The Expression of -Endorphin and pain relief

in Wet-Cupping Therapy
Imam Subadi1, Harjanto2, Aboe Amar Joesoef3, Hening Laswati1
1
Department of Physical Medicine and Rehabilitation Faculty of Medicine Airlangga University
2
Department of Physiology Faculty of Medicine Airlangga University
3
Department of Neurology Faculty of Medicine Airlangga University

ABSTRACT

Introduction. Pain is a chief complaint most frequently seen in daily practice. Wet
cupping therapy has been used for pain management but the mechanism of action is
unclear.

Objective. Objective of this study is to show the relation expression of -endorphin

and pain relief in wet cupping.

Material and Methods. This is an experimental study with randomized post test
only control group design. Sixteen Wistar rats (Rattus norvegicus) was assigned to
two groups of 8 subjects, which are group undergoing Complete Freunds Adjuvant
(CFA) only (control group) and group undergoing CFA and wet cupping. Samples
was retrieved from skin and performed immunohistochemical of monoclonal anti -
endorphin. Pain threshold reaction time was measured by hot-plate. Data was
statistically analysed by Independent-Sample t Test, Linear Regresion analysis using
SPSS version 17.

Results. This study found increased expression of -endorphin (p= 0,000) and pain
threshold reaction time on wet cupping p= 0,001 compared with control group. There
are relation between increase -endorfin with pain threshold reaction time in wet
cupping (p= 0,012); = 0,608.

Conclusion. Wet cupping decreases pain caused by the expression of -endorphin.

Key word : wet-cupping, pain, -endorphin

Aim

Pain is the main complaint encountered in the daily practice of physicians (Smith et
al., 1999). Research on chronic pain in 15 countries in Europe reported that the
prevalence was 19% (Breivik et al., 2006). The prevalence of chronic pain in the
United States amounted to 30.7% (Johanes et al., 2010), while in Hong Kong
amounted to 34.9% (Wong and Guild, 2011). Chronic pain affects sleep disorders,
sports activities, walking, doing household chores, attend social activities, sexual life
and self-sufficiency lifestyle (Breivik et al., 2006), quality of life (Katz, 2002) and
occupacy (Smith et al ., 2001).

Currently Western treatment of chronic pain include pharmacologic therapy, non-

pharmacological and therapeutic interventions. Pharmacological therapies include
nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids (Buvanendran and
Lipman, 2010), opioids (Inturrisi and Lipman, 2010) and herbal therapy (Kaye et al.,
2011). Non-pharmacological therapeutic modalities include physical therapy, and
psychological therapy. These treatment options demonstrate mixed efficacy and
success. In some cases, typical Western treatment are completely ineffective.

Wet-cupping is an ancient medical technique and contemporary practice in many

parts of the European and Eastern world, including Indonesia. Wet cupping therapy
is a method of therapy in which superficial incisions are made to the skin dan blood
is removed from the body through negative pressure (Michalsen et al., 2009).

In the last decade researchers reported that wet cupping therapy effective in reducing
headache (Ahmadi et al., 2008), brachialgia parasthetica nocturna (Ludtke et al.,
2006), carpal tunnel syndrome (Michalsen et al., 2009), low back pain (Farhadi et al,
2009). Although wet cupping therapy known to reduce pain but the mechanism of
pain reduction is not clear. We hypothesized that expression -endorphin is
associated with pain decreased.
Material and methods

Study design

The design of the study is a post test only control group design. Sixteen Wistar rats
(Rattus norvegicus) was assigned to two groups of 8 subjects, which are group
undergoing Complete Freunds Adjuvant (CFA) only (control group) and group
undergoing CFA and wet cupping.

Animal model of pain : one hundred microliter of CFA was injected into the plantar
surface of the left hind paw. Ten superficial punctures with lancet are made on skin
of the back. Negative pressure (- 200 mmHg) applied on the back for 5 minutes.

Beta endorphin expression from the skin were measured using indirect
immunohistochemistry technique. Quantitative assessment done visually with a light
microscope with magnification 1000 times against keratinocyte cells expressing -
endorphin. Calculations carried out on the keratinocyte cell cytoplasm
Immunoreactive brown in twenty different field. Main outcome measure : reaction
time pain threshold in second measured by hot plate (Ugo Basile) 24 hour after wet
cupping. Data was statistically analysed by Independent-Sample t Test, Linear
Regresion analysis using SPSS version 17.

Results

Analgesic effects and expression -endorphin of wet cupping in CFA-induced

inflammatory rats were observed. The results are shown in table 1. Test for normality
with the Kolmogorov-Smirnov expression of -endorphin in all groups showed
normal distribution of data (p> 0.05). Levene's test of homogeneity of the test
showed the expression of -endorphin has a variance between groups were
homogeneous (p> 0.05).
Table 1. Mean and standard deviation -endorphin expression and pain treshold
reaction time
Variable Group X SD min max T-test
p
Beta control 5.12a 1.72 3 8 p < 0.05
endorphin wet cupping 22.37b 3.62 18 29
Pain treshold control 11.78a 3.58 7.50 18.00 p < 0.05
reaction time
wet cupping 22.81b 6.34 1430 30.00
Description: Significant at = 0.05. Different superscript indicates difference between groups (based on T-test).

As shown in table, the average -endorphin expression of the groups are 5.12 1.72
(control); 22.37 3.62 (wet cupping). The average pain treshold reaction time of the
groups are 11.78 3.58 (control); 22.81 6.34 (wet cupping). The results show that
the expression of -endorphin and pain treshold reaction time significantly increase
compared to control group, p= 0.000 ( p< 0.05) and p= 0.001 ( p< 0.05).

Positive and significant correlation in the -endorphin to pain treshold reaction time
(r = 0.608, p = 0.002). There is strong correlation between the expression of -
endorphin on pain treshold reaction time.

The results of immunohistochemical techniques showed an increase in the number of

cells expressing -endorphins in keratinocytes which gives a brown color reaction to
the monoclonal anti--endorphin antibody on wet cupping therapy group compared
control (Figure 1).

A B

Figure 1. Incision of skin tissue of mice using monoclonal antibody anti--endorphin in the negative
control group (A), wet-cupping group (B). 400 x magnification with a light microscope and camera
Olympic. Positif: keratinocyte cells react to the color of monoclonal antibody anti -
endorphin. (negatif) (positif)
Discussion
In this study suggests that wet cupping therapy increased the expression of -
endorphin. Increased expression of -endorphins causes increased pain threshold
reaction time.

Stretching and puncture the cell in wet cupping therapy causing cell stress. In
mammals , activation of the hypothalamic - pituitary - adrenal ( HPA ) axis is a major
endocrine response to stress and a marked increase in corticotropin releasing
hormone ( CRH ) . In the cells of the pituitary corticotrophs , CRH binds to CRHR1
receptor stimulates transcription of the gene pro-opiomelanocortin ( POMC ) . Pro-
opiomelanocortin is adrenocotropic progenitor hormone ( ACTH ) and - endorphin
( Slominski et al . , 2000) . Meer et al (1996 ) conducted a study in mice induced IL -
1 , TNF - and IL - 6 and IL - 1 and was reported that IL - 6 and TNF - triggers
the expression of CRH , in which IL - 1 is more potent trigger CRH expression than
IL - 6 and TNF - . Karalis and colleagues ( 2004) reported that the induction of
NFkB in the cells of the pituitary corticotrophs by CRH triggers the POMC gene
( Karalis et al . , 2004) . Fagarasan and colleagues ( 1989) reported that the induction
of IL - 1 in the pituitary cells stimulates the expression of - endorphin , but
depending on dose and time .

The expression of -endorphin trigger the expression of mu opioid receptors.

Endogenous opioid peptides interact directly with opioid receptors on immune cells
and nociceptive nerve endings (Bigliardi et al, 2003). Bigliardi and colleagues
(1998) reported that the mu opioid receptor binds to -endorphin in keratinocytes.
Mu opioid receptors have analgesic effects by activating signaling pathways Gi / o.
Opioid receptor binding with ligands led to decreased production of cyclic adenosine
monophosphate (cAMP) through the barriers that adenyl cyclase expression
decreased glutamate (McDonald and Lambert, 2005). Glutamate is a
neurotransmitter for excitatory nociceptive nerve fibers so decreased expression of
glutamate will decrease the pain.
Conclussion

Wet cupping therapy decreases pain caused by the expression of -endorphin.

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