The Effect of Wet Cupping on Blood Haemoglobin Level

Abstract

Although wet cupping is quite a popular procedure that is practised worldwide, there is not enough evidence that it may cause anaemia as a side effect. In this observational retrospective pre–post study, we looked through the previously recorded data of patients who received wet cupping at King Abdulaziz University Hospital. We included in the study all those who had their complete blood count done before and immediately after the procedure (n=364). Then, we recorded their blood haemoglobin, red blood cell count, mean corpuscular volume, mean corpuscular haemoglobin and haematocrit before wet cupping, immediately after it, within 3 months after it, then, finally, from 3 months to 6 months after it. Three comparisons took place for each blood test by comparing the pre-reading with each one of the three post-readings. There was no statistically significant difference in any of the pre–post comparisons of those blood tests. However, after excluding those who were not anaemic and keeping only the anaemic patients, the comparison showed statistically significant improvement, but not clinically significant, when comparing the red blood cell count and the haematocrit before and immediately after wet cupping — p value was 0.000 for both. The mean difference for red blood cell count was –0.80 million cells/L (–0.12 to –0.39) while the haematocrit mean difference was –0.64% (–0.96 to –0.33). In conclusion, anaemia was not found as a side effect of wet cupping.

Full text

The Effect of Wet Cupping on Blood Haemoglobin Level
Samiha A. Mourad1* and Soad K. Al-Jaouni2
1Prophetic Medicine Research Clinic, King Abdulaziz University, Jeddah, Saudi Arabia
2Department of Hematology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
*Corresponding author: Samiha A. Mourad, Prophetic Medicine Research Clinic, King Abdulaziz University, Jeddah, Saudi Arabia, Tel: +966502337393; E-mail:
dr.samiha-mourad@hotmail.com
Received date: June 3, 2016; Accepted date: June 21, 2016; Published date: June 27, 2016
Copyright: © 2016 Mourad SA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Although wet cupping is quite a popular procedure that is practised worldwide, there is not enough evidence that
it may cause anaemia as a side effect. In this observational retrospective pre–post study, we looked through the
previously recorded data of patients who received wet cupping at King Abdulaziz University Hospital. We included in
the study all those who had their complete blood count done before and immediately after the procedure (n=364).
Then, we recorded their blood haemoglobin, red blood cell count, mean corpuscular volume, mean corpuscular
haemoglobin and haematocrit before wet cupping, immediately after it, within 3 months after it, then, finally, from 3
months to 6 months after it. Three comparisons took place for each blood test by comparing the pre-reading with
each one of the three post-readings. There was no statistically significant difference in any of the pre–post
comparisons of those blood tests. However, after excluding those who were not anaemic and keeping only the
anaemic patients, the comparison showed statistically significant improvement, but not clinically significant, when
comparing the red blood cell count and the haematocrit before and immediately after wet cupping — p value was
0.000 for both. The mean difference for red blood cell count was –0.80 million cells/μL (–0.12 to –0.39) while the
haematocrit mean difference was –0.64% (–0.96 to –0.33). In conclusion, anaemia was not found as a side effect of
wet cupping.
Keywords: Wet cupping, Safety, Haemoglobin, Anemia, Prophetic
medicine, Saudi Arabia
Introduction
Cupping is a well-known traditional healing remedy in many parts
of the world. Wet cupping is dened as “the process of using a vacuum
at dierent points on the body but with incisions in order to remove
‘harmful’ blood which lies just beneath the surface of the skin” [1]. It is
known in Arabic language as hijama. For Muslims, it has special
importance because it was recommended by the Prophet Mohammed
(peace be upon him) on many occasions. For example, he said, “Indeed
the best of remedies you have is hijama (cupping)” [1].
Although wet cupping has been a well-known treatment procedure
for many years, there is no clear evidence regarding its safety on
patients’ haemoglobin levels. is study should help to build a solid,
safe base for future wet-cupping studies and clinical practice on
anaemic patients. e objectives of this study are to determine the
eect of wet cupping on blood haemoglobin level, and measure the risk
of anaemia caused by this procedure. Furthermore, the study will
assess the eect of wet cupping on haemoglobin level within the
subgroup of anaemic patients by comparing it before and aer the
procedure.
Literature Review
Few studies have investigated the eect of wet cupping on blood
haemoglobin level. e most relevant one is a study conducted in Iran
in 2009 by Mahdavi et al. [1], who performed wet cupping on 56
healthy men between 20 and 40 years old, on one point between the
two scapulae on the back, opposite T2-T5. ey did many blood tests
before the procedure and 2 weeks aer it, including complete blood
count. e mean haemoglobin level before wet cupping was 15.67 ±
1.2, and aer cupping it was 15.12 ± 1.25. e p value was 0.045, which
was a statistically signicant dierence, but, apparently, a clinically
nonsignicant dierence. But we cannot generalise those results
because it was a small sample size and they included only healthy,
young men.
A number of case reports testify that patients performed excessive
wet cupping for a long period and then developed anaemia. We have
found six such case reports in the literature with similar stories of a
patient who developed anaemia and even some had anaemia with
complications following an excessive course of wet cupping—and, in
one case, dry cupping. Five of those case reports or case series were for
Korean patients [2-5] and one was from Turkey [6]. All those cases had
a common history of performing what was described as repeated,
excessive, or long-duration cupping. e sessions were performed very
frequently; for example, two to three times per week as described in
one study [3]. e duration of treatment was long in all of those studies
ranging from 2 months [2] to more than 10 years [4]. Logically, the
very frequent cupping and the long duration might have caused the
severe anaemia in those cases, but this cannot be conclusively
determined by only those case reports. On the other hand, this still
cannot answer the question if the performance of less frequent wet-
cupping sessions for a shorter duration can have the same eect on
haemoglobin or not.
Methods
e design of this study is an observational retrospective pre–post
study to investigate the eect of wet cupping on dierent blood
parameters and answer the question if wet cupping or hijama causes
Alternative & Integrative Medicine Mourad and Al-Jaouni, Altern Integr Med 2016, 5:2
http://dx.doi.org/10.4172/2327-5162.1000217
Research Article Open Access
Altern Integr Med
ISSN:2327-5162 AIM, an open access journal Volume 5 • Issue 2 • 1000217

anaemia. e study was performed at King Abdulaziz University
Hospital in Jeddah in the Prophetic Medicine Clinic, which is funded
and supervised by the Y.A. Jameel, Scientic Chair of Prophetic
Medical Applications. is clinic mainly provides wet-cupping therapy
for patients referred from other clinics in the hospital who ask for
hijama for dierent reasons. e data were taken from the records of
the patients who attended that clinic during January 2013 to December
2013. We included all the patients who attended the clinic during that
period and excluded those who did not have a complete blood count
(CBC) before receiving hijama. We also excluded those who had no
CBC done immediately aer hijama. Aer excluding those patients,
the sample size was 364 participants.
All participants who received wet cupping at the Prophetic
Medicine Clinic signed a consent form indicating that their data would
be used in multiple studies funded by the scientic chair.
Condentiality of data was ensured throughout the study.
e usual hijama procedure in the Prophetic Medicine Clinic
involves cleaning the target area with an alcohol swab, placing the cup
over the area and starting suction. e cup is then gently removed and
ve very supercial incisions, about 0.3 cm to 0.7 cm in length and 0.2
mm in depth, are made parallel to each other. Aer creating the
incisions, the cup is placed over the same area and the suctioning is
repeated. is procedure is performed on all or most target hijama
sites at the same time. e amount of blood extracted per session is
about 50 mL to 100 mL from all sites in the body. Aer that, the areas
are cleaned and dressed. Usually, there is at least a month gap before
the next hijama session at the clinic.
e investigations used for comparison are haemoglobin (HB),
haematocrit (HCT), red blood cell (RBC) count, mean corpuscular
volume (MCV) and mean corpuscular haemoglobin (MCH). ose
investigations’ readings were taken at dierent time points: before
hijama, immediately aer hijama, within 3 months aer hijama and
between 3 months and 6 months aer hijama. Some patients had no
measurements taken within 6 months, other than that done
immediately aer hijama, so those were included only in the rst
comparison and excluded from the following ones.
Statistical analysis was done using SPSS program version 16.0.
Baseline categorical variables are presented in frequencies and ratios,
while baseline continuous variables are presented in means and
standard deviations. Student’s t-test analyses will be used to compare
mean HB, HCT, RBC count, MCV and MCH before wet cupping and
immediately aer it, before wet cupping and within 3 months aer it,
and before wet cupping and from 3 months to 6 months aer it. e
diversity of the patients included in the study is the reason for not
using ANCOVA (discussed in the “Results” section). Moreover, we
repeated the same set of comparisons within the subgroup of anaemic
patients to assess if hijama is safe to be performed among them.
Results
e patients who were chosen for this study had a wide age range,
from 14 to 86 years, but most of them were within the adults’ range of
18 and 65 years old. Most of the participants were female, with a ratio
of about 1 male to 3 females. e mean values of the participants’ HB,
RBC, MCV, MCH and HCT were all within the normal ranges. e
majority of the participants had more than one hijama session on
dierent days, and the average number of hijama sites in each session
was about nine sites of wet cupping. Unfortunately, there were no data
available for the average amount of blood extracted from the patients
in each hijama session. Table 1 shows more details about the baseline
characteristics of the participants.
Baseline characteristic n Result Range (if applicable)
Mean age, years (± SD) 363 44.4 (± 13.9) 14 to 86 years
Male: female ratio 364 92:272 –
Smoker: non-smoker ratio 364 38:320 –
Mean HB level (± SD) 364 12.9(± 1.8) 4.5 to 17.9
Mean RBC (± SD) 364 4.7 (± 0.6) 3.0 to 6.7
Mean MCV (± SD) 322 82.2 (± 6.8) 55.9 to 113.5
Mean MCH (± SD) 322 27.8 (± 5.0) 15.2 to 86.8
Mean HCT (± SD) 364 50.3 (± 203.6) 16.9 to 3907.0
Mean number of hijama
sessions
328 2.8 (± 1.7) 1 to 14
Mean number of hijama
sites per session
323 9.3 (± 4.3) 2 to 37
Table 1: Baseline characteristics of participants before hijama.
e majority of the patients who were referred to the Prophetic
Medicine Clinic had pain as their main complaint. Nevertheless, many
of them reported to the clinic with more than one complaint; 120 of
the 364 included in the study had multiple complaints. Table 2 gives
the full description of all the complaints that the patients had, with the
frequency of each complaint.
The complaint of the participant The frequency of the complaint*
Back pain 136
Shoulder pain 48
Knee pain 40
Other pain 87
Headache and migraine 66
Hypertension 28
Infertility 25
Citation: Mourad SA, Al-Jaouni SK (2016) The Effect of Wet Cupping on Blood Haemoglobin Level. Altern Integr Med 5: 217. doi:
10.4172/2327-5162.1000217
Page 2 of 6
Altern Integr Med
ISSN:2327-5162 AIM, an open access journal Volume 5 • Issue 2 • 1000217

Diabetes Mellitus 10
Hormonal disturbance 8
Allergy 8
Chronic fatigue 8
Rheumatoid arthritis 7
Psychological problem 5
Other complaints 37
No complaint** 81
* Note that many participants had more than one complaint.
** Some people receive hijama for general well-being, without having a specific complaint or disease.
Table 2: Participant complaints.
Many comparisons were drawn from the participants’ results to
show the dierence between their blood results before and
immediately aer hijama, then before and within 3 months aer
hijama and nally before and from 3 to 6 months aer hijama. e
aer-hijama readings were taken aer the nal hijama session, because
most of the participants had more than one hijama session. Each
comparison was displayed in mean dierence with p values and
condence intervals. In general, there were no statistical dierences
between any of the readings before and aer hijama. Table 3 shows
those comparisons in depth.
Comparison Comparison between baseline and
results immediately after hijama
Comparison between baseline and
results within 3 months after hijama
Comparison between baseline and
results within 6 months after hijama
Haemoglobin (HB)
Number of cases 364 193 78
Mean HB before hijama (±
SD) 12.9 (± 1.8) 12.6 (± 1.8) 12.3 (± 1.8)
Mean HB after hijama (± SD) 12.9 (± 1.8) 12.5 (± 1.8) 12.2 (± 1.8)
Mean difference (95% CI) 0.02 (–0.06 to 0.08) 0.10 (0 to 0.19) 0.03 (–0.18 to 0.24)
p value 0.689 0.055 0.764
Red blood cell (RBC) count
Number of cases 364 194 78
Mean RBC before hijama (±
SD) 4.7 (± 0.6) 4.7 (± 0.5) 4.6 (± 0.6)
Mean RBC after hijama (±
SD) 4.7 (± 0.5) 4.6 (± 0.6) 4.6 (± 0.6)
Mean difference (95% CI) –0.01 (–0.03 to 0.02) 0.02 (–0.01 to 0.05) –0.01 (–0.07 to 0.05)
p value 0.639 0.152 0.79
Haematocrit (HCT)
Number of cases 364 193 78
Mean HCT before hijama (±
SD) 50.3 (± 203.6) 12.6 (± 25.8) 37.8 (± 7.1)
Mean HCT after hijama (±
SD) 38.8 (± 4.4) 12.5 (± 4.8) 36.8 (± 5.2)
Mean difference (95% CI) 11.54 (–9.43 to 32.50) 0.10 (0.00 to 0.19) 0.98 (–0.47 to 2.42)
Citation: Mourad SA, Al-Jaouni SK (2016) The Effect of Wet Cupping on Blood Haemoglobin Level. Altern Integr Med 5: 217. doi:
10.4172/2327-5162.1000217
Page 3 of 6
Altern Integr Med
ISSN:2327-5162 AIM, an open access journal Volume 5 • Issue 2 • 1000217

p value 0.28 0.196 0.183
Mean corpuscular volume (MCV)
Number of cases 321 190 78
Mean MCV before hijama (±
SD) 82.2 (± 6.8) 81.7 (± 7.0) 80.5 (± 7.3)
Mean MCV after hijama (±
SD) 82.2 (± 7.3) 81.7 (± 7.2) 79.8 (± 1.0)
Mean difference (95% CI) 0.02 (–0.28 to 0.33) –0.02 (–0.26 to 0.22) 0.69 (–0.47 to 1.84)
p value 0.884 0.872 0.241
Mean corpuscular haemoglobin (MCH)
Number of cases 321 190 78
Mean MCH before hijama (±
SD) 27.8 (± 5.0) 27.7 (± 6.1) 27.1 (± 0.7)
Mean MCH after hijama (±
SD) 27.9 (± 5.8) 27.7 (± 6.6) 27.1 (± 6.8)
Mean difference (95% CI) –0.15 (–0.49 to 0.18) 0.04 (–0.72 to 0.80) 0.04 (–1.85 to 1.94)
p value 0.361 0.923 0.966
Table 3: Comparison between the HB, RBC, HCT, MCV and MCH levels before and within 3 and 6 months aer hijama.
e same method of comparison was repeated for only the
participants who initially had anaemia before the rst session of
hijama. e denition of anaemia by the World Health Organization is
less than 13 g/dL for males and less than 12 g/dL for females [7]. is
denition was followed in the selection of the anaemic patients.
Although the results showed a statistically signicant increase in the
RBC and HCT when comparing their mean values before and
immediately aer hijama, it was not a clinically signicant dierence.
For the RBC, the mean value before hijama was 4.4 million cells/μL (±
0.5) and aer hijama was 4.5 million cells/μL (± 0.6). For the HCT, the
mean value before hijama was 33.6% (± 3.2) and aer hijama was
34.3% (± 3.8). In the following comparisons, this dierence
disappeared during the 3-month and the 6-month follow-up
investigations. However, we need to point out here that there were
fewer participants this subgroup than the total number of participants
that we started with, which decreases the power of the results. In Table
4, more details are shown regarding this subgroup.
Comparison Comparison between baseline and
results immediately after hijama
Comparison between baseline and
results within 3 months after hijama
Comparison between baseline and
results within 6 months after hijama
Haemoglobin (HB)
Number of cases 99 58 31
Mean HB before hijama (± SD) 10.8 (± 1.3) 10.7 (± 1.4) 10.6 (± 1.6)
Mean HB after hijama (± SD) 10.9 (± 1.5) 10.7 (± 1.7) 10.8 (± 1.5)
Mean difference (95% CI) –0.12 (–0.33 to 0.07) –0.06 (–0.25 to 0.13) –0.17 (–0.55 to 0.20)
p value 0.198 0.553 0.355
Red blood cell (RBC) count
Number of cases 99 58 31
Mean RBC before hijama (± SD) 4.4 (± 0.5) 4.4 (± 0.6) 4.4 (± 0.6)
Mean RBC after hijama (± SD) 4.5 (± 0.6) 4.4 (± 0.6) 4.5 (± 0.6)
Mean difference (95% CI) –0.80 (–0.12 to –0.39) –0.04 (–0.10 to 0.02) –0.04 (–0.17 to 0.08)
p value 0.000 0.214 0.495
Citation: Mourad SA, Al-Jaouni SK (2016) The Effect of Wet Cupping on Blood Haemoglobin Level. Altern Integr Med 5: 217. doi:
10.4172/2327-5162.1000217
Page 4 of 6
Altern Integr Med
ISSN:2327-5162 AIM, an open access journal Volume 5 • Issue 2 • 1000217

Haematocrit (HCT)
Number of cases 99 58 31
Mean HCT before hijama (± SD) 33.6 (± 3.2) 33.4 (± 3.7) 33.3 (± 4.1)
Mean HCT after hijama (± SD) 34.3 (± 3.8) 33.7 (± 4.4) 33.7 (± 4.1)
Mean difference (95% CI) –0.64 (–0.96 to –0.33) –0.30 (–0.79 to 0.19) –0.45 (–1.44 to 0.54)
p value 0.000 0.226 0.359
Mean corpuscular volume (MCV)
Number of cases 88 56 30
Mean MCV before hijama (± SD) 77.3 (± 7.5) 76.6 (± 7.5) 75.6 (± 7.4)
Mean MCV after hijama (± SD) 77.5 (± 7.6) 76.6 (± 7.8) 75.9 (± 7.1)
Mean difference (95% CI) –0.19 (–0.45 to 0.07) –0.002 (–0.569 to 0.566) –0.29 (–1.34 to –0.57)
p value 0.148 0.995 0.570
Mean corpuscular haemoglobin (MCH)
Number of cases 88 56 30
Mean MCH before hijama (± SD) 25.4 (± 5.8) 25.3 (± 6.9) 25.6 (± 9.1)
Mean MCH after hijama (± SD) 25.5 (± 5.8) 24.4 (± 3.4) 24.2 (± 3.1)
Mean difference (95% CI) –0.06 (–0.18 to 0.05) 0.93 (–0.83 to 2.70) 1.46 (–1.91 to 4.83)
p value 0.287 0.294 0.384
Table 4: Comparison between the HB, RBC, HCT, MCV and MCH levels before and within 3 and 6 months aer hijama, among anaemic
participants only.
Discussion
All the results prove that anaemia is not a side eect of wet cupping,
or hijama. e diversity of the patients included in the study gives it
more strength and easier generalisability, because it contains a wide
spectrum of age and a wide variety of dierent complaints. On the
other hand, it would be better if we had a consistent number of
patients in all of the follow-up results comparisons to have similar
powers in all of them, but that was not possible because of the fact that
it was a retrospective observational study and we had no control or
choice on the investigations done—a drawback of using a retrospective
design. We recommend that future studies use a prospective design. It
will also be benecial to accurately measure the amount of blood
extracted in each session, as this might aect the outcome.
If we compared the results of this study with the previously
mentioned studies, we can say that the results are consistent with the
study by Mahdavi et al. [1]. Clearly those results are dierent from the
case reports that were listed previously. ey all reported very frequent
wet or dry cupping for a long duration followed by the patients
suering from anaemia [2-6]. erefore, the anaemia might be due to
the unusual excessive cupping sessions that were done in those reports.
is is unlikely to happen with the usual wet-cupping procedure as we
described here. Although some hijama practitioners claim that hijama
might be a treatment for anaemia, it was clear in this study that such a
treatment did not improve the HB levels in those who were anaemic at
the beginning of the study.
Conclusion
Wet cupping does not cause anaemia, and it is safe for anaemic
patients; however, it is yet to be proven as a valid treatment for
anaemia.
Acknowledgements
is study was funded by Y.A. Jameel, Scientic Chair of Prophetic
Medical Applications in King Abdulaziz University (Jeddah, Saudi
Arabia). We acknowledge all the sta who work in the Prophetic
Medicine Clinic in King Abdulaziz University Hospital, Dr. Anhar
Gazaz, Dr. Manal Dahlawi, Mrs. Zakeia Abdulsattar, Mrs. Sabria
Kholy, Mrs. Fatmah Ahmed, Dr. Iman Al-Feqy and Ms. Rasha
Ramadan. Special thanks to Mrs. Khadija Lokman for the data entry
and Dr. Nouran Aleyeidi for her help in the data analysis and research
writing.
References
1. Mahdavi MR, Ghazanfari T, Aghajani M, Danyali F, Naseri M (2011)
Evaluation of the Eects of Traditional Cupping on the Biochemical,
Hematological and Immunological Factors of Human Venous Blood. In:
Bhattacharya A, editor. A Compendium of Essays on Alternative
erapy. Rijeka: InTech, Croatia, pp. 67–88.
2. Kim KH, Kim TH, Hwangbo M, Yang GY (2012) Anaemia and skin
pigmentation aer excessive cupping therapy by an unqualied therapist
in Korea: a case report. Acupunct Med 30: 227-228.
Citation: Mourad SA, Al-Jaouni SK (2016) The Effect of Wet Cupping on Blood Haemoglobin Level. Altern Integr Med 5: 217. doi:
10.4172/2327-5162.1000217
Page 5 of 6
Altern Integr Med
ISSN:2327-5162 AIM, an open access journal Volume 5 • Issue 2 • 1000217

3. Lee SJ, Suh YS, Lee YJ, Cho DG, Lee MJ, et al. (2011) Iron Deciency
Anemia due to Long-time Bloodletting Using Cupping. Korean J Fam
Med 32: 56-59.
4. Sohn IS, Jin ES, Cho JM, Kim CJ, Bae JH, et al. (2008) Bloodletting-
induced cardiomyopathy: reversible cardiac hypertrophy in severe
chronic anaemia from long-term bloodletting with cupping. Eur J
Echocardiogr 9: 585-586.
5. Lee HJ, Park NH, Yun HJ, Kim S, Jo DY (2008) Cupping erapy-induced
Iron Deciency Anemia in a Healthy Man. Am J Med 121: e5-e6.
6. Akdogan RA, Akdogan E (2011) An unusual cause of iron deciency
anemia in a healthy man: Hijamah. Turk J Hematol 28: 254-256.
7. WHO (2011) Haemoglobin concentrations for the diagnosis of anaemia
and assessment of severity. Vitamin and Mineral Nutrition Information
System. WHO/NMH/NHD/MNM/11.1.
Citation: Mourad SA, Al-Jaouni SK (2016) The Effect of Wet Cupping on Blood Haemoglobin Level. Altern Integr Med 5: 217. doi:
10.4172/2327-5162.1000217
Page 6 of 6
Altern Integr Med
ISSN:2327-5162 AIM, an open access journal Volume 5 • Issue 2 • 1000217