Introduction
Athletes has long been interested in increasing their athletic performance. Studies have shown that paying attention to some issues such as nutrition and recovery during competitions can be as effective as the long-term training in achieving professional sports goals and health. Given the role of the recovery period in the adaptations of different organs of the body, there is a great deal of interest in research to understand the mechanisms of returning to the initial state and when to start the next training session. If the duration and intensity of the recovery period are not enough, athletes may suffer from complications such as chronic fatigue, illness, and overtraining, which often negatively affect the quality and quantity of their performance. 
Injury and muscle pain are common experiences after physical activity. Indicators of cell damage include morphological changes in tissues, decreased function, inflammation, delayed contusion, and most the activities of creatine kinase (CK) and lactate dehydrogenase (LDH). The increase in CK level following heavy activities causes cell damage. LDH is an enzyme that converts lactate into pyruvate, during which the nicotinamide adenine dinucleotide (NAD) is reduced to nicotinamide adenine dinucleotide phosphate (NADH), which measures the enzyme activity by measuring the rate of conversion. This enzyme is widely distributed in the cytoplasm of body tissues with different concentrations and also in the red blood cells. The increase in LDH and lactate production during exercise in people without physical activity compared to active people is an important matter. 
The use of sports supplements can improve the athletic performance by delaying fatigue and increasing lactate tolerance. They are also used to prevent muscle injuries. According to studies, creatine supplementation increases the level of creatine, which plays an important role in the rapid accumulation of adenosine diphosphate (ADP) produced from adenosine triphosphate (ATP) hydrolysis, especially in type II fiber. Dry cupping therapy is a traditional way to reduce muscle pain and fatigue in athletes. It is also used to regain and restore athletes’ balance. It is done by using cups to create suction in selected parts of the body and draw the blood into the cup. The present study aims to examine the effect of dry cupping therapy and creatine supplementation on LDH and CK levels following anaerobic exercise in male handball players.
Methods
In this study, 12 male handball players aged 18-25 years were randomly selected from Qazvin province’s handball team. One week before the intervention, baseline data including body height, body weight, body mass index, body circumference, and body composition were measured early in the morning during 9-12 o’clock. The next day, blood samples were collected by an experienced technician. The GS6.5B InBody body composition analyzer was used to measure their weight. Their heart rate and blood pressure were measured using a digital sphygmomanometer in the pre-test and post-test phases. A blood sample kit (DGKC) was to measure LDH and another kit (CK-NAC) was used to measure CK before and after the intervention. After performing all the measurements, they performed Wingate anaerobic test. Then, the intervention was performed in three intervention groups. Creatine supplementation was provided in 4 servings of 5 g with a six-hour interval between servings. Differences between groups at baseline were assessed using one-way analysis of variance (ANOVA). The analysis of covariance (ANCOVA) was used to examine the between-group differences. Paired t-test was used to examine the within-group differences. Significance level was P< 0.05.
Results
Table 1 presents the mean levels of CK and LDH in four study groups.


Dry cupping therapy alone and in combaination with creatine supplementation had a positive effect on CK reduction following the anaerobic test (P<0.05).
However, dry cupping therapy and creatine supplementation (alone or combined) had no effect on LDH level following the anaerobic test (P>0.05).
Discussion
The aim of the present study was to evaluate the effect of dry cupping therapy and creatine supplementation on lactic acid, LDH and CK following Wingate anaerobic test in male handball players. The results showed that dry cupping therapy and creatine supplementation had an effect on the CK level of young male handball players following the Wingate aerobic test. Coco et al. also showed that creatine supplementation significantly reduced CK. Rosno et al. showed that creatine supplementation did not increase any of the markers of cell damage (CK and LDH), while Atashk et al. reported that creatine supplementation along with resistance training had a significant effect on CK activity. Pro Prozki et al. reported that creatine supplementation had no significant effect on cell damage markers (CK and LDH). In a study on 30 gymnasts, the results showed that 30 minutes of moxibustion therapy plus cupping resulted in a faster return to elevated CK level. In overall, the use of creatine supplement and dry cupping therapy can positively affect the recovery of athletes after intensive exercise by reducing CK. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of Imam Khomeini International University (code: IKIU.1768-1399).

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

Authors' contributions
This study was extracted from a master thesis approved by Imam Khomeini International University.

Conflicts of interest
The authors declare no conflict of interest

Acknowledgements
The authors would like to thank the participants as well as the Vice-Chancellor for Research of Imam Khomeini International University.


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