**6. Contraindications**

*Pain Management - Practices, Novel Therapies and Bioactives*

periods is warranted.

**5.5 Carpel tunnel syndrome**

country [51]. Further research with better designed studies and longer follow-up

Carpal tunnel syndrome (CTS) is a peripheral nerve entrapment due to the compression of the median nerve in the carpal tunnel of the wrist joint. It usually manifests as numbness and burning pain in the palm and the first three fingers (sensory involvement), and reduction in the grip strength (motor involvement) [54]. The beneficial effects of cupping therapy were observed when used in combination with physiotherapy or alone. Mohammadi *et al* studied the effects of cupping in combination with physiotherapy compared to physiotherapy alone on CTS patients. Modified cups were used in this study to accommodate the anatomical shape of the wrist joint. The pressure level used during the treatment sessions was 50 mmHg and the cups were applied for 4 minutes. A total of 10 sessions were done and the effects were assessed after completion of all the sessions. Four CTS-related parameters were measured: symptom severity, functional status, distal sensory latency, and distal motor latency. The study concluded that there was a significant improvement in the symptom severity scale and reduction in the distal sensory latency in the cupping group compared to the control group. In addition, subjects in the cupping group had an improvement in the functional status scale and reduction in the distal motor latency but the differences were not statistically significant. The limitations of the study included the lack of regular time intervals to assess the effects, and the uneven distribution of patients with severe disease between the two arms of the study [55]. Furthermore, two case reports had documented the beneficial effects of cupping in CTS patients [56, 57]. The first case report used wet cupping and reported profound reduction in pain, numbness and paresthesia. These clinical findings were confirmed by significant improvement in the electrophysiological measures as demonstrated by both nerve conduction velocity and electromyography [56]. The second case report used self-applied cupping at least once daily for 3 to 5 minutes for a period of 3 months in a patient with mild CTS symptoms. The patient reported an improvement in the symptoms after 1 week of treatment and complete resolution of all symptoms after 6–8 weeks. The nerve conduction study showed that median distal latency had returned back to the normal range after

Fibromyalgia is a disorder characterized by chronic generalized pain, fatigue, cognitive disturbances, sleep disorder, and pronounced somatic and psychological distress [58]. The main aim of treatment for fibromyalgia patients is to relieve pain and to improve the patients' quality of life [59]. Few studies were conducted to investigate the effects of cupping in fibromyalgia. Lauche *at al* reported that cupping therapy was more effective than usual care in patients diagnosed with the fibromyalgia syndrome after 18 days from treatment in terms of reduction in pain intensity and improvement in quality of life [60]. Moreover, the other studies were conducted to evaluate the effectiveness of a combination therapy of cupping and acupuncture together with conventional medications (anti-depressants) compared to medications alone [61, 62]. A total of 242 patients were included in both studies. Significant reduction in pain scores (MD −1.65, 95%CI −2.10 to −1.31, < 0.00001) were reported in the combination group compared to the control group [29]. Further research with better quality studies is needed to determine the effectiveness

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of cupping in this group of patients.

3 months [57].

**5.6 Fibromyalgia**

Cupping therapy is a process where suction with or without scarification is done as a treatment for different types of pain and medical problems. Direct application of cupping on specific sites of the body is contraindicated as the negative pressure created during cupping therapy might be harmful [23]. These sites are veins, arteries, nerves, inflamed and injured skin, body orifices, eyes, lymph nodes, varicose veins, bone fractures, and sites of deep vein thrombosis [23]. Ahmedi et *al* classified the contraindications into absolute, relative and with cautions [5]. The contraindications are summarized in **Table 1**.
