardio vascular protective effect[60].

Meridian theory and Balancing of ‘Qi’.The sites of WCT are on the energy Meridians as per the Chinese medicine to balance the ‘qi', yin and yang.The mechanical effect of negative pressure on Acupuncture meridian affects the metabolism, immune function and blood biochemistry.A study on interscapular region revealed, that it has abundant Brown Adipose tissue with large deposits of ferruginous mitochondria(energy source), dense network of capillaries with low blood velocities making an ideal excretion site.Alteration of temperature (Short-term cold exposure)in Brown Adipose tissue triggers the absorption of triglyceride-rich lipoproteins and result in clearance of plasma lipids.Apparently, this site has proximity with sympathetic ganglion, Thoracic duct and major blood supply attributing to its beneficial role[61].

Islamic theory.The Islamic theory suggest that the preferred site for WCT are the location in proximity with the lymphatic drainage of the body.The bloodletting in these areas causes stimulation of the immune function of the body and aid in maintaining the health of the individuals.

Placebo effect theory.This will be remaining the most accepted theory until the exact mechanisms is not understood and proven.It is believed there is condition of Euphoria after WCT which have psychological effects attributing for its therapeutic benefits.

Conclusion

Present review suggests that among the most troublesome conditions of present day the use of WCT may provide an efficient and cost-effective management approach that can be adopted in a large number of populations.The researches in future should focus on these conditions like, in heavy metal accumulation in body, autoimmune pathologies, iron overloads syndromes, pain management, disease conditions having potential role of gut micro biome,oncological conditions, cardiovascular conditions,psychological conditions, endocrine and metabolic conditions.Apart from these the researches based on importance of particular site for a particular disease condition should also be taken up, and exploration of long-term effect of WCT as a regimental therapy may provide a conclusion on the preventive aspect and more interestingly anti-ageing or life prolongation effect of WCT.