EFFICACY OF FIRE CUPPING (ḤIJĀMA NĀRIYYA) IN ALLEVIATING SYMPTOMS OF WAJA'AL-MAFĀṢIL-I-KATIF (FROZEN SHOULDER): CASE REPORT

Abstract

ABSTRACT
Background:- Frozen shoulder, also known as adhesive capsulitis, is the major cause of
shoulder pain and disability in the general population. The prevalence is 2-5% in the general
population and 10- 20% in diabetics. It typically affects females aged 40 to 60. In 12% of
cases, both shoulders are affected, although the left shoulder is more frequently afflicted.
Objectives:- In This case study our objective is to evaluate the efficacy of Fire Cupping
(Ḥijāma Nāriyya) in Alleviating Symptoms of Waja‘al-Mafāṣil-i-Katif(Frozen shoulder).
Methods:- A 61-year-old diabetic male patient presented to the OPD of the Regional
Research Institute of Unani Medicine, Srinagar. Over a 4-week period, the affected shoulder
was treated with Ḥijāma Nāriyya (fire cupping) on specific spots three times per week, with
weekly assessments. Result- This study found that regimental therapy Ḥijāma Nāriyya (fire
cupping) effectively reduces pain, stiffness, and increases mobility in the shoulder joint, as
well as enhancing range of motion in frozen shoulder. The patient's VAS scores was decreased and also indicating a decrease in symptoms. Conclusion- The treatment was safe
and bearable, and the patient's quality of life improved significantly. After treatment, there
was a statistically significant decrease in VAS and Improvement in overall shoulder mobility.
KEYWORDS: Frozen Shoulder, Case Report, ḤijāmaNāriyya, fire Cupping, Adhesive
Capsulitis, Unani Management.

Full text

Sheeraz et al. World Journal Of Pharmacy and Pharmaceutical Research
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173
EFFICACY OF FIRE CUPPING (ḤIJĀMA NĀRIYYA) IN ALLEVIATING
SYMPTOMS OF WAJA‘AL-MAFĀṢIL-I-KATIF (FROZEN SHOULDER):
CASE REPORT
Adnan Ali1, Mohammed Sheeraz Mushtaque Ahmed*2, Sadiya Khatoon3 and Sahiba3
1PG Scholar (M.D), Department of Moalajāt, Regional Research Institute of Unani Medicine,
University of Kashmir, Habak, Naseembagh Campus, Hazratbal, Jammu and Kashmir, India.
2Research Officer Level II & Reader, Department of Moalajāt, Regional Research Institute of
Unani Medicine, University of Kashmir, Habak, Naseembagh Campus, Hazratbal, Jammu
and Kashmir, India.
3PG Scholar (M.D), Department of Moalajāt, Regional Research Institute of Unani Medicine,
University of Kashmir, Habak, Naseembagh Campus, Hazratbal, Jammu and Kashmir, India.
ABSTRACT
Background:- Frozen shoulder, also known as adhesive capsulitis, is the major cause of
shoulder pain and disability in the general population. The prevalence is 2-5% in the general
population and 10- 20% in diabetics. It typically affects females aged 40 to 60. In 12% of
cases, both shoulders are affected, although the left shoulder is more frequently afflicted.
Objectives:- In This case study our objective is to evaluate the efficacy of Fire Cupping
(Ḥijāma Nāriyya) in Alleviating Symptoms of Waja‘al-Mafāṣil-i-Katif(Frozen shoulder).
Methods:- A 61-year-old diabetic male patient presented to the OPD of the Regional
Research Institute of Unani Medicine, Srinagar. Over a 4-week period, the affected shoulder
was treated with Ḥijāma Nāriyya (fire cupping) on specific spots three times per week, with
weekly assessments. Result- This study found that regimental therapy Ḥijāma Nāriyya (fire
cupping) effectively reduces pain, stiffness, and increases mobility in the shoulder joint, as
well as enhancing range of motion in frozen shoulder. The patient's VAS scores was
Received: 06 November 2024 Revised: 26 November 2024 Accepted: 16 December 2024
Corresponding Author: Mohammed Sheeraz Mushtaque Ahmed
Address: Research Officer Level II & Reader, Department of Moalajāt, Regional Research Institute of Unani
Medicine, University of Kashmir, Habak, Naseembagh Campus, Hazratbal, Jammu and Kashmir, India.
Email ID: dr.adnan.ali999@gmail.com
World Journal Of Pharmacy and Pharmaceutical
Research
ISSN: XXXX-XXXX
Case Study
Impact Factor: 0.000
2025
Volume: 02
Issue: 01
Page: 173-180

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decreased and also indicating a decrease in symptoms. Conclusion- The treatment was safe
and bearable, and the patient's quality of life improved significantly. After treatment, there
was a statistically significant decrease in VAS and Improvement in overall shoulder mobility.
KEYWORDS: Frozen Shoulder, Case Report, ḤijāmaNāriyya, fire Cupping, Adhesive
Capsulitis, Unani Management.
INTRODUCTION
The periarthritis affecting the periarticular soft tissues of the shoulder, also known as
adhesive capsulitis or frozen shoulder, is one of the most prevalent causes of shoulder
discomfort and impairment in the general population.1,2 Women and those between the ages
of 40 and 60 are the groups most affected. It is more likely to impact the left
shoulder.3Twelve percent of people have been discovered to have problems with both
shoulders. Rarely does the same shoulder recur.4In the general population, frozen shoulder
affects around 3% of people and peaks between the ages of 40 and 70,5 whereas 10 to 36% of
those with diabetes mellitus also have it.6 The shoulder capsule thickens and develops
adhesions, which are taut, rigid bands of tissue, in cases of frozen shoulder. The shoulder
joint's range of motion is often restricted by a decrease in synovial fluid in the joint.7 It is
common in clinical practice to diagnose frozen shoulder in any patient who has a painful, stiff
shoulder.8It is yet unknown what causes sticky capsulitis. However, the development of
adhesive capsulitis is linked to a number of medical conditions, including autoimmune
diseases, diabetes, age, thyroid disease, chest or breast surgery, impingement syndrome,
pulmonary disease, myocardial infarction, and cerebrovascular accident, as well as prolonged
immobilisation.9-13Although it can appear as early as six months or as late as ten years,
adhesive capsulitis often appears between twelve and forty-two months. Frozen shoulder
syndrome was divided into "primary" and "secondary" categories by Lundberg.14Patients who
come with no noteworthy symptoms in their history, clinical examination, or radiographic
evaluation to account for their discomfort and lack of mobility are said to have primary
adhesive capsulitis. Patients with secondary adhesive capsulitis, on the other hand, often
report upper extremity injuries or surgery before shoulder symptoms appear.15
Concept of Ḥijāma in the unani system of medicine
One of the regular therapies that works well for reducing pain and soreness is cupping
therapy, also known as Ḥijāma. It is a tried-and-true method of treating carpal tunnel

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syndrome, arthritis, fibromyalgia, and joint pain without resorting to intrusive procedures.
According to the Unani medical system, the primary goals of Ḥijāma are diversion of matter
(Imala-e-mawad, Aleeluzwa se uzwa-e-shirki ki janib) to the related organ, evacuation of
matter (Ikhraj-e mawad/Tanqiya Ghalba-e-khilt) when the cause of pain may be
accumulation of morbid matter, Taskeen alam (to relieve pain), Tehleele auram (to reduce
inflammation), and Tehleele riyah and Taskheene muqam (local calorific).16
MATERIAL AND METHODS
This study was conducted in 2024 at the Regional Research Institute of Unani Medicine,
Srinagar, University of Kashmir. The study's results were published without divulging
patient identities, as per their agreement. A ḤijāmaNāriyya kit with medium-sized glass fire
cups was used to apply the cups to the afflicted region.
Case History
A 61 year old Diabetic male patient presented with complaint of pain and stiffness in the left
shoulder for the last 6 month. He had been treated by his family physician, who had
prescribed him analgesic and anti-inflammatory medications with physiotherapy, and he
continued to worsen on these treatments. He then came to the Regional Research Institute of
Unani Medicine, Srinagar, University of Kashmir, with restricted movements in the left
shoulder and acute pain in the posterior arm. He found it difficult to dress and comb his hair
using his left hand, and the ache worsened by moving in arms and lying on the affected arm.
History of the patient The pain started off slowly, a condition which is commonly referred to
as insertion of the deltoid or deltoid muscle region and bicipital tendon. Movement of the
shoulders had aggravated the pain especially when doing external rotation and direct pressure
over the affected side during sleeping, and could be relieved by limiting extremity use. The
patient complained of soreness in the proximal upper back and neck that may have been due
to compensatory overuse of accessory muscles. He complained of inability to put on a coat,
to reach into the hip pocket for a wallet, and to comb his hair as if having a frozen shoulder.

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Examination
Table.1:
Category
Findings
Diagnosis
Primary adhesive capsulitis (Frozen shoulder), Phase Two
Symptoms
Stiffness and limited mobility in left shoulder, pulling sensation in
antagonist muscle groups (trapezius, levator scapulae, scalene
muscles)
Previous History
No prior symptoms, trauma, or surgery related to shoulder joint
Cervical Spine
Movements
Right lateral flexion, right rotation, and flexion induced pulling
sensation in antagonist muscles
Facet Joint Findings
Aberrant motions with tenderness in left C2-3, C7-T1, T3-4 facet
joints on static and motion palpation
Active ROM (Left
Shoulder)
- Internal Rotation: 15°
- External Rotation: 10°
- Flexion: 20°
- Extension: 20°
- Abduction: 10°
Resisted Strength
(Left Shoulder)
- Flexion: 2/5
- Abduction: 2/5
- Internal Rotation: 2/5
- External Rotation: 2/5
Passive ROM (Left
Shoulder)
5° more than active ROM in each direction
Joint Mobility
Restricted and painful posterior and postero-inferior movements at
the left glenohumeral joint
Tenderness
Severe point tenderness over the left deltoid tubercle
Intervention of therapy
In the present case study, procedure was explained to the patient in detailed before the
intervention and written consent was obtained from the patient. The treating physician first
gently massage manually with Roghan-i-Bābūna on affected part for 5 min and then applied
4 (Ḥijāma Nāriyya)fire cups on the following Ḥijāma points.One cup on the anterior aspect
of Left shoulder, one cup posterior, one cup lateral side of the shoulder and one cup superior
aspect. Follow up and assessment was done on alternate days i.e three days in a weeks for
two weeks and during the treatment, no adverse effects like burning, erythema, blisters,
itching were noticed and treatment was safe and tolerable to the patient.
ROM: Range of Motion
At baseline, pain, tenderness, and stiffness were noted using Visual Analog Scale (VAS) for
pain. After some necessary briefing to the patient, he was told to rate his pain, tenderness, and
stiffness at shoulder joint on a linear scale of 1 to 10 after every sitting for two weeks. At

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baseline, VAS scores for pain, tenderness, and stiffness were 9, 8 and 9 respectively. After 4
weeks of therapy, VAS scores for pain, tenderness, and stiffness were reduced from9 to 1
respectively with 87.5% improvement in pain, and upto 95% improvement in tenderness and
stiffness.
Follow up and outcome measures
The treatment was given every week up to 28 days, follow up on every week for four weeks;
and findings and outcomes were monitored and patient was then assessed on days 0, 7th 14th,
21st and 28th dayof the treatment with the help of objective parameters i.e, Visual Analogue
Scale (VAS) and WOMAC Scores for measurement of pain and active range of motion
(Observing intensity of joint stiffness during the daily life activities). The total VAS was 9
(pain is very severe at this score) at Baseline 0th day-9, 7th day-8, 14th day-6, 21st day-4 and
on 28th day was 1, pointing to reduction in the severity of symptoms.
RESULTS AND DISCUSSION
In the present case study, the treating physician first gently massage manually with Roghan-i-
Bābūna on affected part for 5 min and then applied 4 Ḥijāma sterile glass fire cups on the
following Ḥijāma points. One cup on the anterior aspect of Left shoulder, one cup posterior,
one cup lateral side of the shoulder and one cup superior aspect. Follow up was done on
alternate days at every week for two weeks. The patient was assessed on the first, seventh,
and fourteenth days of treatment using objective parameters such as the Visual Analogue
Scale (VAS) for pain measurement and active range of motion scores (observing the intensity
of joint stiffness during daily activities). Although no trigger point was found in our patient,
tender points were treated. A very promising improvement was noted in the range of motion
of the shoulder and pain on VAS scale. At the affected shoulder the WOMAC was apply to
assessment of joint range of movements Measurement was done for the active and passive
motion of each of these movements from baseline and to end of the treatment on i.e; 0th, 7th,
14th, 21st, and 28th day. There was a marked improvement in the quality of life and
improvement in VAS score and WOMAC Score for pain, tenderness, and stiffness (Table 2).
Outcomes of the case study
The patient was asked to rate his knee pain on VAS scale and WOMAC scale at the Baseline,
7th, 14th, 21st, and 28th day, for four weeks as shown in Table 2.

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Table.2:
Parameters
Baseline 0thday
7th day
14th day
21st day
28th day
VAS
9
8
6
4
1
WOMAC
90
56
44
34
18
WOMAC Scale
The WOMAC questionnaire consists of three sub-scales: pain (five questions), stiffness (two
questions), and physical function (17 questions). The sub-scale scores range from 0 to 20 for
pain, 0 to 8 for stiffness, and 0 to 68 for physical functioning. The total WOMAC score is
computed by combining the items from all three sub-scales. (0-96). Higher WOMAC ratings
indicate increased pain, stiffness, and functional limitations. Table 3 displays the WOMAC
baselinescores on the 0th, 7th, 14th, 21st, and 28th days of therapy.
Table 3: WOMAC Scale Scores
Parameters
Baseline 0thday
7th day
14th day
21st day
28th day
Rt Shoulder joint
46
40
26
20
18
Lt Shoulder joint
90
56
44
34
18
Visual analog scale Figure.1
The VAS scale is used to measure the level of pain, with 0 indicating no pain at all and 10
indicating severe pain that requires immediate medical intervention.[17]
CONCLUSION
In this case study, we have tried to illustrate the potentials of “Ḥijāma Nāriyya (Fire cupping)
therapy” in a diabetic patient with a frozen shoulder. The frozen shoulder was treated
successfully through Ḥijāma Nāriyya (Fire cupping) therapy, one of the unique modes of
treatment described in the Unani system of medicine. However, further researches with
randomised controlled studies on a large scale are required to elaborate the effectiveness of
this modality of treatment.[18]

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Declaration of patient consent
The authors confirm that all appropriate patient consent forms have been submitted to them.
The patient signed these forms, agreeing to the journal's disclosure of their clinical data.
Although every effort will be taken to protect the patient's identity, complete anonymity
cannot be guaranteed. The patient understands that their names and initials will not be
published.
ACKNOWLEDGEMENT
The authors are thankful to Dr. Irfat Ara, Deputy Director of the Regional Research Institute
of Unani Medicine in Srinagar, as well as the Library staff, for their invaluable assistance and
provision of a wide range of literature related to this manuscript while writing this case report.
Conflict of Interest
None.
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