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Blog

16/03/16
During recent years there has been a dramatic growth of Al-Hijama across the western world. Within the UK there are clinics in Birmingham, Sheffield, Leicester, London, Cardiff and Glasgow amongst other towns and cities. A snapshot review of UK internet sites in early 2015 identified just under 100 therapists who provided details of their services. These figures belie the total number of practitioners in the UK knowledge of whom is largely spread by word of mouth. However, for most clinicians and lawyers it is a therapy about which little is known. Who practices Hijama and why? This lack of knowledge concerning Al Hijama is also reflected to some degree in the White Paper, Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century, which states

“Some existing professionals who are not statutorily regulated have been in
practice with patients for many years; practice that carries at least the same
potential risk to members of the public who use their services as that of the
statutorily regulated professions. The Government believes that these
professionals should also be subject to a system of regulation that is
proportionate to the risks and benefits entailed.”

However, Al-Hijama is not a new therapy and so would seem to fall outside many of the recommendations put forward in the White Paper for training, registration and policing. Its traditional role contained a large preventive element. In contrast the role of therapeutic Al-Hijama requires the practitioner to have diagnostic skills, be aware of the nature of informed consent and have the ability to assess clinical response. It is, therefore, necessary for all practitioners to reflect upon the consequences of such thinking and act before requirements are imposed from outside their profession.

Al-Hijama is a technique founded in the practice of wet cupping and commended within the Hadith. Its origins predate Islam and variations include dry cupping, cupping massage and flash cupping. Although these techniques do not fall within Al-Hijama they are practiced by many therapists and are most commonly used by cupping practitioners who are not Muslims. Integral to wet cupping or Al-Hijama is the practice of multiple small superficial cuts which leads to bleeding within the cup. This bleeding is central to Al-Hijama and should impose on the practitioner the need for a modern-day clinical approach to the procedure. The rapid growth of Al-Hijama clinics, the availability of mobile services and widespread advertising by practitioners on the internet means that there is an urgent need to develop a national code of practice. In addition the profession needs a central register of practitioners who have undergone appropriate training, who practice within recognised guidelines and undergo regular continuing professional development. Such a register will act as a quality indicator and protect the public both from charlatans and those who are inadequately trained.

At present there is no single recognised registration body for such practitioners. Without statutory support the creation of such a body will always be limited by the existence of less stringent organisations which will provide training, register successful students and promote their services. Although the emergence of such a statutory body is unlikely in the immediate future, this is not a reason to fail to create a transitional organisation which will promote the highest standards in training, clinical practice and on-going education. It is to be hoped that such a body will also encourage critical and robust research. It may even become necessary for it to support its own academic journal to ensure appropriate publication in what is likely to be a sceptical scientific world.

What should be the criteria for Al-Hijama therapists who practice in the UK and indeed in any jurisdiction? The choice of the word jurisdiction is deliberate. Clinical practice carries with it responsibilities and obligations. When these are not fulfilled recourse to a court, whether religious or not, is a likely outcome. The criteria, therefore, needed for registration of individual therapists should include aspects of:

* Clinical training
* Forms of assessments of a student’s practice

For example, practitioners need a basic knowledge of anatomy and physiology. In the case of those who come from a non-clinical background there must be evidence of time spent studying these disciplines including a formal assessment of understanding. Training organisations and individual trainers should expect to be regularly policed so as to ensure quality and reproducible standards of assessment. Within all programs there must be evidence of hands-on supervised experience. Although modern technology provides many opportunities through simulated practice, direct observation of experienced practitioners on You Tube as well as web-based and distance learning there must be time during training where students meet real patients, take real histories, obtain informed consent and perform hijama under direct supervision. During such encounters between student therapist and client there is an opportunity to develop history taking skills and to understand the difference between empathy and sympathy. It is also a time when a student should come to learn the limits to his or her expertise and to know when to refer the patient to someone else either with more experience or for formal medical assessment. In the twenty first century these are the minimum requirements that patients should expect from a therapist.

Once trained the modern therapist needs to ensure that he or she:

* Continues to update themselves through on-going professional education. This needs to be recorded and registered with the
regulatory body.
* Practices within an environment where they can discuss issues with colleagues. Ideally each practitioner should have a mentor
who can be empathic. Alternative arrangements include local fora where practitioners come together on a regular basis. In other
words the therapist should not work in isolation.
* Keeps a careful clinical record of their practice and follows up patients to check on outcomes. Essentially this is auditing one’s
practice and so identifying areas where further training is needed.
* Provides a secure environment for storage of clinical details. In the UK this means registration with the Information Commissioner.
The Data Protection Act requires that you:

“only collect information that you need for a specific purpose; keep it secure; ensure it is relevant and up to date; only hold as much as you need, and only for as long as you need it; and allow the subject of the information to see it on request.”

* Ensures patient information is treated confidentially and only discussed with other clinical professionals.
* Registers with a regulatory body which understands and supports the practice of Al Hijama. This is one reason why there is a need
for a specific regulatory body for Hijama therapists. Such a body will need to be appropriately funded and this should come through
an annual subscription.

A Regulatory Council for Al Hijama should be an independent body whose membership should include therapists and lay people. It should also draw on other clinical and legal professional groups but such members must have a specific understanding of the philosophy of health care embodied in Al Hijama. At least 30% of its therapist members should be elected and serve for a period of 3 to 5 years. Its powers would include review of professional practice with the right to suspend therapists from practice or to prescribe a course of remedial education. For many independent practitioners such powers may seem Draconian but are essential if such a body is to be regulatory rather than advisory in function. Of course until such a body is given statutory powers its role, at best, would be seen as giving a stamp of approval to certain practitioners. However, those practitioners would have a superior status and it is possible that local authorities concerned with the spread of Al Hijama would require practitioners within their areas to have such recognition.

The introduction of a robust form of registration for all trained Al Hijama therapists is not a threat to ijazah where an individual is authorised to pass on knowledge to new students. Rather it strengthens such a process and recognises the need for teaching, learning from an experienced practitioner and the passing on of sound knowledge and practice to the next generation. Its benefits will be to eliminate the poorly trained and to set high standards of practice. This is essential in a time of general scepticism and to ensure that Al Hijama practice is held in high regard. A recent review by the BBC underlines the importance of establishing an independent and authoritative body for the regulation of Al-Hijama. It reported that a spokesperson for the Complementary and Natural Health Care Council said:
“If practitioners of Hijama cupping want to be considered for registration with CNHC, their profession would need to make a case to Skills for Health for the development of relevant National Occupational Standards in the first instance.”

Skills for Health is a not-for-profit organisation, licensed by the UK government, to help organisations:

* Raise quality standards around healthcare and improved patient safety
* Reduce clinical incidents to zero following introduction of new training
* Certify staff through new competence based roles
* Implement career frameworks for staff progression and improved retention
* Introduce new competence based flexible learning and awards
* Innovate new franchise models for private practice
* Optimise budgets and raise productivity
* Standardise processes around workforce development

A core activity to achieve these objectives is the development of National Occupational Standards. Their purpose is to:

“describe the skills, knowledge and understanding needed to undertake
a particular task or job to a nationally recognised level of competence.
They focus on what the person needs to be able to do, as well as what
they must know and understand to work effectively. They cover the key
activities undertaken within the occupation in question under all the
circumstances the job holder is likely to encounter.”

In themselves such objectives are praiseworthy. However, the very nature and tradition of Al Hijama means that practitioners should be able to develop their own standards. Of the 89 UK therapists identified through a snapshot review of web sites only 9 had some form of clinical background and 14 had no evidence of any formal training including Al Hijama.

Clearly in the case of Al Hijama the rapid growth in independent unregulated practice gives an urgency to the establishment of a regulatory body. It would not simply protect the public but also the reputation and status of Al Hijama itself. The recognition of Hijama as a therapy, with approved training, formal testing and regulation has been given further impetus in 2015 by the actions of the Saudi government who have introduced a 4 stage assessment process and which requires all practitioners to register and comply with these standards. Within the United Arab Emirates the practice is supervised by the Ministry of Health. In those societies where there is already knowledge of the role of Al Hijama regulation is becoming the norm. Within the UK a general lack of awareness is responsible for the growth of an unregulated practice and it is incumbent on concerned practitioners to come together and ensure that appropriate regulation is introduced.

References:

BBC (2015) Call for Hijama therapy regulation
http://www.bbc.co.uk/news/health-32653971 (Accessed 28/5/2015)

Hijama treatment needs government nod
http://www.emirates247.com/news/region/hijama-treatment-needs-government-nod-2011-10-03-1.421632 (Accessed 7/6/2015)

Ministry of Health Portal Kingdom of Saudi Arabia (2015)
http://www.moh.gov.sa/en/Ministry/MediaCenter/News/Pages/News-2015-02-17-002.aspx (Accessed 29/5/2015)

Skills for Health (2015)
http://www.skillsforhealth.org.uk/about/independent-sector (Accessed 28/5/2015)
http://www.skillsforhealth.org.uk/standards/item/215-national-occupational-standards (Accessed 28/5/2015)

Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century (2007)
The Stationery Office (London)
28/01/16
Lactose intolerance is a common problem. It is more frequent amongst people of Mediterranean and Asian background. It becomes more common as one gets older. It is due to an inability to break iactose down into its component parts which are glucose and galactose. This is done by an enzyme called lactase. This enzyme is found in the lining of the small bowel. When lactose is not broken down it ferments and causes bloating, abdominal discomfort and diarrhoea. Many people believe that it is also responsible for a number of other symptoms which can include headaches and nasal stuffiness. Almost 100 years ago there was a study published which suggested that in people with this problem some lactose was absorbed across the small bowel lining and it was this that caused such symptoms.

There has been considerable discussion as to the amount of lactose that can cause symptoms. It is usually suggested that the amount of lactose found in a glass of milk is needed. However, there have been a few studies which suggest that even the small amounts of lactose found in some tablets is sufficient to cause symptoms. Lactose is commonly used as a whitening and sweetening agent by both the pharmaceutical and food industries. It is often found in unusual situations and it is for this reason that almost 50% of the lactose we eat each day is described as hidden. It can be quite difficult to identify whether lactose is present in many foods. It is not always clearly labelled and care should be taken when it is written that the product contains milk solids or other derivatives of a milk origin.

Although some people believe that the source of milk is important this is only the case where there is sensitivity to milk protein. Milk protein sensitivity and lactose intolerance are very different. For such people with milk protein sensitivity there can be an advantage to using either goat’s or sheep’s milk. In addition, there is a growing fashion for using buffalo milk or camel milk. In all four of these milks the protein is different. However, lactose is the same whatever its source. Reactions to cow’s milk protein are quite distinct from reaction to lactose. Although reactions to cow’s milk
protein were considered to mainly occur in children it is now recognised that they also occur in adults.
How can I check whether I have lactose intolerance?

There are various ways that you can formally check lactose intolerance. These include blood, breath and biopsy tests. However, you can carry out a simple test at home. Simply stop drinking and eating all sources of lactose for three days and then drink a glass of normal milk. If this causes symptoms it is likely that you have lactose intolerance.

What can I do if I have lactose intolerance?

You need to stop eating and drinking lactose. This is much easier said than done. Lactose is very common in many foods. You will need to look at labels of food that you buy to see if there is lactose present. You can now buy lactose-free dairy products. There are also substitutes such as soya, rice or oat-based milks. Unfortunately some people who are intolerant of lactose also experience problems with soya.

It is possible to purchase lactase tablets. These can be taken with favourite foods such as ice cream and so allow you to still enjoy them. In addition, some people find live yoghurt helpful. This is because such yoghurt contains lactobacillus or other bacteria which can digest lactose. However, if there is lactose present in the yoghurt this can sometimes cause symptoms before you experience the benefits of the bacteria. As well as live yoghurts some people use kefir which they grow at home.

One potential advantage of kefir is that it is possible to develop a product which is water-based. However, kefir is not generally available commercially in the UK at present.

If you are following a lactose free diet you will need to ensure that you have an adequate intake of calcium. Dairy products provide a good source of calcium and if you are not eating them regularly it puts you at possible risk of bone thinning conditions such as osteoporosis. In this situation you need to consider taking calcium supplements.

Further Reading:

Harrington LK & Mayberry JF (2008)

A re-appraisal of lactose intolerance

International Journal of Clinical Practice 62: 1541 - 1546