ContraindicationsFurhad Bokhari 2019 stated that patients who

Contraindications

Furhad & Bokhari (2019) stated that patients who are using pacemaker and those who are suffering from cancer, any organ failure (heart, renal and hepatic failure) and hemophilia or any similar blood disorder are an absolute contraindications to cupping. While patients with acute infection, using anticoagulants, severe chronic disease (like cardiovascular diseases), pregnancy, pueriperium, menstruation, anemia, recent wet cupping session, recent blood donation, medical emergencies, and patient's refusal of the procedure are relatively contraindications to cupping therapy (Aboushanab & AlSanad, 2018). They also do not recommend the application to geriatric patients and pediatric patients; and those with high serum cholesterol are at higher risk of developing cardiovascular ailments with cupping.

Sites with deep vein thrombosis, open wounds, and bone fractures are the anatomical contraindications and that Cupping should not be done directly on nerves, arteries, veins, varicose veins, skin lesions, body orifices, lymph nodes, eyes or areas with skin inflammation (Furhad & Bokhari, 2019).

Conclusion

Cupping Therapy and Hijama per se, use is highly favored around the globe right now as an alternative treatment for differerent kinds of ailments as many advocates, not only in the countries that originated it, continue to develop it by further research on the efficacy and the scientific basis of the said therapy.

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Many current and useful referrences were found by the writer that are available to the public for research and in depth analysis of this topic. Certain clinical studies and exploratory researches provided good results on the effects of cupping to a long list of medical conditions.

Furthermore, some countries are suggesting establishment of safety protocols for standardization in clinical practice to provide safe and effective use.

Another issue with the writer is the safety of the procedure (for the patient, the practitioner and the infection control). Khalil, Al-Eidi, Al-Qaed & AlSanad (2018) stated that, at the moment, there are training centers in Saudi Arabia for those who wish to study and practice the prophetic medicine of Hjamah and that Saudi Arabia has commenced the standardization and integration of its practice as it is one of the most commonly used religious traditional medicine in the country by establishing the National Center for Complementary and Alternative Medicine under the Ministry of Health. They are reponsible for the regulation of cupping therapy including the practitioners, practice place or centers and cupping equipment along other alternative traditional medicine in the country; and as of the first and current phase of the new regulation, only medical professionals (physicians, physiotherapists and nurses) and other practitioners who studied traditional and complementary medicine were the only ones given license to provide cupping therapy to decrease the risks as it is done by qualified practitioners (Khalil, Al-Eidi, Al-Qaed & AlSanad, 2018). The writer find it very important to have this regulating body for the infection control aspect because it is for the safety of the patients or clients and the practitioner as well to prevent the spread of infectious diseases.

The writer worked as a Physiotherapist in Saudi Arabia for about eight years and that patients and clients who comes in for treatment that have Hijama scars is very common. It was very unusual to the writer to witness lacerated scars from cupping at first because cupping therapy is not that very popular in the Philippines unlike in any other Asian countries who practice it. Back in 2010, the writer can still clearly remember the first time she saw wet cupping scars on the back of a middle aged male patient who was diagnosed to have chronic low back pain secondary to Lumbar Spondylosis at a military hospital in a far flung province of Riyadh. The writer interviewed the patient for many information regarding the wet cupping therapy done because the scarifications were still acute and inflammed and it is contraindicated in applying any modality in Physical Therapy except for exercises. In that interview, the writer learned that wet cupping done in Saudi Arabia is based on Islam and that all muslims especially Saudis practice it because the teachings of their religion, that they have to live by the example of their Prophet Mohammad and that they believe that wet cupping can cure all their afflictions and illnesses according to their prophet.

In a recent study about the knowledge, attitude and perception of Saudis as to cupping done by Al-Yousef, Wajid & Sales (2018), it is found out that majority of the respondents use cupping therapy for treatment and that the common most common source of information about their knowledge about cupping is from books or periodicals followed by the recommendation of their family and friends who have used or still using cupping therapy. They also found out that majority of the respondents are just contacting a specialist to perform Hijama in the comforts of their home. Their strong trust to the efficacy of cupping therapy as an alternative treatment is clearly traced to their religious practice and beliefs.

The Saudi government provides all health care services to all its citizens without any cost. And in the writer's own personal experience, the usual scenario of most, if not all, government healthcare facilities are very crowded. Patients wait for queues or sometimes arranges an appointment for consultations, blood work, X-rays, medication and etc. And more often than not, most Saudis want a quick fix with regards to their health problems and instead of seeking medical attention, they would rather get Hijama done at their home because of its easy access and for a cheap price.

In a Physical Therapist's point of view, there is nothing wrong in practicing any traditional beliefs in regards to wellness and well-being as long as it is safe and is supported by science and evidence based studies. However, in a country that had no schools up until 1937, no school for girls until 1961 and no medical school until 1969 (Khaliq, 2012), it is best that people should be educated on the importance of medical advice with regards to their health rather than just by relying on traditional practices. Because sometimes, patients will just see a doctor when the efficacy of Hijama wears off or it did not have any effect at all and the disease is already serious or the illness is already debilitating. They should also be educated to discern which treatment that will be most effective.

The writer recommends exercise as an alternative treatment for most of their musculoskeletal afflictions as it is still the best treatment and is proven safe and effective as well it is free and can be done at home. Based on the writer's immersion to the country and its community, it is also recommended to make conscious efforts to promote active lifestyle and healthy and nutritious foods because many Saudis have sedentary lifestyle and consume large amounts of food daily.