Introduction
Cell changes that occur with ageing reduce the function of the immune system in the elderly. The humoral immune system is one of the important parts of the body, and immunoglobulins, as a part of this system, play an important role in the fight against pathogens [3]. Regular exercise is associated with increased longevity and lower risk of cardiovascular diseases, diabetes, metabolic syndrome, hypertension, infectious diseases, and cancer [8]. On the other hand, various methods for improving humoral and fibrolytic immune system function have been proposed including traditional treatments such as cupping [16]. In cupping, as the blood is removed from the body, the production and function of the immune system increases and the reaction begins. Following the occurrence of cell damage after cupping, it causes the development of macrophages, neutrophils and monocytes [21]. The aim of the present study is to compare the effect of an aerobic training course and a wet cupping session on the serum concentration of immunoglobulins in the immune system of older women.

Methods
This is quasi-experimental study with a pre-test/post-test design. The study population consisted of older women aged 60-65 years without any specific diseases (diabetes, anemia, cardiovascular diseases, or hypertension) who were taking medication. Of these women, 40 volunteers were selected based on BMI and VO2max and randomly divided into 4 groups: One time cupping (n=10), two times cupping (n=10), aerobic exercise (n=10) and control (n=10). Before and 48 hours after the end of the last training session, blood sampling was done from the radial veins during fasting (12 hours) in a sitting position.
Aerobic exercise was performed for 6 weeks, started with 50% of heart rate reserve and ended with 75% of heart rate reserve. It included 10-min warm up, 6-16 minutes of interval soft running and 20-30 minutes of low-impact aerobic exercise with music (march steps, easy walk, V and reverse V-step, forward step, backward step, mambo step, chase step, step knee up). At the end of each session, 5 minutes of stretching movements were performed to cool down.
For wet cupping, people were naked from the waist down and in a sitting position on a special bed. After disinfecting the position, it was performed using a special cup on the two shoulder blades in the middle line and on the T3 and T4 vertebrae. In the first experimental group, wet cupping was done once in the third week of the study while in the second experimental group, it was done twice in the second and fifth weeks of the study [28].
For statistical analysis, Kolmogorov-Smirnov test (to ensure the normal distribution of the data) and Levene’s test (to check the homogeneity of variances) were first used. Then, analysis of covariance and Bonferroni post hoc test were used to compare the groups and assess the mean difference. Paired t-test was used to compare the pre-test and post-test scores. The significance level was P≤0.05.

Results
According to the results obtained in the pre-test phase, there was no significant difference in the variables of weight, age, BMI and vo2max among the groups. After interventions, there was a significant difference in serum IgG concentration between the groups (P=0.003). The results of the Bonferroni post hoc test showed that the two times cupping group (P=0.001) and the aerobic group (P=0.001) had a significant decrease in IgG compared to the control group. This difference was also significant between the one time cupping group and the aerobic group (P=0.001), but there was no significant difference between one time cupping and two time cupping groups of (P=0.412). Also, the results of the paired t-test showed a significant decrease in the post-test serum concentration of IgG in the two times cupping group (P=0.004) and aerobic group (P=0.001) compared to the pre-test phase (Table 1).


There was also a significant difference in serum IgE concentration among groups after interventions (P=0.013). The results of the Bonferroni test indicated a significant decrease in IgE in the one time cupping group (P=0.001) and the aerobic group (P=0.001) compared to the control group. Also, a significant difference in serum IgE was seen in the one time cupping (P=0.001) and two times cupping (P=0.031) groups compared to the aerobic group. There was also a significant difference between the one time cupping and two times cupping groups in IgE (P=0.033). The results of the paired t-test also show a significant increase in the post-test IgE serum concentration in the two times cupping group (P=0.004) and aerobic group (P=0.007) compared to the pre-test phase (Table 1).
In the IgA level, the results also showed a significant difference among groups after the intervention (P=0.026). The Bonferroni test results showed that the two times cupping (P=0.041) and aerobic (P=0.012) groups had a significant decrease in IgA compared to the control group, but no significant difference was seen between the two times cupping and aerobic groups (P=0.821) (Table 1).

Conclusion
According to the obtained results, after six weeks of aerobic exercise and wet cupping, the amount of IgG, IgE and IgA decreased. Aerobic exercise caused a 16% decrease in IgG, a 33% decrease in IgE and a 2% decrease in IgA levels. It seems that wet cupping and aerobic exercise are able to create a significant change in the immunoglobulin levels of older women. Aerobic exercise in particular and wet cupping with a lesser effect (but positive) can be of great help along with pharmacological methods to strengthen the immune system of older women.

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of Qom University (Code: IR.QOM.REC.1399.020). All participants signed a written informed consent form. Study objectives and methods were explained to them and their information was kept confidential. 

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
The authors contributed equally to preparing this paper.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank all seniors participated in this study for their cooperation.


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