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Journal of Drug Delivery and Therapeutics

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Open Access Full Text Article   Case Report

Efficacy of Wet Cupping in the Management of Sciatica: A Case Report

Anam Tariq¹*, Niyazi Abdullah Khizar ¹, Mohd Nayab ², Abdul Nasir Ansari ³

¹ PG Scholar, Dept. of Ilaj Bit Tadbeer, National Institute of Unani Medicine, Bengaluru

² Associate Professor, Dept of Ilaj Bit Tadbeer, National Institute of Unani Medicine, Bengaluru

³ Professor, Dept of Ilaj Bit Tadbeer, National Institute of Unani Medicine, Bengaluru

 

 

INTRODUCTION:

In clinical practice, back pain is a prevalent complaint that can be difficult to diagnose because of its wide range of possible causes. One of those etiologies is sciatica, which is characterized by radiating pain along the sciatic nerve, standing out for its debilitating nature and impact on the daily lives of patients.  The causes of sciatica are usually lumbar disc herniation, spinal stenosis, or degenerative disc degeneration. Sciatica is caused by compression or irritation of the lumbar nerve roots. Sciatica patients may present with different clinical presentations; however, common symptoms include back pain, tingling, numbness, and weakness along the affected nerve distribution. ^1,2 It is an extremely prevalent complaint with an annual incidence of 1 to 5%. However, its prevalence in general population is 1.6% and in selected working population is 43%.³ In unani irqunnasa is an Arabic term, which means “name of a nerve” which originate from gluteal region and radiates toward lateral aspect of thigh and extends upto the ankle. ^4,5,6,7 Irqunnisa is a type of wja ul mafasil. ^1,8,9 A major cause of sciatica that significantly increases morbidity and impairs the quality of life is lumbar disc herniation.¹ Sciatica discomfort is often unilateral, and it can start suddenly during physical exertion or develop gradually over time. Pain may be sharp and aching, may vary from a mild ache to severe burning, shooting, or tingling in nature which radiates along a broad pattern from the middle or lower buttock up to the dorsolateral aspect of the thigh in case of L5 nerve root compression, anterolaterally in case of L4 compression and posteriorly in thigh when compression is at S1 root. Sciatica can manifest as acute, sub-acute or chronic.¹⁰ middle age, smoking, mental stress and physically strenuous work are the risk factors of sciatica. ³ The main cause of the irqunnasa is typically khilt-e-dam or Khilt-e-Balgham kham wa galeez which accumulates in the hip joint, but most of the time, the cause is Khilt-e-Balgham or a mixture of Khilt-e-Balgham wa Safra. ^11,10   The intensity of pain depends upon the madda (morbid matter) involves.¹²

According to Ibn-e-Sina, Irq-un-Nasa is a subtype of Waja-ul-Mafasil, in this condition the pain starts from the hip joint and radiates to the back of the thigh; and occasionally extends to the knee, ankle and up to the toes. Ibn-e-Sina further explains that because of its chronicity and overabundance of of morbid matter, the affected leg and thigh become weak and asthenic, which eventually leads to an inability to bend or to stand upright. ¹³ the principal treatment of Irq-un-Nasa in Unani Medicine varies according to the underlying etiology and derangement in temperament (Mizaj). Evacuation (Istefragh or Tanqia) is necessary if morbid khilt is dominant either quantitatively or qualitatively. For Irq-un-Nasa, there are different kinds of regimens given, which are more effective with less adverse effects and, at the same time, cost-effective like Ḥijama, Irsal-e-Alaqs (Leech therapy), Dalk (massage), Abzan (Sitz Bath), and Fasd (Venesection). In unani system, Hijama Bish Shart is recommended for various subtypes of waja ul Mafasil and other diseases also including irqunnasa. ^13,4 Razi states that Hijama bish shart will be done over hip when disease starts from the site of pain. He further states, ―If the humors become thick in the affected joint due to improper treatment Hijāma becomes very useful for this condition.  Ibne Sina writes under the treatment of Irqunnasa that if the drug treatment is unable to treat the problem then Hijāma (cupping) with and without scarification over the hip will be helpful. A Hijama is a type of minor surgical excretory procedure that opens the skin barrier by causing superficial skin scarification. It also improves blood clearance and waste excretion through the skin by creating a pressure gradient and traction force across the skin and underlying capillaries.¹⁴

PATIENT INFORMATION AND CLINICAL FINDINGS:

CASE 1: This patient was a 38-year old female housewife who attended the outpatient department of the National Institute of Unani Medicine on 8|05|2024 with complaints of pain in lower back for 2 months and radiates to the left lower leg. She had no history of trauma, diabetes mellitus or hypertension. Her vitals were stable (BP= 126|78 mmHg, Pulse rate= 72|min, Respiratory rate=20|min and temperature 98.6 ⁰F). Her Hb was 13.2gm%, Bleeding time 2.30 minutes, Clotting time 5 minutes. Viral markers ( HIV I & II, HBsAg ) were carried out and found negative and nonreactive. She showed his previous investigation reports in which MRI of the lumbosacral spine revealed diffuse bulge of L5-S1 and postereo central disc protrusion at L5-S1 levels with thecal sac indentation, lateral recess- neural foramen narrowing and exiting nerve root compression. X-ray lumbosacral spine showed lumbar spondylosis. Her ECG was normal. This hemodynamically stable patient was diagnosed with a case of sciatica based on general and specific (SLR – 30degree) examinations.

CASE 2: This patient was a 42-year-old male who attended OPD of the National Institute of Unani Medicine on 18/01/2024 with complaints of severe pain in the lower back for 8 months radiating to the right buttock, thigh and calf, for 15 days with numbness and tingling sensation. He was a glass worker by occupation. He had no history of DMT2, Hypertension, or trauma. His Hb% was 14gm%, BT 2 minutes, CT 3.70 minutes. His vitals were stable (BP = 130/80 mmHg, Pulse rate = 86/min, Respiratory rate = 20/min, Temperature = 98.6⁰F) Viral markers (HIV I and II, HBsAg) were carried out and found negative and non-reactive. X-ray lumbosacral spine showed lumbar spondylosis. His ECG was normal. He showed his previous investigation reports in which MRI of the lumbosacral spine revealed a posterior disc bulge at L5-S1 level indenting the anterior thecal sac, causing mild spinal canal stenosis. The general examination of this hemodynamically stable patient was performed, including an SLR of the right leg, which was found positive at 30degree and diagnosed as a case of sciatica.

INTERVENTION: 

After the assessment, First, the patient will be positioned correctly for Hijama and the area to be cupped will be exposed properly; hairs if present on the area will be removed to fix the cup firmly on the body. Negative pressure inside the cups will be created with the help of a vacuum pump and the cups will remain placed at that site for up to 10 minutes. Thereafter, these cups will be removed, and skin cleaned with spirit and betadine solution. At that specific part of back multiple superficial small incisions will be made in the form of pricks with 11 no. sterilized surgical blade. The same cups will be applied to the area of incision. During this procedure vitals and general condition of the patient will be monitored continuously to observe any adverse effects. Once the blood had coagulated, the cup was taken out, and the cupped region was cleaned with antiseptic lotion, and bandaged with antiseptic solution, The blood will be collected in a measuring pan. The dressing will be removed after 10-12 hours. 

Site of cupping: Lumbosacral region, thigh and calf as shown in figure 1

Size of cups: 6.5 cm (large cups).

Number of cups used: 4

Number of sittings: 4 (once weekly for four weeks).

Duration of Study: 28 days.                                                                                     

ASSESMENT: 

The pain was assessed on the 0^thday, 14^thday, 21^th day and 28^thday on the basis of visual analogue scale.

RESULTS: 

The assessment of the patients was done based on the Visual Analogue Scale (VAS) for pain. Before the first sitting the VAS score was 8 on 0 day, and on the last sitting it was 4, indicating significant improvement. In case2 before the first sitting it was 7 and after 28 days it was 4 which means there is a significant improvement was observed as shown in table 1.

 

 

Figure 1:

(TABLE 1) Show the Result According to VAS

 

 

DISCUSSION:  

Sciatica is an overwhelming ailment in which an affected person may experience pain or paresthesia in the distribution of the sciatic nerve or an associated lumbosacral nerve root. ¹⁵ The outcome of these case studies shows that wet cupping provides an opportunity to alleviate sciatica. Two patients with lower back pain with radiating pain   were followed up on for 28 days in our case study. For local application, wet cupping was administered to the patients. In conventional medicine, the available treatment is, oral NSAIDs, Opioid and non-opioid analgesics and surgery. The long term use of these medications causes many adverse effects. Therefore, it is the need of the hour to develop a therapy that can manage pain without any side effects. wet cupping was chosen to evacuate morbid humour from the body that cause pain and was found to be effective in this case. In Unani medicine, Wet cupping functions based on the Tanqiya-i-Mawad principle, which involves removing the morbid matter from the affected area. ^{16, 17}

According to Gallin, the use of cupping becomes very advantageous when the humours in affected joint thicken. It opens the skin pores, improves blood circulation, supplies fresh blood to the affected area, and fortifies the eliminative function, all of which help the body get rid of the Akhlāt-i-fāsida. ¹⁸   The exact physiological mechanisms by which wet cupping may work are yet unknown. Various factors, including (I) neural, (II) haematological, and (III) immune system functioning, are thought to contribute to the effects of wet-cupping.¹⁸  particular, wet-cupping may "suppress pain" by affecting three distinct neural systems: (a) The "analgesia" system in the brain and spinal cord, which includes the periaqueductal gray and periventricular areas the Rapha magmus nucleus, the Nucleus reticularis paragigantocellularis (b) the brain’s opiate system (endorphins and enkephalins), and (c) most influential, through inhibition of pain transmission by simultaneous tactile sensory signals.¹⁹  Moreover, diffuse noxious inhibitory controls (DNICs) might contribute partially to the pain-relieving effect witnessed.  ²⁰ 

It is also plausible that the observed analgesic effect is partially attributed to diffuse noxious inhibitory controls (DNICs). ¹⁹ In the neural system, the effect occurs through the regulation of neurotransmitters and hormones like serotonin, dopamine, endorphin, acetylcholine etc. ^21,22,23 In the hematological system, the primary effects occur by these two pathways: 1. Regulation of coagulation and anticoagulation systems like a decrease in the level of a haematological element such as fibrinogen 2. Reduction in the hematocrit, followed by an increase in blood flow and oxygenation of the end organs. ¹⁴

In the immune system, the main effects occur by these three pathways: 

1. Irritation of the immune system by producing local simulated inflammation followed by activation of the complementary system and increased level of immune products such as interferon and tumour necrotizing factors.

2. Organize lymph traffic and boost lymph flow through lymph vessels.

3. Effect on thymus. ¹⁸ this reveals that Hijama not only induce evacuation and diversion but it has anti-inflammatory and demulcent effects as well.²⁰ it may provide quicker relief of leg pain in sciatica than conservative treatment. ²⁴

CONCLUSION: 

The results of this study suggest that wet cupping offers a more substantial immediate therapeutic benefit than conventional care or treatment. Following the treatment, the individuals did not report any adverse effects.

Acknowledgment: I owe a debt of gratitude to all authors for their inspiration, guidance, and assistance in helping me to put this work together.

Funding Source: No funding sources

Source of Support: Nil

Conflict of Interest: The authors report no conflict of interest.

Informed Consent: before the study intervention the patient gave their informed consent and the patient was willing to participate in it.

Author Contributions:

AT: Conceptualization, Writing, Data curation, Formal analysis, Investigation.

AAKKA: Writing and editing, Data curation, Formal analysis, Investigation, Software

MA: ORCID: Visualization, Validation, Writing review and editing

ANA: Email: Supervision 

Data Availability Statement: The data presented in this study are available on request from the corresponding author. 

Ethics approval: N/A

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