Arya Nielsen
Introduction and history
Gua sha and Ba guan are Traditional East Asian Medicine (TEAM) therapies used for centuries in Asia, in Asian immigrant communities as a form of self or familial care and by acupuncturists and practitioners of TEAM worldwide in clinical practice (Chirali 2014, Manz 2009, Nielsen 2013, So 1987, Zhang & Hao 2000). Both Gua sha and ‘dry cupping’ are instrument-assisted techniques applied to the surface of the body that result in
transitory therapeutic petechiae
and ecchymosis called ‘sha’ in Chinese medicine (
Fig. 11.1
). With Gua sha, sha petechiae and ecchymosis are produced over a body area, sometimes as stripes; cupping sha often appears as round, ‘nummular’ shapes of petechiae and ecchymosis, with larger areas associated with moving cups (
Fig. 11.2
). (In a variant known as ‘wet cupping’ a surface site is superficially poked with a needle or lancet and then cupped to intentionally draw blood into the cup. Wet cupping will not be detailed here except to note that both wet and dry cupping have been a part of TEAM, the traditional medicine of Gulf Arabs (hijamah) (Al Bedah et al. 2016) and in early Western medicine descending from ancient Greek, Roman and Egyptian traditions.)
TEAM dates from the twenty-first century BC with the earliest known medical texts dating to 200 BC (Lu & Needham 1980). The first acupuncture text is found in 90 BC (Epler 1980); the earliest Chinese text linked to Gua sha is the
Shi Yi De Xiao Fang
(1337) (Nielsen 2013). Cupping dates to the Han scripts (200 BC), specifically the
Bo Shu
(Cao et al. 2010).
This chapter discusses Gua sha and Ba guan in medical terms, indications and specifics of palpation, evidence of effect, biomechanism and relationship to connective tissue, recommendations for safe practice, and a palpation exercise for practitioners to confirm or rule out the presence of sha. Techniques like Graston and instrument-assisted soft-tissue mobilization, derivatives of Gua sha, are not discussed here but can be accessed elsewhere (Hammer 2014).
Gua sha, Ba guan terms and tools
Gua sha
The literal translation of ‘gua’ to ‘scrape’ or ‘scratch’ (So 1987) has led to mistaking Gua sha as ‘dermabrasion’ which removes the epidermis and is clearly distinct from transitory surface sha petechiae and ecchymosis. Other common translations of Gua sha in Western medical literature include ‘coining’, ‘spooning’, ‘cao gio’ (Vietnamese) and kerik (Indonesian) (Nielsen 2009).
Gua sha consists of repeated unidirectional press-stroking with a smooth-edged tool at a lubricated area of the body surface until sha petechiae appear. Traditional tools include a soup spoon, coin, honed horn, bone, jade or stone. These blunt tools create a certain discomfort for the patient, avoided with the smooth-edged, thinner gauged cap that is also disposable after a single use (
www.guasha.com/gua-shatools
) (Nielsen et al. 2012, Nielsen et al. 2014).
Ba guan
The Chinese term ba
means to pull out or pull up, while the term guan
refers to a jar or pot. Ba guan
cupping involves the application of suctioned round cups on the skin (Nielsen et al. 2012). A vacuum is produced in each cup by flame (fire cupping) or by mechanical suction (suction cupping) that causes the tissue to tumefy and stretch into the cup. Nummular shaped areas of petechiae and ecchymosis are produced from the vacuum.
Sha
In TEAM, Qi stasis pain is defined as responsive to movement, massage, acupuncture or even a hot
shower. ‘Blood stasis’ pain is fixed, persistent or recurring at an area. It can be severe and does not resolve with movement, massage, acupuncture or application of heat alone.
Sha
is a polysemous term describing the presence of surface blood stasis associated with pain or sickness. Sha is also the petechiae/ecchymosis that are raised from applying Gua sha or Ba guan. The literal translation of
sha
from Chinese is ‘sand, sharkskin or red, raised, millet-size rash’. The fresh petechiae raised from Gua sha or Ba guan immediately begin to fade and blend to ecchymosis, disappearing in several days for Gua sha, longer for cupping depending on the length of time that cups are applied (
Figs 11.1
and
11.2
).
Sha pathology may be asymptomatic, pre-symptomatic, or mildly symptomatic with potential to worsen. Symptomatic pathology includes persistent, fixed, recurring, even excruciating pain. Sha may be associated with ‘sha syndrome’, defined as ‘
disease caused by the exposure leading to blockage of channels and manifesting as chilliness, fever, distension and pain of the body, or vomiting and diarrhea, or rigidity and numbness of extremities
’ (Nielsen 2013).
Figure 11.1
Applying Gua sha.
Sha is also translated as cholera (Weiger 1965) wherein sha petechiae and ecchymosis resemble cholera’s end-stage rash. Gua Sha in the East, like frictioning in early Western medicine (Jackson 1806), was used in the treatment of cholera and cholera-like disorders (So 1987), mimicking the crisis stage of an illness that is deployed as a cure per Hippocrates and Hippocratic doctrine ‘the crisis is the cure’ (Nielsen 1996).
Indications
Gua sha and Ba guan are used for acute or chronic pain, problems with movement or range of motion, and/or disturbed organ or system function, including acute infectious or chronic illness (Nielsen 2013, Zhang & Hao 2000, Manz 2009) for reduction of fever and in the case of Gua sha, for thermal dysregulation in potentially life-threatening heat stroke (Ruan & Cui 2005, Nielsen 2013). Blood stasis pain is fixed, persistent and or recurring. This can be associated with trigger point ‘loading’ or reflect deeper organ pathology or fascial constriction (Nielsen 2013).
Palpation and palpation literacy
Palpation in myofascial work evaluates asymmetry, range of motion, tissue texture changes and tenderness (ARTT) with emphasis on ‘temperature, texture, surface humidity, elasticity, turgor, tissue tension, thickness, shape, irritability, motion
’ (Chaitow 2012). In TEAM there are additional filters to palpation: indications of surface ischemia called ‘sha’, as well as focus on patterns of pain trajectory, ‘affiliation’ and relationship with known points, channels and organs. The TEAM channels are now recognized to
coincide with cleavages of connective tissue planes (Langevin & Yandow 2002), with potential for propagation of mechanical signaling (Langevin et al. 2001, Langevin 2006) and a ‘body-wide mechanosensitive signaling network
’ (Langevin 2006).
Palpating for ‘sha’ is informed by observable changes that represent ‘blood stasis’ or ischemia in the surface tissue. If there is tenderness and pain with pressing palpation, where resulting blanching is slow to fade, indicating normal surface perfusion is hindered – that is sha! (So 1987) (
Figs 11.2
and
11.3
) Surface ischemia should be part of palpation literacy because any perfusion restriction can be associated with persistent pain, reduced oxygen and glucose, leading to muscle or relevant tissue ‘fatigue’ (Chaitow & Delany 2011), restriction in tissue stretch, mobility, and myofascial dysfunction (Chaitow 2012).
Causes of dysfunction in myofascial tissues have been reduced to misutilization: overuse, misuse, abuse or disuse, with exceptions for congenital problems and impact of emotion or psychological stress (Chaitow & Delany 2011). A glaring omission that is based in every system of original medicine is the effect of exposure. Exposure to elements of wind, cold, heat, dryness and dampness beyond the body’s ability to compensate, or even because of how the body compensates, can lead to pain and illness. For example, cooling of the feet provokes symptomatic lower urinary tract infection in cystitis-prone women (Baerheim & Laerum 1992).
For decades, researchers held that the rhinovirus was the cause of the common cold and exposure to cold was considered to be an ‘old wives’ tale’. However, exposure to cold can influence the onset of common cold symptoms. A decline in either temperature or humidity, and not necessarily low temperature or humidity in the three days prior to onset, increases the risk of influenza (Jaakkola et al. 2014) and human rhinovirus infections (Ikaheimo et al. 2016) in a cold climate. Increased duration of exposure to cold is associated with greater susceptibility to infection (Mourtzoukou & Falagas 2007). Respiratory epidemics following a period of very cold weather may also be due to conversion of subclinical infections into symptomatic clinical infections (Mourtzoukou & Falagas 2007). Not every exposure results in an infection; every person exposed is not equal in terms of vulnerability to exposure or compounding risks like lack of sleep, proper nutrition, immune status or stress. It is conceded now that exposure is a risk.
Exposure can contract the surface vessels, result in surface ischemia that does not resolve with warming and is discoverable in ‘sha’ palpation. Pain stasis related to sha often becomes exacerbated by body
work. Patients may feel better with massage or a hot shower but will report feeling worse later. This should trigger an evaluation and palpation inspection for sha. See
Box 11.1
for indications for Gua sha or Ba guan.
Figure 11.2
Detail of sha from Gua sha and cupping, representing transitory therapeutic petechiae and ecchymosis that fade in 3–5 days.
Evidence
Changes from Gua sha and Ba guan are commonly felt immediately and are sustained, to some degree, over time, where repeating treatment may be indicated to reach maximum benefit. The recovery of the tissue is expressed by immediate improvement in myofascial pain, with changes in pulse, tongue, digestion, urine, stool, sleep, libido, flexibility, mood and so on (Nielsen 2013). In the language of TEAM Gua sha and Ba guan: resolve blood stasis and pain related to stasis, dredge the channels, vent heat, and quicken internal organ function
.
Chinese randomized controlled trials (RCTs), comparative studies and case series apply Gua sha for adult and pediatric painful musculoskeletal conditions, acute infectious illness, respiratory conditions, autoimmune and inflammatory disorders including organ disease states (Nielsen 2013). In Western RCTs Gua sha was found to be effective in painful breast engorgement, mastitis (Chiu et al. 2010), chronic neck pain (Braun et al. 2011), and for chronic neck and back pain (Lauche et al. 2012b). A 2017 systematic review with network analysis found that compared with placebo-sham, acupuncture and Gua sha combined with warming acupuncture and moxibustion
were effective for decreasing pain intensity in myofascial pain syndrome (Li et al. 2017b).
Figure 11.3
Palpating for sha.
Compared to controls, 8 weeks of weekly Gua sha therapy decreased perimenopausal symptoms: hot flashes, sweating, paresthesia, insomnia, nervousness, melancholia, fatigue and headache (Meng et al. 2017). The benefits in these perimenopausal symptoms were not mediated by any changes in serum estrogen, follicle-stimulation hormone or luteinizing hormone.
Gua sha has been shown to improve muscle strength of university students performing a bench press (Zhao et al. 1995) and to enhance the performance of weightlifters where a series of Gua sha treatments allowed greater weight to be lifted while the subject’s weight sense remained stable (Wang et al. 2014). This benefit may relate to interoceptive nerve stimulation altering sympathetic output, which increases local blood flow, and matrix hydration, as discussed below. Gua sha was found to benefit parasympathetic nervous activity and modulate heart rate variability (HRV) in healthy men and weightlifters (Wang et al. 2015). In the latter trial, serum markers showed a sparing of creatinine kinase (CK) and blood urea nitrogen (BUN) that is associated with exertional muscle damage indicating the potential of Gua sha to facilitate muscle and fascia loading in athletic performance.
Cupping has been described in Western medical literature longer than Gua sha (Dekkers 1694). In systematic reviews of trials, the main purpose of cupping therapy was to relieve pain, whether related to disease or musculoskeletal problems (Cao et al. 2010, Cao et al. 2012). A 2017 systematic review found cupping to be comparable to acupuncture in relieving pain related to cervical spondylosis, scapulohumeral periarthritis and lateral femoral cutaneous neuritis (Zhang et al. 2017). Dry cupping has been found effective for neck pain (Lauche et al. 2011, Lauche et al. 2012a, Lauche et al. 2013a), chronic neck and shoulder pain (Chi et al. 2016), carpal tunnel syndrome (Michalsen et al. 2009) and equal to E-stim for plantar fasciitis (Ge et al. 2017). Home-based cupping ‘massage’ was found superior to progressive muscle relaxation in patients with chronic neck pain (Lauche et al. 2013b).
As with acupuncture therapy, Gua sha and Ba guan are applied segmentally to a region of interest (Nielsen 2013). This creates more petechial substrate and increases areas of tissue stretch, which, per TEAM perspective, resolves stasis, and supplies and drains an affected area. For example, in treating carpal tunnel syndrome, Gua sha is applied to the neck, shoulder area, upper back and then the arm (Nielsen 2013, Braun et al. 2011). In a trial of cupping for carpal tunnel syndrome, cups were applied to the trapezius muscle on the affected side (Michalsen et al. 2009).
Contraindications
Gua sha and dry cupping are contraindicated where the dermis or flesh is injured or compromised as in sunburn, abrasion, rash or contusion. Gua sha or Ba guan are indicated for injury but are not applied directly at the area of trauma but adjacent, proximal or distal to a site. Gua sha and Ba guan are always applied to areas that are relaxed, allowing for painless tissue stretch and expression of petechiae (Nielsen 2013).
Gua sha, Ba guan and acupuncture are contraindicated in areas where a patient has regularly used topical antibiotics or steroid creams as in eczema, for example (see
Safety
below), since such topicals increase the risk of colonization of
Staphylococcus
or even MRSA at the skin (Hon et al. 2013), whereby penetrating treatment can deepen the pathogen into the body causing systemic infection.
Gua sha and Ba guan are safe for patients who are weak or menstruating, or pregnant. Effective manual techniques may be preferable to some medications that may carry risk in pregnancy, for sinusitis, colds and cough, for headache, neck, shoulder, back and hip pain, and sciatica. Gua sha and Ba guan can be used safely in patients with a stable INR (International
Normalized Ratio) who take anticoagulation medication because the capillary bed is not damaged with Gua sha (Nielsen et al. 2007). With Ba guan, the practitioner must be attentive to the amount of suction and length of application of the cups to avoid hematoma, erroneously attributed to acupuncture by Kenz et al. (2012).
Biomechanism/physiology
Observation
When applying Gua sha, the practitioner experiences a clear stretching of the surface tissue with a gradual expression of small red petechiae (sometimes brown, blue, very deep red or nearly black). Gua sha is continued until all the sha is expressed, something gained from experience. The patient often feels exhilarated, invigorated, even excited. Pain is immediately affected, sometimes completely resolved. Nausea and vomiting cease, wheezing, shortness of breath and/or coughing lessen or completely resolve (Nielsen 2013). It is the closely timed repeated press-stroking and unidirectionality that facilitates the appearance of petechiae. And it is the myofascial stretching, the intentional extravasation of petechiae and their resolution over time that has unique physiological significance.
When applying cups, a practitioner observes surface tissue draw into the cup. The expression of petechiae may be similar if slower. Stationary cups reduce the area of sha expression seen with Gua sha or moving cups. Patients also report a shift in symptoms including improvement in pain and mobility.
Patients experience a warming effect with both Gua sha and Ba guan, with a notable adaptogenic response where a cold or chilled patient will become warm and a patient who has fever or is overheated, as in sunstroke, will have heat and stasis ‘vented’ (Nielsen 2013).
Biological measures
Biologic research contributes to a partial and building knowledge of the therapeutic physiology involved with Gua sha and Ba guan. Basic lab studies in perfusion, temperature and serum markers help to contextualize the immediate and longitudinal effects.
Perfusion
Gua sha increases surface microperfusion 400% for 7.5 minutes and significantly for 25 minutes after treatment at but not outside a treated area, while immediately reducing pain locally and distally (Nielsen et al. 2007). Skin blood flow increases with moving dry cupping, the technique that is closer to Gua sha, at 10 minutes following treatment (Tian et al. 2013). Increase in local blood oxygen at and surrounding a treatment site is reported in a five-minute cupping study that produced nummular petechiae similar to Gua sha (Li et al. 2017a).
Temperature
Gua sha and Ba guan treatment both result in sense of warming in the area treated, with measured increase in surface skin temperature (Xu et al. 2012, Chi et al. 2016). It is important to note that while there is an established increase in temperature, this may or may not result in an increase in overall body temperature, but rather, as in the case of fever and inflammation, results in a reduction.
Pain, inflammation and immunity
Nitric oxide (NO) mediation
Nitric oxide (NO) is an important mediator in both health and disease affecting smooth muscle relaxation, vasodilatation, platelet function, inflammation, and pain perception (Mackenzie et al. 2008) with roles in angiogenesis, neurotransmission and wound healing (Nichols et al. 2012). Blood flow is normalized in the presence of NO which may reduce ischemic pain and inflammation, even with small amounts of transiently produced NO (Abramson 2008). Nitric oxide’s action on physiology is highly dependent on location, source, and concentration (Nichols et al. 2012). While nitric oxide is a small molecule
produced in confined compartments within different types of cells, its site-specific effects are sensed throughout the entire organism. The effects of this molecule at the organism level are not the result of a long half-life, high stability or free diffusion, but the consequence of localized effects of nitric oxide at various cellular levels and in different cell types, modulating and orchestrating complex responses requiring cross-talk among organs (Villanueva & Giulivi 2010). Production of NO in the process of increased perfusion and vasodilation is one hypothesis for the immediate pain relief experienced locally and distally with Gua sha (Nielsen 2013).
Acupuncture is associated with production of nitric oxide (Tsuchiya et al. 2007) with authors suggesting that regional increase in NO accounts for changes in local circulation and that both are implicated in the complex analgesic effect of acupuncture. NO contribution has shown potential benefit in wound healing from increase in NO secretion, sensitivity or both (Cao et al. 2013), including burn wounds and in connective tissue repair (Nichols et al. 2012). NO release from fibroblasts promotes collagen synthesis, highlighting the potential of NO-releasing therapies in tendon repair (Witte et al. 2000). In an observational study of 1008 patients including children, acupuncture given as first aid immediately after, optimally within 48 hours, of a burn injury reduced pain, reddening, pigmentation, scarring and PTSD that commonly follows traumatic burns (Loskotova & Loskotova 2017).
Other manual therapies have been studied in terms of their release of NO including osteopathic manipulation (Salamon et al. 2004), cranial–thoracic trapezius stretch (Kiernan 2010), and self-myofascial release using a foam roller also shown to reduce arterial stiffness (Okamoto et al. 2014), increase joint range of motion, muscle recovery and performance (Cheatham et al. 2015). In vitro study found that reduced wound closure rates and enhanced cell death activity in response to injurious repetitive motion strain was attenuated by a single dose of modeled myofascial release (Cao et al. 2013, Meltzer et al. 2010).
Interoception
Interoception is the sense of the physiological condition of the body, which includes muscle effort and homeostasis sensations such as the need to get warm, urinate, train or to run. Interoceptive nerve endings are prevalent in muscle tissue. With a large initial drop in interstitial fluid pressure at the onset of acute inflammation (Langevin et al. 2013), stimulation of interoceptive receptors results in increased matrix hydration via plasma extravasation (Schleip 2003) as is seen with Gua sha and Ba guan. Gua sha’s potential to alter interoception is seen in enhanced athletic performance, muscle and fascia loading (Wang et al. 2015).
Ferroheme metabolism: upregulation of heme oxygenase-1 (HO-1)
Extravasated petechiae immediately change to ecchymosis, blend and fade over 3–5 days with Gua sha and a bit longer for cupping depending on the extent of pressure and length of time the cups are applied (Zhao et al. 2009). The resolution of petechiae involves what is called the ferroheme metabolic pathway. Extravasated blood cells are re-absorbed and metabolized, catalyzing the transformation of ferroheme into biliverdin, carbon monoxide (CO), and free iron with upregulation of genetic expression of HO-1. HO-1 is the rate-limiting enzyme of the ferroheme metabolic pathway that has the functions of anti-oxidation, anti-inflammation, anti-apoptosis and anti-smooth muscle hyperplasia (Xia et al. 2008). A Harvard study has shown Gua sha upregulates genetic expression of HO-1 at multiple internal organ sites and over a period of days following a single treatment (Kwong et al. 2009).
Activation HO-1 is described as an adaptive response in tissue injury (Agarwal & Bolisetty 2013).
A study of acute exercise such as a half marathon (Thompson et al. 2005), but not a short exhaustive run or ‘eccentric’ exercise (Fehrenbach et al. 2003), increased HO-1 mRNA accumulation in human lymphocytes (Thompson et al. 2005). HO-1 is an emerging therapeutic target in many disease models such as asthma, organ transplant rejection, inflammatory bowel disease and experimental autoimmune encephalomyelitis, even though the immune pathological mechanisms of these diseases are dissimilar (Xia et al. 2008).
Upregulation of HO-1 has been reported to be effective in the control of hepatitis B virus (HBV) infection and offers hepatoprotection in animal models (Protzer et al. 2007, Wunder & Potter 2003). Induction of HO-1 decreases hepatitis C virus (HCV) replication, as well as protecting against oxidative damage, suggesting a potential role for HO-1 in antiviral therapy and therapeutic protection against hepatocellular injury in HCV infection (Zhu et al. 2008). Even before discovery of these mechanisms, Gua sha has been used and studied for acute and chronic hepatitis in China (Nielsen 2013). Chan et al. (2011) describe a case in a Western journal where a single Gua sha treatment in a patient with active chronic hepatitis reduced levels of liver enzymes, modulated T-helper (Th)1/Th2 balance and enhanced HO-1, which they suggest is responsible for the hepatoprotective effect (Chan et al. 2011).
While Gua sha provides an anti-inflammatory rescue to an inflamed liver, it does not alter liver function in healthy subjects (Chan et al. 2013). Benefit for hepatitis is not attributed to placebo as ‘liver status’ is not subject to expectation.
HO-1 can exert a significant antiviral activity against a wide variety of viruses, including HIV, hepatitis C virus, hepatitis B virus, ‘enterovirus 71’, influenza virus, respiratory syncytial virus, dengue and Ebola virus (Espinoza et al. 2017) and acute inflammatory, infectious even neoplastic gastrointestinal disease (Chang et al. 2015). A single Gua sha treatment has been shown to increase the immune response to intradermal vaccination (Chen et al. 2016).
Connective tissue model
Painful conditions or illness may be accompanied by altered or inflamed connective tissue and are observed to respond to manual therapies, including Gua sha and cupping. Palpable sensations of physical release reported by manual therapists cannot be due to ‘deformations produced’ in the firm or dense fascial tissue, since dense fascial tissues require very large forces, far outside human physiologic range, to produce even a 1% compression or shear (Chaudhry et al. 2008). Rather, manual therapy may stimulate fascial mechanoreceptors that trigger tonus changes in connected skeletal muscles, in addition to NO relaxation of skeletal muscles vis-à-vis vasodilation.
Subcutaneous tissue is a part of a bodywide network of ‘loose’ connective tissue that is intimately associated with all other tissues, including organ systems (Langevin 2006). ‘Loose’ connective tissues serve to transmit mechanical signals to and from abundant fibroblasts, immune, vascular and neural cells present within tissues (Iatridis et al. 2003). They generate dynamic evolving patterns that interact with one another as a ‘body-wide mechanosensitive signaling network’ that influences, and is influenced by, function that is normal, pathological (Langevin et al. 2006, Langevin 2006) and, by inference, responsive to manual intervention.
The channels of TEAM communicate through what the ancients called the ‘li’ or ‘cou li’ lining which corresponds to fascia and connective tissue (Nielsen 2013, Lin and Yu 2009) (
Fig. 11.4
). TEAM was the first medical system to propose this ‘lining’ as an actual organ, the San Jiao or Triple Burner (Unschuld 1986), the only organ that lacked a recognized Western analogous structure, until the relatively recent focus on fascia and connective tissue. The San Jiao governs and links the ‘exterior with the interior’, the outer flesh to the organs via the channels that reside in the ‘li’, lining (Epler 1980, Unschuld 1986); hence the fundamental construct of a global physiologic network that coincides with the connective tissue model (Langevin 2006, Langevin & Yandow 2002).
Figure 11.4
Western and Eastern surface anatomy. Biao is the surface. The Cou Li, or lining, corresponds to the superficial fascia in Western anatomy. Arteries, veins, nerves, lymph vessels and nodes run through the deep layer of superficial fascia and Jing Lo vessels also run through this layer. Wei Qi moves through the fatty layer. From Nielsen A 2013 Gua sha, a traditional technique for modern practice, 2nd edn. Churchill Livingstone Elsevier, Edinburgh, p 34, with permission.
Connective tissue is sensitive to directionality of manual therapy. Dense ‘regular’ connective tissue of tendons, ligaments, aponeuroses and intermuscular septa respond to tensile loading with collagen strands in parallel arrangement along the direction of the loads imposed (Langevin & Huijing 2009).
Directionality
Gua sha and Ba guan share in the NO release associated with manual therapies, but to a greater degree with the increased vasodilation seen with Gua sha or Ba guan. Directionality of manual therapy also elicits a specific response. Acupuncture needle rotation that is unidirectional produces more torque in connective tissue that is, in turn, more responsive, than to bi-directional rotation (Langevin et al. 2007). Endothelial constitutive nitric oxide synthase (ecNOS) mRNA expression has been shown to be time- and mechanical force-dependent (Ziegler et al. 1998b) wherein the effect of unidirectional force or stress differs from oscillating or alternating force or stress in vascular endothelium production of nitric oxide (Ziegler et al. 1998a).
The mechanical response behavior of ‘loose’ connective tissue is linear and viscoelastic under uniaxial tension (Iatridis et al. 2003). Anti-inflammatory cytokine secretion is activated by directionality of myofascial release: pressure and shear that create uni-axial fibroblast strain can account for improved range of motion (ROM), decreased edema, and reduced analgesic requirements as well as for ‘long-term benefits despite short-term treatment’ (Meltzer et al. 2010, Standley & Meltzer 2008). Gua sha is always applied with unidirectional stroking. While dry cupping may
be stationary or slow gliding bidirectionally, it is typically with and not across the muscle fiber direction.
Safety
The most significant and consistent complication reported in the Western medical literature for Gua sha is the misattribution of the sha petechiae and ecchymosis as a burn, bruise, or dermatitis/factitial dermatitis caused by ‘abuse’, ‘battery’, ‘torture’, ‘pseudo-abuse’ (Nielsen et al. 2007; Nielsen 2009). This ignorance and bias represents a risk to patients that can be mitigated by providing a handout explaining the technique, describing the normal presence of therapeutic petechiae, and providing the clinician’s contact information (
www.guasha.com
).
A report of acute epiglottitis following Gua sha at the trachea represents a negligent use and not a side effect or risk of appropriate Gua sha (Tsai & Wang 2014). Adverse events associated with negligent cupping include suction bullae blisters, fire cupping burns, psoriatic Koebner phenomenon, factitial panniculitis, keloid formation, and
Staphylococcus
, herpes simplex, and
Mycobacterium
infection (Xu et al. 2013, Nielsen 2015, Hon et al. 2013).
Practitioners need to be aware of patients who may have an increased risk of infection – have reduced immune response via disease, chemotherapy, steroids or other immune suppressant medication, altered skin barrier, use of topical steroids or antibiotics that may in turn increase colonization of staph and MRSA (Nielsen 2015).
Universal precautions and contamination risks
Gua sha and cupping instruments that are intended for re-use are considered semi-critical instruments according to the Centers for Disease Control and Prevention (CDC) and must be high-level disinfected or sterilized before reuse (Rutala et al. 2008). Because bone and horn tools cannot sustain high-level disinfection or sterilization required, single-use disposable caps with a smooth edge are recommended (Nielsen et al. 2012, Nielsen et al. 2014). Dedicated instruments intended for specific patients must also be sterilized or high-level disinfected between each use to be compliant with CDC standards.
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Patient reports pain that is fixed, persistent or recurring
