الفهرس 
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Abstract
Knee pain in older adults is a common disabling problem, managed mostly within primary care. Osteoarthritis (OA) is the most common rheumatic disease in the general population, its prevalence increasing gradually among individuals older than 40 years. Disease process of osteoarthritis involves many joint. Knee is the most frequent joint after hand joint. The disease usually evolves with increasing levels of pain, mobility restriction, and physical disability. Osteoarthritis is a leading cause of disability worldwide, particularly among the elderly population.
Cupping Therapy is one form of Complementary and Alternative medicine/Traditional Medicine (CAM/TM) that has been practiced in most cultures in one form or another with long historical background. Cupping Therapy is indicated in treatment of a broad range of conditions; blood diseases such as haemophilia, hypertension, and rheumatic conditions ranging from arthritis, sciatica, back pain, migraine, anxiety and general physical and mental well-being.
The family practitioners are specialist physicians trained in the principles of the discipline. They are personal doctors, primarily responsible for the provision of comprehensive and continuing care to every individual seeking medical care irrespective of age, sex and illness. They care for individuals in the context of their family, their community, and their culture and always respecting the autonomy of their patients. Family physician provides prevention and care of chronic disease and disability through risk assessment, health education, early disease detection, preventive treatment and behavioral change.
The current study was conducted as a quasi randomized clinical trial to assess effectiveness of cupping in pain reduction and improving quality of life in patients with knee osteoarthritis combined with conventional medication compared to conventional medication alone.
The patients recruited in the study were the patients suffering from knee osteoarthritis attending Family Practice Center affiliated to Suez Canal University- which serves the rural community of El-Mahsama village in Egypt.
Ethical consideration of the study, Patients were offered a detailed explanation of the research procedure, subject understanding of the research was considered and a written consent form was obtained prior to commencing the study. Patients wishing at anytime to withdraw from the study or withhold any information were allowed to do so. Ethical approval was sought from Suez Canal University- Faculty of Medicine Ethical Committee.
The study procedures consisted of 2 phases; first phase was concerned with Identification of the sample population with confirmed diagnosis of knee osteoarthritis according to American College of Rheumatology (ACR) criteria. Furthermore, the patients were assessed for presence or absence of inclusion and exclusion criteria that make them eligible to participate in the study. In phase 2, the 122 diagnosed patients with knee osteoarthritis whom willing to participate in the study were randomly assigned into tow equally matched groups, from which 114 patient completed the study as follow: intervention (n=58) and control (n=56).
In intervention group, the patient had been offered 3 cupping sessions at monthly intervals at specific cupping points (medial aspect of the knee and over C7 in back of the neck). Both groups were offered (Paracetamol) as rescue medication for knee pain as needed.
The outcomes parameters were assessed in both groups using Western Ontario and Mcmaster Universities Osteoarthritis index (WOMAC) and Short-Form 36 (SF-36) at baseline, after 3 and 6 months. Furthermore, the use of offered pain medication (Paracetamol) was assessed in both groups during the three months of intervention; in addition to documentation of Adverse Events in intervention group pre and post each cupping session.
The results of the study showed that regarding the socio-demographic characteristics, no statistical group difference was observed among the both studied groups. Nearly two thirds of the studied groups are females (65.8%). the mean age for control was (53.6) years versus of (53.9) years for intervention group. The majority of the studied groups were married (90.4%). More than half of the studied groups were illiterate (61.4%). The majority of females were housewives (82.7%) while nearly half of males were retired (51.3%).
The outcomes parameters results showed that by comparing the pain intensity category there was a highly significant difference among the studied groups in favor of cupping therapy, as after 6 months the percentage of patients having severe to very severe pain in control group decreased to (55.3%) and (57.2%) regarding right and left knee respectively compared to the percentage of the patients having the same category of pain in intervention group which dropped to (18.9%) and (22.4%) in left and right knee respectively.
Furthermore, the mean WOMAC global score after 3 and 6 months showed highly significant improvement in intervention group (p <0.001). As the intervention group had better mean WOMAC global score of (34.4±12.6 and 46.6±11.6) versus (55.1±10.6 and 57.4±10.7) in control group after 3 and 6 months respectively.
In the other hand, the mean of SF-36 Physical Component Scale was significant better (p<0.001), in the intervention group (41.7±4.6) compared to the control group (34.1±4.4) after 3 months, and also after 6 months (36.9±3.4) versus (33.2±4.3), respectively (p <0.001). In contrast no significant group difference was observed for the SF-36 Mental Component Scale after 3 and 6 months.
Regarding the comparison of the mean analgesic (Paracetamol) tablets use for knee pain per month in the studied groups during the three months of intervention, it was found that the difference between the intervention and control group was highly statistically significant (p< 0.001), as the intervention group considerably had lower mean analgesic tablets intake of (30.3±16.1) in 1st month, (18.9±14.3) in 2nd month and (15.4±12.9) in 3rd versus (40.3±14.3), (36.6±13.7) and (36.9±13.4) in control group respectively.
In the current study, it was found that the most common adverse event reported by the patients in intervention group after cupping was pain at cupping site which they described as mild to moderate tolerable discomfort, reported by nearly more than half of the patients with significant decrease (p<0.001) over the following sessions.
The most frequent general bodily symptom reported by the patients was dizziness (12.1%, 3.4% and 3.4%) followed by others general bodily symptoms (numbness in legs, fatigue, and muscle ache) (8.6%, 6.9% and 5.2%) and the least reported bodily symptom was headache (3.4%, 5.2% and 3.4%). The frequency of general bodily adverse events was significantly decreased over the following cupping sessions compared to 1st session (p<0.001).
The effectiveness of Wet Cupping Therapy in relieving symptoms and improving quality of life of patients with osteoarthritis of the knee had been researched and the results revealed statistically significant differences in support of cupping therapy which might be a valuable treatment modality in primary health-care services. It could be used in addition to other analgesic treatment e.g. pain medication on demand.
Wet (Bloodletting) Cupping is a simple procedure, economic, practical and easy to apply. The procedure of Wet Cupping has no documented serious adverse events in the current study and could be considered a safe simple procedure if done appropriately.