Osteoarthritis is the most widespread and common chronic musculoskeletal disorders and is a major cause of morbidity, limitation of activity, and healthcare utilization, especially in elderly patients (OA) of the knee. The number of people affected with osteoarthritis is rising in the whole world as the dominance of risk factors such as obesity, poor levels of physical fitness and years of life expectancy are persistently increasing.

Current recommendations for managing OA focus on relieving pain and stiffness, and maintaining or improving physical function as important goals of therapy. No curative therapies exist for OA; both pharmacologic and non- pharmacologic management focus on controlling pain and reducing functional limitation. Pharmacologic therapies include non-opioid analgesics (such as acetaminophen), NSAIDs (including COX-2 enzyme selective inhibitors), topical analgesics (capsaicin cream), opioid analgesics, and intra-articular steroid and hyaluronate injections. Pharmacologic management is full of adverse effects (hepatotoxicity, nephrotoxicity, hematological toxicity etc.

Unani medicine offers a large variety of pharmacological and regiminal therapies for the management osteoarthritis. There is a long list of single and compound drugs and also regimental therapy such as Fasad (venesection), Irsaal-e-alaq (leech therapy), hijama (cupping) etc. which are mentioned in Unani literature to be useful in waja-ul-mafasil. Hijama.

In Unani literature, osteoarthritis is not mentioned as such, but by comparing the signs and symptoms of Osteoarthritis it can be concluded that Waja-ul-Mafasil Barid have more resemblance with it.

As per the Unani doctrine derangement of the humoral temperament is occurred due to the presence of morbid humours/matters in the blood circulation which is responsible for the disease. Hence Cupping therapy is applied for the purpose of elimination of morbid material (Tanqiya-e-Mawad) from the body. Various eminent Unani physician has recommended cupping for the treatment of arthritis. in their respective text

Ali-Ibne-Abbas-Majoose-has reported cupping to be significantly beneficial in the treatment of arthritis and he has also listed the methods for the same.in his famous book Kamil-us-Sana, he says ‘for the treatment of Waja ul Mafasil, at first, Mahajjama Bila Shurt Should be applied and should be sucked with great force. After this, Hurt Should be applied, and Mahejjama should be applied at the point nearest to the joint’9.

1) Al-Raazi Quotes in his book Al Havi Al Kabeer, in the treatment of Hip joint arthritis, When Humours are thick and difficult to evacuate, the use of mahajjama is advised and it is very beneficial

2) Razi described Ahran, who, while describing wajaul warik, has quote mahajjama as being the most important and the most beneficial. He further says that if this (application of Mahajjama) is preceded by the use of advia Harra ,than it is still better

3) Ibne Sina says , cupping below the knee is beneficial in such trouble of the knee which results from acute humars11 â€˜.Has also stated the mahajjama to be a possible beneficial treatment for arthritis. He is quoted by Razi in his book Al Havi

4) Ibne –ul- kahaf  in his book kitabul umda fil jarahat, hs described the metghod of cupping in the treatment  of arthritis. He sdays, ‘the method of cupping on the knee is such that the patient keeps his legs on the ground and Mahajjama is applied at the point of knee joint on the lower end of the femur. This helps in treating arthritis of the knee

In this treatment modality, suction is created by various means Cupping may be done either wet or dry. Dry cupping is simply placing the suction cups on the skin. Wet cupping, or cupping with Scarification is a form of bloodletting procedure that involves an incision on the skin, then applying the suction cups to suck out of blood.

Though this therapy is being widely practiced across the globe for treating many chronic and intractable ailments Many of the therapeutic uses raised the questions about cupping therapy about its principals of action, how it works and to what extent it may be beneficial. Therefore, Searching for a better conservative economic and effective line of treatment and to develop standard operative procedures of cupping therapy in various diseases is the need of the hour.

religious texts and sayings about Hijama (cupping) also attracted the attention of researchers to the scientific values Prophet Mohammad peace be upon him recommended cupping therapy as a treatment: “If there is a benefit in any of your treatment modalities, benefit will be in the blade puncture in cupping therapy, a gulp of honey and cauterizing, but I do not like cauterization”. This further motivated us to search and establish the novel evidence-based scientific mechanism of action of cupping therapy and how effective is this therapy in different diseases. 

 Biomarkers of Osteoarthritis:

Osteoarthritis (OA) is a slowly progressive degenerative joint disease that is traditionally associated with radiographic signs of joint space narrowing, osteophytes formation, and subchondral sclerosis. Its main clinical symptoms are variable joint pain and stiffness, and occasional effusion. However, radiographic signs and clinical symptoms only develop in late-stage OA when significant joint damage has already occurred. Development of disease modifying treatment modalities for OA is challenging; lack of in-depth understanding of disease pathogenesis, the slowly progressive character of OA, the insensitivity of monitoring methods, and the limited relation between pain, disability and structural changes, still necessitate long and large-scale therapeutic trials. Therefore, current treatment strategies are limited and mainly based on analgesics and, eventually, surgical procedures. Biochemical markers can suppose to elucidate joint changes more directly and early than   imaging and also provide a direct measure of drug and intervention effect Biomarkers are defined as characteristics that are objectively measured and evaluated as indicators of normal biological processes, pathogenic processes, or pharmacologic responses to therapeutic interventions. A lot of effort has been put into the development of biochemical markers that can aid diagnosing early-stage OA, predicting OA progression, and assessing therapeutic response. Serum cartilage oligomeric matrix protein (COMP) and serum Hyaluronic acid (HA) are the two diagnostic biomarkers which are most often used. The availability of such biochemical markers could be used to diagnose the condition in early stage and to assesses the disease progression and efficacy of treatment.