PG on Bekam

Traditional And Complementary Medicine Division

Ministry of Health Malaysia.

Traditional and Complementary Medicine Practice Guideline on

Bekam

First edition 2011

Copyright 2011, Ministry of Health Malaysia.

All rights reserved. No part of this book may be reproduced, stored, or transmitted in any form or by any means, electronic

or otherwise, including photocopying, recording, internet or any storage and retrieval system without prior written permission

from the publisher.

Published by:Traditional and Complementary Medicine Division

Ministry of Health Malaysia

ISBN 978-967-10715-2-6

Cover design by: Mohd Afendy Baharuddin

Traditional and Complementary Medicine DivisionMinistry of Health Malaysia

Acknowledgements 1. Introduction 2. Definition 3. Types of Bekam and Treatment Concept

3.1 Bekam Kering/Bekam Angin (Dry Cupping)3.2 Bekam Basah (Wet Cupping)

4. Treatment Criteria4.1 Accepted Age4.2 Indications4.3 Contraindications4.4 Recommended Time4.5 Precautions4.6 Side Effects and Complications

5. Treatment Procedures5.1 Apparatus5.2 Points of Application5.3 Standard Precautions5.4 Duration5.5 Monitoring5.6 Referral

6. Documentations7. Practice Facilities8. Conclusion9. Appendices

Appendix 1: Sterilization and Disinfection TechniquesAppendix 2: Standard Precautions in Health CareAppendix 3: Disposal of Infectious Clinical WasteAppendix 4: Environmental Quality Act 1974Appendix 5: Bekam Clerking FormAppendix 6: Consent FormAppendix 7: Bekam Apparatus

10. ReferencesEditorial Board

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CoNTENTS

Acknowledgements

Special thanks to every individual and organizations that have in

one way or another contributed materials, comments and advices

during the preparation of this practice guideline on Bekam.

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Traditional and Complementary Medicine Practice Guideline on Bekam

1. Introduction

Bekam (or cupping) is a form of traditional medicine practice found in many cultures worldwide. It involves placing cups containing reduced air or pressure (creating suction or a relative vacuum) on the skin. It is known in other languages as badkesh, bahnkes, nuhang, bantusa, kuyukaku, gak hoi, hijamah and many other names [20].

Bekam practices is thought to date back as early as 3000 B.C., the earliest record is from the Ebers Papyrus, one of the oldest medical textbooks in the world. The book describes the systematic use of cupping by the early Egyptians, as far back as 1500 B.C. In China, archeologists found evidence of cupping dating back 1000 B.C. Cupping was mentioned in the writing of Hippocrates and was practiced by the Greeks in 400 B.C [8,21,25].

Prominent historical persons advocating cupping as one of the treatment methods includes Galen (a prominent Roman physician and philosopher of Greek origin) [21,25], Avicenna (or also known as Ibn Sinna, preferred wet cupping), Matre de Monderville (surgeon to King Philippe of France who wrote a textbook on surgery, including a long section on cupping, detailing the points in cupping), and The Prophet Muhammad (Peace be Upon Him), who said, “Healing is in three things: A gulp of honey, cupping and branding with fire (cauterizing). But I forbid my followers to use branding with fire.” [2,3,22,23,24] . Imam Ahmad recorded in his Musnad that the Prophet Muhammad (Peace be Upon Him) said, “Verily, cupping is among your best remedies.” [2] During The Prophet Muhammad’s (Peace be Upon Him) time, cupping is a common practice.

The aim of bekam is to extract blood that is believed to be harmful from the body which in turn rids the body of potential harm from symptoms that leads to a reduction in well being [23]. It is reputed to:

Drain excess fluids and toxins• Loosens adhesions• Lift connective tissue• Enhance circulation in stagnant musculature and fascia• Stimulate the peripheral nervous system•

Bekam is claimed to work via a range of mechanisms from counter-irritation to detoxification, but these are mere theories that have not been tested or investigated. Results of several studies appear to be encouraging and the authors conclude that “cupping therapy effectively relieves symptoms and pain...” [16].

Bekam helps in the treatment of various ailments. However, it does not cure diseases. Rather, it helps to alleviate or reduce the effects/symptoms and helps in controlling the disease and acts as

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a complementary medicine. Bekam is usually done as a complement to other practices such as massage, and commonly, an herb preparation is prescribed to be taken after bekam.

Currently, any person can claim themselves as a bekam practitioner. However, due to its invasive nature, there is a need to regulate the practice. Ideally, a bekam practitioner should have a proper training and adequate working experience. For practitioners with a Diploma, they should have at least six months of work, under supervision, or equivalent to 40 case presentations. In future, the practice can only be performed by a practitioner with either a Diploma or Bachelor’s Degree in the relevant studies.

The emphasis on training is appropriate in this current world and age due to the emergence of various blood borne infectious diseases such as HIV/AIDS, Hepatitis B and Hepatitis C. It is therefore important that a proper guideline, which focuses on proper handling of patients and clinical wastes, be developed for implementation to ensure the safety of both practitioners and patients alike.

2. Definition

Bekam is the Malay word for cupping.Cupping is a treatment in which evacuated glass cups are applied to intact/scarified skin in

order to draw blood toward/through the surface. It is used for disorders associated with an excess of blood, one of the four humors of medieval physiology.

* The American Heritage Dictionary of the English Language

3. Types of Bekam and Treatment Concept [1,4]

There are generally two types of bekam;

3.1 Bekam kering/bekam angin (dry cupping/wind cupping) Evacuated cups are applied to the intact skin. There is no bleeding or scarification of the

skin.

3.2 Bekam basah (wet cupping) In this method, evacuated cups are applied to the scarified skin and blood is drawn

through the wound to be evacuated.

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Table 1: Types of bekam, treatment concept and purpose of treatment. [1,4]

Type

Treatment concept

Purpose of treatment

Bekam Kering (Dry Cupping)

Wellness

Bekam Basah (Wet Cupping)

Therapeutic

• To draw inflammation away from deep parts toward thesurface,tomakemoreaccessibletomedicine

• Todivert an inflammatory process to neighbouring and lessimportantorgan

• Toinfusewarmthandbloodintoanaffectedorgananddispersevapourfromit.

• Toalleviatepain.

4. Treatment Criteria

4.1 Accepted age [1,2,4]: Patients who wish to receive bekam therapy should be between 10 to 65 years old. For

those who are above 65 years old, bekam may be performed on him/her if he/she is in a good state of health.

4.2 Indications [1,2,4,5,9,10,11,12,13,14,15]: Bekam is indicated in the treatment of a number of musculo-skeletal conditions as well

as a general measure to maintain and promote well-being. It is used in conditions such as listed below;a. For pain relief (chronic and acute)b. In inflammatory conditions (e.g. in rheumatoid arthritis)c. For mental and physical relaxationd. As a means of deep tissue massagee. For menstrual pain, amenorrhoea or irregular mensesf. In gastrointestinal disorder such as gastritis and indigestiong. In lung disorders such as chronic cough and asthmah. To relieve insomniai. In cases of paralysis

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Table 2: Contraindications for bekam therapy [1,2,4,5].

Relativecontraindications

Absolute contraindications

• Inpregnantandmenstruatingwomen• Overthebreastinwomen• Overanybonyprominences• Inareasofinflammationandskindisorders• Inareaswithcutskin• Communicablediseases

• InHIVandHepatitisinfections–bekammayonlybeperformediftheapparatususedaredisposableones,andifthepractitionerobservesastrictinfectiousdiseasecontrolmeasures

• Otherinfections–bekammaybeperformedoncetheinfectionhasclearedup(especiallyfever)

Bekam Basah

• Cancerpatients• Overvaricoseveinsandlymph

nodes• Haemophiliapatients• Patientswithlowplatelet

count(e.g.inimmunethrombocytopaenia)

• Patientsonanticoagulationorantiplatelettreatment(e.gonaspirin,warfarinorheparin)

• Inpatientswithbonefractureor muscle spasms

• Atsitesofdeepveinthrombosis(DVT)

• Atsitesofulcers,overarteriesorwherepulsescanbefelt

• Cancerpatients• Overvaricoseveinsandlymph

nodes• Inpatientswithbonefracture

or muscle spasms• Atsitesofdeepvein

thrombosis(DVT)• Atsitesofulcers,overarteries

orwherepulsescanbefelt• Inpatientswithbleeding

disorders(e.ghaemophilia,thrombocytopaenia)

Bekam Kering

4.3 Contraindications: Contraindications for bekam are as listed in the table below.

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4.4 Precautions [2,4]:a. Precautions should be undertaken when performing bekam therapy in these

conditions;b. If done over the neck may induce amnesiac. Patients with diabetes mellitus d. Patients with cardiovascular diseasese. Patients with infectious diseases

Requires the use of disposable equipments and proper disposal of clinical waste • (blood/body fluid soiled linens, cotton wool etc.) and contaminated items (Appendix 2 and 3).Develop and implement control measures, to eliminate or minimize the risks of • exposure or transmission.Supply, maintain and use protective equipment to reduce the risk of infection • (gloves, goggles, aprons).

4.5 Side Effects and Complications :a. Discomfort at site of applicationb. Light-headedness or syncope [10,11]

c. Excessive bleedingd. Anaemia [17,18]

e. Blisters and burns (if using fire to heat up the air inside the cups) [19]

f. Infections at scarified areas – which may arise later after therapyg. Visible marks at the cupping site

5. Treatment Procedures

5.1 Apparatus :a. Cups; The cups used in bekam may be made from various materials. Traditionally it is made

from buffalo horn, bamboo, copper or porcelain. Modern cups are made from glass. It has a valve at the top of the cup in which a pump is attached to remove the air inside the cups obviating the need to heat the air inside the cups prior to application. These cups should be sterilized after each treatment session. The used cups should not be applied at different sites or on different patients. Be sure to choose a cup size that is suitable for the area to be applied.

b. Sterile lancets; Only sterile, single use, disposable lancets are to be used to puncture the skin in

bekam basah.

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5.2 Points of Application [1,2,4,5]: The table below provides a list of common sites of application and its indications.

5.3 Standard precautions:a. Practitioners are required to observe standard precautions in health care (Appendix

2) at all times and all waste management have to adhere to clinical waste management (refer to Guidelines on Handling and Management of Clinical Wastes in Malaysia, Department of Environment, 2009, and Appendix 3).

b. To maintain sterility and prevent infection, disposable lancets should be used for all bekam basah procedures.

c. The skin at the area to be treated with bekam basah should be cleansed with 70% isopropyl alcohol and allowed to dry before scarification.

d. All instruments used should be disinfected and sterilized according to the recommended methods of sterilization and disinfection (Appendix 1) prior to use on individual patients.

e. Practitioners are required to use personal protective equipments, especially gloves during treatment procedure and must always observe good personal hygiene.

Site

Nape of neck

Overthetwoposteriorneckveins

Betweentheshoulderblades

Underthechin

Legs

Innerthighs

Frontofthighs

Behindhips

Behindknee(poplitealspace)

Overanklebone(maleoli)

Overoutersideofhips

Overthebuttocks,towardsanus

Indications

Heavinessofeyelids,eyeitchiness,badbreath

Headtremor,andotherconditionsofthehead(face,

teeth,ears,eyes,throat,nose)

Paininupperarmsandthroat,torelaxcardiacsphincter

of the stomach

Teeth,throat,cleansesheadandjaws

Cleansestheblood,provokesmenstrualflow

Inflammatorymassesinupperpartofthigh,pustules,

podagra,piles,bladder,uterus,renalcongestion

Inflammationoftesticles,legulcers

Inflammatoryconditionsandulcersofbuttocks

Chronicabscesses,septiculceroflegandfoot

Suppressedmenses,sciatica,podagra

Sciatica,podagra,piles,inguinalhernia,tissueswithinhip

joints

Drawshumorfromalloverthebody,fromhead,benefits

theintestines,curessuppressedmenses

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5.4 Duration [2,4]:a. Each cup should only be applied for 10 to 15 minutes, or until the site under the cups

begins to appear reddish.b. An average of 10 cups should be applied per procedure.c. The same site can only be cupped 3 times, at which a new bleeding point is made each

time. The maximum application per site is 7 times.

5.5 Monitoring :a. Patients who underwent bekam therapy should be monitored for development of

complications or adverse events.b. The blood loss/drawn in bekam basah is to be observed and treatment should be

abandoned if there is excessive bleeding. Each procedure should not draw more than 10 ml/kg of blood (e.g. in a person weighing 45 kg, blood loss should be 450 ml or less). A maximum of 450 ml blood loss is allowed per procedure.

c. Post-procedure, the bleeding time should not exceed 15 minutes. Patients with suspected prolonged bleeding time should be referred to the medical professional as soon as possible after undertaking appropriate measures to control the bleeding (e.g. pressure bandage).

d. All patients who underwent bekam basah should be monitored for at least 15 minutes post-procedure and should be questioned about their occupation. Patients in whom fainting would be especially hazardous to themselves or to others (e.g. pilots, surgeons, bus drivers) should probably refrain from work for up to 12 hours post-procedure, especially if the total amount of blood drawn is the maximum allowed.

5.6 Referral: a. Emergency medical services must be contacted immediately in the event of

cardiorespiratory collapse (e.g. 999, St. John’s Ambulance). b. Patients should be referred to the nearest available healthcare facility in event of

occurrence of complications or adverse events with adequate information or account of events and procedures done.

c. Appropriate measures should be taken whilst awaiting the arrival of medical help (e.g. provision of basic life support or first aid, or call for help).

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6. Documentations

6.1 The number and type of cups used and its placement sites must be recorded.6.2 The estimated blood loss/drawn in bekam basah is to be documented clearly. 6.3 Patients who underwent bekam therapy should be monitored for development of

complications or adverse events and recorded accordingly. Measures taken should be documented clearly.

6.4 Consent must be obtained prior to commencement of therapy. Patients should be competent to give consent of care. In case of minors (aged 18 years and below) and mentally impaired adults, practitioners requires the consent of a guardian.

7. Practice Facilities

7.1 Each practice facility should have a dedicated room for treatment which is equipped with a treatment bed, equipment tray/trolley, and proper waste bins (refer Appendix 3: Figures 3, 4, 5 and 6). Segregation of clinical wastes shall be done using the standard waste bag with appropriate colour coding (refer to Guidelines on Handling and Management of Clinical Wastes in Malaysia, Department of Environment, 2009).

7.2 Treatment rooms should be well lighted and ventilated.7.3 There should be a regular cleaning schedule which is diligently adhered to keep the

environment clean and safe.7.4 There should be proper management of spillage, soiled/contaminated linen, and disposal

of sharps and clinical waste (refer Appendix 2).

8. Conclusion

Bekam is an invasive procedure with potential for transmission of communicable diseases. Due to this invasive nature, there is a need for the development of a guideline to assist bekam practitioners on the proper practices and practice facility set up to prevent or minimize risk of transmission of communicable diseases. This guideline also encourages all practitioners to adhere to the code of ethics and code of practice, and maintains a high level of medical professionalism. It is also hoped that with the birth of this guideline, the safety and well-being of both patients and health personnel are protected.

Appendices

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(Source: WHO - GPA/TCO/HCS/95/16 p.15.)

Appendix 1: Sterilization and Disinfection Methods

Methods of sterilization

Steam sterilization is the most widely used method for instruments made of metal. It is nontoxic, inexpensive, sporicidal and rapid if used in accordance with the manufacturer’s instructions (e.g. time, temperature, pressure, wraps, load size and load placement). Steam sterilization is only fully effective when free from air, ideally at 100% saturated steam. Pressure itself has no influence on sterilization, but serves as a means of obtaining the high temperatures required.

Recommended sterilizing temperatures and times for steam under pressure, and for dry heat, are shown in the table below.

Instruments made of rubber or plastic which are unable to stand the high temperature of an autoclave can be sterilized chemically, at appropriate concentrations and ensuring adequate immersion times (e.g. 6% stabilized hydrogen peroxide for six hours).

It should be noted that boiling needles in water is not sufficient for sterilization, nor is soaking in alcohol, since these methods do not destroy resistant bacterial spores or certain viruses.

Recommended methods of sterilization

* Steam under pressure (e.g. autoclave, pressure cooker)

Required pressure: => 15 pounds per square inch (101 kilopascals)

Time

30 minutes

15 minutes

10 minutes

3 minutes

Time

120 minutes

60 minutes

30 minutes

Temperature

115°C

121°C

126°C

134°C

Temperature

160°C

170°C

180°C

* Dry heat (e.g. electric oven)

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Methods of Disinfection

A high level of disinfection is achieved when instruments are boiled for 20 minutes. This is the simplest and most reliable method of inactivating most pathogenic microbes, including HIV, when sterilization equipment is not available. Boiling should be used only when sterilization by steam of dry heat is not available. Hepatitis B virus is inactivated by boiling for several minutes; HIV, which is very sensitive to heat, is also inactivated by boiling for several minutes. However, in order to be sure, boiling should be continued for 20 minutes.

Chemical disinfection is used for heat-sensitive equipment that may be damaged by high temperatures. Most disinfectants are effective against a limited range of microorganisms only and vary in the rate at which they destroy microorganisms. Items must be dismantled and fully immersed in the disinfectant. Care must be taken to rinse disinfected items with clean water so that they do not become recontaminated. Chemical disinfectants are unstable and chemical breakdown can occur. They may also be corrosive and irritating to skin. Protective clothing may be required. Chemical disinfection is not as reliable as boiling or sterilization. The agents include:

chlorine-based agents, e.g., bleach• aqueous solution of 2% glutaraldehyde• 70% ethyl or isopropyl alcohol.•

(Source: WHO - GPA/TCO/HSC/95/16 p.16 and WHO AIDS Series 2, 2nd edition, p.3, 1989.)

Appendix 2: Standard Precautions in Health Care

* Standard Precautions. AIDS/STI Section, Ministry of Health, 2002.

STANDARD PRECAUTIONS PRACTICES

Standard Precautions involve work practices which avoid direct contact with blood and all body fluids and guard against needle-stick injuries and exposures to mucous membranes. The infection control practices should include:

1. Hand washing. Hand washing is a process of removing of transient, potentially pathogenic micro-organisms

from the hands and it is a critical factor in the management of patients with HIV/AIDS. Hands should be washed routinely;

Before and after coming into contact with patient• When they are contaminated with blood and body fluids•

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Figure 1: Hand Washing Technique.

After removing gloves• Before and after each patient-care procedure,•

2. Appropriate use of personal protective equipment (PPE) including gloves, mask, eye goggles, face shield and gown.

a. GlovesSterile surgical gloves should be worn for all surgical and invasive procedures• Disposable latex/rubber gloves should be worn when touching blood, body fluids, • secretions, mucous membranes, non-intact skin, excretions, and contaminated items.Gloves should be promptly removed after touching these materials.• Change gloves in between procedures and between patient contact.• Gloves should be discarded after a procedure.• Hands should be washed immediately after removing gloves.•

Palm to palm. Right palm over left hand and vice versa.

Palm to palm, fingers interlaced.

Back of finger to opposing palms with fingers interlocked.

Rotational rubbing of right thumb clasped in left palm and vice versa.

Rotational rubbing, with clasped fingers of right hand in left palm and vice versa.

3

6

2

5

1

4

Hands should be properly washed following the effective hand-washing technique as shown in Figure 1.

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b. Mask, eye goggles or face shields Mask, eye goggles or a face shield should be worn to protect mucous membranes of

the eyes; nose; and mouth only when performing patient-care procedures that are likely to generate splashes of blood, body fluids, secretions and excretions. Examples of such procedures are irrigation and suction procedures, delivery and dental procedures etc.

c. Plastic aprons/gowns

A separate disposable apron/gown should be worn for each patient. It is worn to prevent soiling of clothing when performing patient-care procedures that are likely to generate splashes of blood, body fluids, secretions or excretions.

3. Use of disposables and proper cleaning, disinfection and sterilization of patient-care equipment.

4. Proper housekeeping and management of spillage.

a. Proper housekeeping There should be a regular cleaning schedule which is diligently adhered to keep the

environment clean and safe.b. Management of spillage

The spillage should be dealt with as soon as possible.• Disposable latex/rubber gloves should be worn throughout the procedure.• Rubber boots and plastic disposable overshoes may be worn if a large area is • grossly contaminated with the spillage.Chloride granules to cover the spillage and left for 5-10 minutes. If it is a large • spillage, it may be covered with suitable absorbent material. The spillage should be wiped up using paper towels or suitable absorbent material. • Avoid direct contact between gloved hands and the spillage.The area should be mopped with Sodium hypochlorite (Chlorox)* 1 : 100.• For a large spill, a mop can be used to wipe instead, but the mop needs to be • disinfected with sodium hypochlorite and rinsed thoroughly.Broken glass pieces should be carefully swept with a broom and discarded into a • sharps container.Equipments used for management of spillage should be decontaminated.•

5. Management of soiled/contaminated laundrya. Staff handling ward linen should wear disposable latex/rubber gloves and masks at all

times. Handling should be done only when necessary and no sorting is allowed.b. Used linen should be placed into laundry bags at site.c. Soiled linen soaked with blood or body fluid should be placed into appropriate laundry

bags with biohazard label.

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6. Disposal of sharps and infectious wastes

a. Disposal of sharpsSharps containers must be placed at the work sites.• Needles should not be removed from disposable syringes, recapped, bent or • broken by hands.Sharps (loose needles, scalpels, blades, razors, IV administration sets, glass pieces • and ampoules) should be picked up with forceps and discarded into sharps containers.Sharps containers should not be more than two-thirds full before disposal.•

b. Disposal of infectious wastesWastes contaminated with blood and blood products (including blood packs) and • soiled dressings should be discarded into yellow-coloured bags, ensuring that no leaking of fluid from the bag.Excreta and other body fluids should be discarded directly into the toilet or into • the sluice that is directly connected to the sewage system.

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Start

End

CentralCollectionArea

InfectiousClinicalWaste

Incineration

Non-sharps

YellowWastebag

Sharps

Sharps

Figure 2: Flow Chart Disposal of Infectious Clinical Wastes

Appendix 3: Disposal of Infectious Clinical Wastes

* Standard Precautions. AIDS/STI Section, Ministry of Health, 2002.

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Figure3:Exampleofclinicalwastebinwithyel-lowbag(forincinerationonly).

Figure4:Exampleofsharpsbin.

Figure5:Exampleofblackgeneralwastebag.

Figure6:Exampleofbluewastebag(wastesforautoclavingorequivalenttreatment).

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Appendix 4: Environmental Quality Act 1974

Section 24 - Restrictions on pollution of the soil.

(1) No person shall, unless licensed, pollute or cause or permit to be polluted any soil or surface of any land in contravention of the acceptable conditions specified under section 21.

(2) Notwithstanding the generality of subsection (1), a person shall be deemed to pollute any soil or surface of any land if –

(a) he places in or on any soil or in any place where it may gain access to any soil any matter whether liquid, solid or gaseous; or

(b) he establishes on any land a refuse damp, garbage tip, soil and rock disposal site, sludge deposit site, waste-injection well or otherwise used land for the disposal of or a repository for solid or liquid wastes so as to be obnoxious or offensive to human beings or interfere with underground water or be detrimental to any beneficial use of the soil or the surface of the land.

(3) Any person who contravenes subsection (1) shall be guilty of an offence and shall be liable to a fine not exceeding one hundred thousand ringgit or to imprisonment for a period not exceeding five years or to both and to a further fine not exceeding one thousand ringgit a day for every day that the offence is continued after a notice by the Director General requiring him to cease the act specified therein has been served upon him.

[Am. Act A953:s.12]

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Appendix 5: Bekam Clerking Form

SAMPLE

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SAMPLE

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Appendix 6: Consent Form

SAMPLE

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Appendix 7: Bekam Apparatus

Figure7:Exampleofamodernbekamapparatus.

Figure8:Exampleofacommonlyprescribedherbpreparationtobeusedafterbekam.

EXAMPLE

EXAMPLE

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Figure9:Bamboobekamset.

Figure10:Traditionalbekamset.

Figure11:Traditionalglasscupsandscarificator.

Figure12:Glasscupwithbuiltinsuckingtube.

Figure13:Hornsusedinbekam.

Figure14:Traditionalcuppingset.

EXAMPLE

EXAMPLE

EXAMPLE

EXAMPLE

EXAMPLE

EXAMPLE

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10. References

1. TheCanonofMedicinebyAvicenna.AdaptedbyLalehBakhtiar.GreatBooksoftheIslamicWorld,1999.2. Cupping:APracticeofTheProphet&AMiraculousWayofTreatment.CompiledbyShihabAl-BadryYasin.

MinhajAn-NubuwwahBookstore,2005.3. MedicineoftheProphet.TranslatedbyPenelopeJohnstone.TheIslamicTextsSociety,1998.4. TheTraditionalHealer’sHandbook,aClassicGuidetotheMedicineofAvicenna.HakimG.M.Chisti.

HealingArtsPress,1988.5. RawatanUmumDalamPerubatanIbnSina.Dr.MohdHilmiB.Abdullah.PustakaHilmi,2007.6. StandardPrecautions.AIDS/STISection,MinistryofHealth,2002.7. JLTurk,ElizabethAllen.BleedingandCupping.AnnalsoftheRoyalCollegeofSurgeonsofEngland(1983).

Volume65.8. Dr.NurdeenDeuraseh.HealthandMedicineintheIslamicTraditionBasedontheBookofMedicine

(KitabAl-Tibb)ofSahihAl-Bukhari.JISHIM,2006.9. Jong-InKim,MyeongSooLee,Dyong-HyoLee,KateBoddy,EdzardErnst.CuppingforTreatingPain:A

SystematicReview.Evidence-baseComplementaryandAlternativeMedicine(eCAM)AdvanceAccesspublishedonline,May2009.

10. KallemUllah,AhmedYounis,MohamedWali.AninvestigationintotheeffectofCuppingTherapyasatreatmentforAnteriorKneePainanditspotentialroleinHealthPromotion.TheInternetJournalofAlternativeMedicine,2007.Volume4,number1.

11. KhosroFarhadi,DavidC.Schwebe,MortezaSaeb,MansourChoubsaz,RezaMohammadi,AlirezaAhmadi.TheEffectivenessofwetcuppingfornonspecificlowbackpaininIran:Arandomizedcontrolledtrial.ComplementaryTherapiesinMedicine,January2009.Volume17,issue1.

12. AndreasMichalsen,SilkeBock,RainerLudtke,ThomasRampp,MarcusBaecker,JurgenBachmann,JostLanghorst,FraukeMusial,GustavJDobos.EffectsofTraditionalCuppingTherapyinPatientswithCarpalTunnelSyndrome:ARandomizedControlledTrial.

13. WanXue-wen.ClinicalObservationonTreatmentofCervicalSpondylosiswithCombinedAcupunctureandCuppingTherapies.ShanghaiResearchInstituteofAcupunctureandMeridian,2007.

14. XYZhang.TraditionalChineseMedicine(TCM)intheManagementofGeneralGynaecologicalDisorders/Conditions.www.womenshealthclinic.co.uk

15. JohnKoo,SumairaArain.TraditionalChineseMedicinefortheTreatmentofDermatologicDisorders.ArchDermatol,Nov1998.Volume134.

16. EdzardErnst.Editorial–TestingTraditionalCuppingTherapy.TheJournalofPain,2009.Volume10,No.6.17. Il-SukSohn,Eun-SunJin,Jin-ManCho,Chong-JinKim,Jong-HoaBae,Ju-YoungMoon,Sang-HoLee,Myung-

JaeKim.Bloodletting-inducedcardiomyopathy:reversiblecardiachypertrophyinseverechronicanaemiafromlong-termbloodlettingwithcupping.EuropeanJournalofEchocardiography,2008.

18. HyoJinLee,NamHwanPark,HuanJungYun,SamyongKim,DeogYeanJo.CuppingTherapyInducedIronDeficiencyAnaemiainaHealthyMan.TheAmericanJournalofMedicine,2008.Volume121,No.28.

19. NiklasIblher,BjoernStark.CuppingTreatmentandAssociatedBurnRisk:APlasticSurgeon’sPerspective.JournalofBurnCareandResearch,2007.

20. www.wikipedia.org21. http://www.greekmedicine.net/therapies/Hijama_or_Cupping.html22. http://www.itmonline.org/arts/cupping.htm23. http://www.integrative-healthcare.org24. http://www.unani.com/cupping.htm25. http://www.ib3health.com26. GuidelinesontheHandlingandManagementofClinicalWastesinMalaysia,thirdedition.Departmentof

Environment,MinistryofNaturalResourcesandEnvironment,2009.http://www.doe.gov.my

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Dr. Ramli Abd. GhaniDirector

Traditional and Complementary DivisionMinistry of Health

Jaafar LassaDeputy Director


Dr. Shamsaini ShamsuddinSenior Principal Assistant Director


Dr. Zalilah AbdullahSenior Principal Assistant Director


Dr. Nur Hidayati Abdul Halim Principal Assistant Director


Editorial Board

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