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A Panoramic view of most commonly used Regimenal Modalities (Tadabeer) for joint pain in Unani System of Medicine: A Critical Review

Mohd Nayab1*, Abdul Nasir Ansari2, Fatima Khan3

Assistant Professor, Dept. of Ilaj bit Tadbeer, NIUM, Bangalore, India

2 Professor & HoD, Ilaj bit Tadbeer, NIUM, Bangalore, India

PG Scholar, Dept. of Ilaj bit Tadbeer, NIUM, Bangalore, India

 

Article Info:

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Article History:

Received 04 Jan 2021;     

Review Completed 12 Feb 2021

Accepted 17 Feb 2021;  

Available online 15 March 2021 

________________________________________________________________

Cite this article as:

Nayab M, Ansari AN, Khan F, A Panoramic view of most commonly used Regimenal Modalities (Tadabeer) for joint pain in Unani System of Medicine: A Critical Review, Journal of Drug Delivery and Therapeutics. 2021; 11(2):228-231                                                                        DOI: http://dx.doi.org/10.22270/jddt.v11i2.4561            

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*Address for Correspondence: 

Dr. Mohd Nayab, Assistant Professor, Dept. of Ilaj bit Tadbeer, National Institute of Unani Medicine, Bangalore

Abstract

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Pain in joints (Waja ul Mafasil) is a major clinical problem that may or may not be associated with inflammation. Researchers and Clinicians are rigorously working to find out the best treatment modality in the management of joint pain. Unani physicians claimed the management of various joint disorders with the help of several Tadabeer. The objective of this critical review is to address the claims of Unani physicians and clinical studies conducted on the efficacy of Dalk or Hijama in the management of joint pain. Classical Unani literature, peer-reviewed journal articles and RCTs that predominantly focused on the use of regimenal modalities (Hijama and Dalk) in the joint pain were included in this review. Several published studies claiming the effect of Dalk and Hijama by Unani physicians, showing significant improvement, were included along with the literature. Various published clinical trials showed the effect of Dalk and Hijama in the management of joint pain, though, the effect showed by some clinical trials was short term. Hence, rigorous, controlled, randomized, blinded, and long duration follow up studies on large sample size are to be conducted by trained clinicians or researchers to establish the efficacy of Dalk or Hijama in the management of musculoskeletal disorders (MSDs).

Keywords: Dalk; Hijama; Waja-ul-Mafasil; Joint Pain; Musculoskeletal Disorders; Unani

 


INTRODUCTION

In the present era, researchers & clinicians all over the world have shown great concern regarding alternative medicine 1. The alternative medicine includes the Unani System of Medicine which has a very rich historical background. It has journeyed through many countries and people. It strives to find the best possible ways by which a person can lead a healthy life 2. Ibne-Sina (980-1037AD) has prioritized the principle of treatment as follows: “Indeed the treatment is completed by one of the three methods, first of which is Tadbeer (Regimen) and Taghzia (Nutrition), second is the use of Advia (Drugs) and the third one is the use of Amal-e-Yad (Surgery)” 3,4.

Ilaj-bit-Tadbeer is one of the principles of treatment in the Unani system of medicine which should be applied as the first line of treatment followed by the rest if required. It includes procedures like Fasd (venesection), Hijamah (cupping), Dalk (Therapeutic Massage), Hammam (Turkish bath), Irsal-e-Alaq (leech therapy), Ishal (Purgation), Qai (Emesis), Riyazat (Exercise), Tareeq (Diaphoresis), Nutool (Irrigation), etc. Tadbeer is an Arabic word meaning regimen or systemic plan, whereas Ilaj means therapy or treatment. So, Ilaj-bit-Tadbeer means treatment through regimens. In this method of treatment, various procedures are performed for the moderation or modification in Asbab-e-Sitta Zarooriya (six essential factors) to restore health of unhealthy individuals or to maintain health in healthy individuals 5.

Hijama is a physical regimenal modality used by Unani physicians and other therapists.  Now a days a glass, plastic, or bamboo cup is used to create suction over the skin of the designated body part for the treatment. There are two types of Hijama therapy; Hijama Bila Shart (Dry Cupping); Hijama bish Shart (Wet Cupping). In Hijama Bila Shart, the cups are placed on intact skin under the effect of negative pressure created either by the fire or suction pump without drawing any blood into the cup while in Hijama bish Shart, the skin is lacerated so that blood can be drawn into the cup 6, 7.

Throughout the history of medicine, Dalk has been used not only by the unhealthy but also by healthy individuals for therapeutic, restorative as well as preventive purposes. Dalk is considered a type of Riyazat in the Unani System of medicine 8.  Eminent Unani physicians advised the use of Dalk for preventive as well as curative intentions in various body ailments. Dalk can be defined as a type of exercise practiced with palm and digits by a skilled person on the surface of the body in a number of ways to dissolve the Akhlat-e-Fasida and to assist the Quwa (Faculties) for therapeutic and preventive measures 9. Dalk is generally used, to relieve pain from musculoskeletal disorders and cancer, rehabilitate sports injuries, reduce stress, increase relaxation, decrease feelings of anxiety and depression, and aid in general wellness 9.   

Musculoskeletal disorders (MSDs) is a worldwide health problem resulting in negative effect on individuals’ well-being and a substantial burden to society 10. The most common musculoskeletal disorders include osteoarthritis, rheumatoid arthritis, cervical spondylosis, lumbar spondylosis, etc. These disorders are the main cause of disability among occupationally active adults which lead to human suffering, work absenteeism, and reduced work productivity 12, 13. Inflammatory joint disorders such as rheumatoid arthritis is one of the main causes of joint pain in younger age group whereas elderly people mainly suffer pain due to degenerative problems such as osteoarthritis 11. MSDs often have a multifactorial origin and risk factors 14. Most of the MSDs are often resistant to current modalities of management 12, 15. In Unani System of Medicine, Waja-ul-Mafasil is a term that encompasses pain in all the joints especially big joints. The pain may have specific names according to the joints or sites involved e.g. when the pain starts from the hip and radiates down the length of the leg then it is called as Irq-un-Nasa (sciatica), and when it appears in the foot or big toe, it is named as Niqris (Gout) 16,17,18. According to Akbar Arzani, Waja-ul-Mafāsil is a joint pain that may or may not be associated with inflammation due to the presence of Sue-Mizaj Sada or Maddi 19.

METHODOLOGY

Hijama (Cupping Therapy) and Dalk (Massage Therapy) are the two most commonly used regimenal modalities in the management of Waja-ul-Mafasil (Joints Pain) in the Unani System of Medicine. Keeping this fact in view, we included these two therapies. Peer-reviewed journal articles and RCTs that predominantly focused on the use of regimenal modalities (Hijama and Dalk) in joint pain were included in this review. The terms joint pain, musculoskeletal disorder, regimenal therapies (Dalk, Dalak, massage, Hijama, Hijamah, Hijamat, Cupping therapy, Irsale Alaq, Taleeq, Leeching, Hammam, Sauna Bath, Steam fomentation, Takmeed, Fomentation, Nutool, Irrigation) combined with joint pain or Waja ul Mafasil were used for search. The Unani literature has been taken from classical Unani treatises such as Kitab al-Hawi fit Tibb by Razi, Alqanoon Fit Tibb by Ibne Sina, Tibb-i-Akbar by Akbar Arzani, Akseer-i-Azam by M. Azam Khan, Zakhira Khawarzam Shahi by Ismail Jurjani, Makhzane Hikmat Kamil by Jeelani, Gina Muna by Al-Quamri.  Various relevant published works both review and RCTs were searched using the online free availability.

RESULTS

Razi in Al Hawi mentioned the treatment of Irq-un-Nasa (Sciatica) that “if thick and hard morbid material gets accumulated in the hip, Hijama becomes necessary” 20.


 

3000 BCE.

The Cong Fou of Tao-Tse in China describes the use of medicinal plants, exercise, and anmo or amma (Physical Therapy or Massage) for the maintenance of health.

700 BCE.

The Greek physician, Asclepius, founded the first gymnasium where Riyazat and Dalk were combined to promote health.

 


In Gina Muna, Jalinoos mentioned that Hijama is very beneficial if the cause of joint pain is accumulation of Khilt-i-Ghaleez. Qusta recommended Dalk in back pain with compound oil formulation like Roghan-i-Zaitoon and Aab-i-Karela. He further added that if heat is to be provided to an area, Dalk should be done 21.

Effectiveness of Hijama (cupping therapy) in painful condition of joints

Farhadi K et al. studied to determine the efficacy of Hijama bish Shart (wet cupping) for treating non-specific low back pain. It was a randomized controlled clinical trial with two parallel groups. The authors reported a significant improvement in pain in favor of Hijama bish Shart 22. In another study, Hanan S.A & Eman S.E reported the highly statistically significant effect of Hijama bish Shart in the treatment of lower back pain and improvement in activities of daily living. The authors recommended the use of Hijama bish Shart for reducing disability and pain of the lower back 23. Jong-In Kim et al conducted a randomized, waiting-list controlled, open-label, parallel-group pilot trial to evaluate the efficacy of Hijama bish Shart (Wet-Cupping) for persistent Non-Specific low back pain and reported a decrease in numerical rating score (NRS) {-16.0 (95% CI: -24.4 to 7.7) in wet cupping group and -9.1 (-18.1 to 0.1) in the waiting-list group}, but there was no statistical difference between the two groups (p=0.52). However, the McGill Pain Questionnaire for pain intensity (PPI) score showed significant differences between the two groups (-1.2 [-1.6 to -0.8] for the wet cupping group and -0.2 [0.8 to 0.4] for the waiting-list group, p<0.01). Further, the authors claimed the less intake of acetaminophen use in the wet-cupping group 24. Khan A. A et al conducted a randomized controlled clinical trial to find out the effect of cupping therapy in the management of knee osteoarthritis. Total 11 sittings of Hijama Bila Shart (Dry Cupping) were performed. The authors reported statistically significant improvement in knee osteoarthritis particularly in relieving pain, edema, stiffness, and disability 25. Michael Teut et al performed a randomized controlled exploratory trial to evaluate the efficacy of pulsatile dry cupping in patients with osteoarthritis of the knee. The researchers reported that the WOMAC global score improved significantly more in the cupping group with a mean of 27.7 (95% CI 22.1; 33.3) in comparison to the control group (p=0.001). However, the WOMAC sub-scores for pain and stiffness were not significant 26.  Romy Lauche et al reported the influence of dry cupping therapy on pain and mechanical threshold in patients with chronic non-specific neck pain in a randomized controlled pilot study. The authors claimed that the patients of the treatment group had significant improvement in pain score after receiving cupping therapy than patients of the waiting-list control group 27.

Effectiveness of Dalk (Massage Therapy) in painful condition of joints

Dalk (Massage) is a very effective modality for the modification of Ḥarkat wa Sukūn-i-Badnī; one of the Sabab among Asbāb-i-Sitta Ḍarūriya (Six Essential Factors). It is considered as a part of Riyāḍat (exercise) 3, 4. Adam I. Perlman et al conducted a randomized dose-finding trial to evaluate the efficacy of massage therapy for osteoarthritis of the knee. The authors reported that WOMAC Global score improved significantly in the 60-minutes massage group compared to the usual care group at the primary endpoint of 8-weeks. WOMAC subscales of pain and functionality, as well as the visual analogue pain scale also demonstrated significant improvement in the 60-minute therapy compared to usual care [28]. Dorothea A. Atkins conducted a randomized controlled clinical trial to evaluate the effects of self-massage on osteoarthritis of the knee. The authors reported that between-group analyses of WOMAC pain, stiffness, function subscales, and total WOMAC scores revealed a significant difference between groups (p<0.050). No significant difference was reported in the range of motion 29. Karen J Sherman et al conducted a randomized trial on therapeutic massage for chronic neck pain and found that the participants experienced clinically significant improvement on the Neck Disability Index (NDI). The study suggested that massage is safe and has clinical benefits for treating chronic neck pain 30.

DISCUSSION:

The Global Burden of Disease 2010 Study shows that musculoskeletal diseases are the fourth greatest burden on health throughout the world, causing 21.3% of years lived with disability 31. Ibn-ul-Quf has mentioned Hijāma vividly in his book Al-umdah-fil-jarāhat. According to him if morbid material is to be evacuated from the superficial part of the body, Hijama should be taken into consideration 32. Several studies conducted on Hijama in the management of pain were compared with various types of control interventions, concentrated on cutaneous nociception which is Undoubted as per the claims made by Unani physicians. Few rigorous clinical trials have been conducted to find out the efficacy of Hijama as a monotherapy in the management of joint pain. The evidence collected from clinical trials and Unani literature seems positive for these therapies. All the data provided suggest the effectiveness of Hijama compared with other treatments.

Dalk is one of the earliest therapeutic tools used to relieve pain 33, 34. With its popularity for pain relief and recovery of function, it has become a widely accepted regimenal modality for musculoskeletal disorders 35, 36.

CONCLUSION:

Most of the interventional studies using Hijama or Dalk in the management of pain have shown significant improvement. An approach that focuses on a healthy lifestyle & the use of regimenal modalities especially Hijama and Dalk, is important to restore and maintain function, to improve participation in the long term, and to provide a management plan instead of a cure. Very few attempts have been made to evaluate the efficacy of Dalk and Hijama in the management of MSDs. Only a few studies are available but are either uncontrolled or have poor methodological quality. The studies performed on Hijama and Dalk show a short-term effect in the management of joint disorders.

It is still believed that the regimenal modalities provide a strong basis for the management of persistent musculoskeletal disorders and may also contribute to the long term prevention of these conditions, but it cannot be concluded that the effect of Dalk or Hijama is superior to other treatment modalities, as the results obtained from the previous studies are mixed ones. Hence, we suggest rigorous, controlled, randomized, blinded, and long-duration follow-up studies on large sample size, to be conducted by trained clinicians or researchers to establish the efficacy of Dalk or Hijama in the management of MSDs.

Conflict of Interest:

The authors declare no conflict of interest.

 

 

REFERENCES:

  1. Nimrouzi M, Jaladat A M, Zarshenas MM, A Panoramic view of medicinal plants traditionally applied for impotence and erectile dysfunction in Persian medicine, Journal of Traditional and Complementary Medicine, 2020; 10:7-12
  2. Taher MA, Nayeem MAB, Ahamed MM, Chowdhury MSI, Ilaj-bil-Tadbeer (Regimenal Therapy): A Review, International Journal of Medical and Health Research, 2017; 3(10): 54-56.
  3. Gruner, O. Cameron. A Treatise on the Canon of Medicine of Avicenna. London: Burleigh press. 1929
  4. Ibne Sina. Alqanoon Fit Tib (Urdu Translation). New Delhi: Idara Kitab us Shifa. 2010
  5. Ibne Sina, Tarjuma wa Sharha Kulliyat-e-Qanoon (Urdu Translation by Hakeem Kabeeruddin), New Delhi: Aijaz Publishing House. 1930.
  6. Jong-In Kim, Myeong Soo Lee, Dong-Hyo Lee, Kate Boddy, Edzard Ernst. Cupping for Treating Pain: A Systematic Review. Evidenced-Based Complementary and Alternative Medicine. 2011:1-7.
  7. Ypung Dal Kwon, Hyeon Joo Cho. Systematic Review of Cupping Including Bloodletting Therapy for Musculoskeletal Diseases in Korea. Korean J. Oriental Physiology & Pathology. 2007; 21(3):789-793.
  8. Ibne Rushd. Kitabul Kulliyat (Urdu Translation by CCRUM). New Delhi. CCRUM. 1987.
  9. Tanweer M.A., Ansari A.H., Anzar M.A. Dalk (Therapeutic Massage) & Their Indication for Musculoskeletal Disorder in Unani Medicine. International Journal of Advanced Ayurveda, Yoga, Unani, Siddha, and Homeopathy. 2013; 2(1):59-70.
  10. Hutting N, Johnston V, Stall J B, Heerkens Y F. Promoting the use of self-management strategies for people with persistent Musculoskeletal Disorders: The Role of Physical Therapists. Journal of Orthopaedic & Sports Physical Therapy. 2019; 49(4):212-215.
  11. Schaible HG, Richter F, Ebersberger A. et al. Joint Pain. Exp Brain Res. 2009; 196:153-162.
  12. Murray C.J, Atkinson C, Ali MK, et al. The State of US Health, 1990-2000; burden of diseases, injuries, and risk factors, JAMA. 2013; 310:591-608.
  13. Aas RW, Thingbo C, Hotte KA, et al. On long term sick leave due to musculoskeletal diseases and disorders. Experiences of work demands. 2011; 39:233-242.
  14. Hernandez AM, Peterson AL. Work-related musculoskeletal disorders and Pain. In: Gatchel RJ, Schultz IZ, eds. Handbook of Occupational Health and Wellness. New York, NY: Springer. 2012:63-86.
  15. Lewis J, O’Sullivan P. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain? Br J Sports Med. 2018; 52:1543-1544.
  16. Razi Z. Kitabul Hawi Fit Tibb. (Urdu translation by CCRUM). Vol. 11. Govt. of India; 2002: 75-100.
  17. Jurjani I. Zakheera Khawarzam Shahi. (Urdu translation by Hadi Hasan Khan). Vol.3rd. Part 6th. Lucknow: Munshi Naval Kishore; 1878: 637-41.
  18. Nayab M, Anwar M, Quamri MA. Clinical Study on Waja-ul-Mafasil and evaluation of efficacy of Hijamat-bila-Shurt in the Treatment. Indian Journal of Traditional Knowledge. 2011; 10(4):697-701.
  19. Arzani A. Tibb-e-Akbar. Delhi: Idara-e-Kitab-ul-Shifa; 1890: 617-28.
  20. Razi Z. Kitab-ul-Hawi fil-Tibb. Vol. 11. Hyderabad: Daerat-ul-Marif; 1962: 101 - 273.
  21. Al-Quamri. Ghina Muna. New Delhi: Central Council for Research in Unani Medicine. 2008
  22. Farhadi K, Schwebel DC, Saeb M, et al. The Effectiveness of Wet-Cupping for nonspecific low back pain in Iran: A Randomised Controlled Trial. Complementary Therapies in Medicine. 2009; 17:9-15.
  23. Hanan S.A, Eman S.E. Cupping Therapy (Al-Hijama): It’s Impact on Persistent Non-Specific Lower Back Pain and Client Disability, Life Science Journal.2013;10(4s):631-642.
  24. Jong-In Kim, Tae-Hun Kim, Myeong Soo Lee, et al. Evaluation of wet-cupping therapy for persistent non-specific low back pain: a randomised, waiting-list controlled, open-label, parallel-group Pilot Trial, Trials. 2011; 12(146):1-7.
  25. Khan A.A, Jahangir U, Urooj S. Management of knee osteoarthritis with cupping therapy. Journal of Ayurved Pharmaceutical Technology & Research. 2013; 4(4): 217-223.
  26. Michael Teut, Stefan Kaiser, Miriam Ortiz, et al. Pulsatile dry cupping in patients with osteoarthritis of the knee – A Randomised Controlled Exploratory Trial. BMC Complementary and Alternative Medicine.2012; 12(184):1-9.
  27. Romy Lauche, Holger Cramer, Kyung-Eun Choi, et al. The Influence of a series of five dry cupping treatments on pain and mechanical thresholds in patients with chronic non-specific neck pain – A Randomised controlled pilot study. BMC Complementary and Alternative Medicine.2011; 11(63):1-11.
  28. Adam I. Perlman, Ather Ali, Valentine Yachou Njike, et al. Massage Therapy for Osteoarthritis of the Knee – A Randomised Dose-Finding Trial. PLoS ONE. 2012; 7(2):1-9.
  29. Dorothea V. Atkins, David A Eichler. The Effects of Self-Massage on Osteoarthritis of the Knee: A Randomised, Controlled Trial. International Journal of Therapeutic Massage & Bodywork. 2013; 6(1):4-14.
  30. Karen J. Sherman, Daniel C. Cherkin, Rene J. Hawkes, et al. Randomized trial on Therapeutic Massage for Chronic Neck Pain. Clin J Pain. 2009; 25(3): 233-238.
  31. Hoy DG, Smith E, Cross M, Sanchez-Riera L, Blyth FM, Buchbinder R, et al. Reflecting on the burden of Musculoskeletal conditions: Lessons learnt from Global Burden of Disease 2010 Study and the next steps forward. Ann Rheum Dis. 2015; 74:4-7.
  32. Ibn-ul-Quf Masihi, Kitab-ul-Umda fil Jarahat, New Delhi: Central Council for Research in Unani Medicine.1986
  33. Brummitt J. The Role of Massage in Sports Performance and Rehabilitation: Current evidence and future directions. Am j Sports Phys Ther. 2008; 3:7-21.
  34. Kong LJ, Zhan HS, Cheng YW. Massage Therapy for neck and shoulder pain: a systemic review and meta-analysis. Evid Based Complementary Alternat Med. 2013.
  35. Patel KC, Gross A, Graham N, Goldsmith CH, Ezzo J, Morien A, et al. Massage of Mechanical Neck disorders. Cochrane Database Syst Rev. 2012; 9:CD004871.
  36. Diederik C bervoets, Pim AJ Luijsterburg, Jeroen JN Alessie, Martijn J Buijs, Arianne P Verhagen. Massage therapy has short term benefits for people with common musculoskeletal disorders compared to no treatment: a systematic review. Journal of Physiotherapy. 2015; 61:106-116.