Acupuncture & TCM Articles

Gua Sha:
Smoothly scraping out the Sha

By Bruce Bentley - Health Traditions

Gua Sha Smoothly scraping out the sha

Bruce Bentley has studied with expert gua sha practitioners at the Shanghai Hospital of Traditional Chinese Medicine (China), and with Mr Trang Lee when he completed a 12-month research project for the Victorian Government titled Folk Medical Practices within the Vietnamese Community. The latter proved an outstanding opportunity to gain rare information about gua sha from a lineage known as the Buddhist wandering monk medical tradition.

By Bruce Bentley

Gua sha is typically performed by rubbing a smooth-edged instrument across the skin surface where a subcutaneous injury or imbalance resides. When treatment is effective, distinctive reddening of the skin, known as sha, is observed. This is a positive response and brings the immediate and lasting benefit of dispelling wind, reducing heat and inflammation, eliminating coldness, and releasing pain from the superficial and deeper levels of the body. Gua sha is used to treat many acute and chronic health problems including colds and flu, fever, headache, indigestion, dizziness, injury, joint pain, fibromyalgia and heat exhaustion. It is also commonly performed to relax tight and aching muscles and to relieve tiredness and fatigue. The stroking action of gua sha to the points and channels can also be practised as a health enhancement method, and can even be performed through light clothing (without the intention of raising sha).

Meaning of the term

You may know it as "spooning", "coining" or "scraping", but all these recent English language substitutes fall short of the tidy meaning that gua sha has in Chinese language. The term gua sha comprises two characters. The first, gua, means to rub or to scrape, and the second, sha, is the name given to the distinctive type of red dotting and discolouration that appears at the skin surface during and after treatment. Gua sha therefore means to rub out sha.

For this reason, I will no longer italicise these Chinese words, as the real meaning is so much better conveyed when left as Chinese terms to become part of the common vernacular. Another term commonly used by the rural population in China is gua feng, meaning to "scrape out the wind". The Vietnamese call it cao gio (pronounced "gow yor") meaning "to scrape out wind". This is interesting because it specifies the etiology of the problem being treated – wind typically being held responsible in rural or traditional communities for just about every type of common illness.

Historical and social background

Like many traditional medical practices, gua sha was probably performed as a folk method long before its first written recording, which dates back around 700 years ago in the Chinese tradition. It may have been discovered way back in prehistoric times when a person happened to rub a painful area repeatedly against a stone jutting out from a cave wall and noted that along with a show of colour, their pain was reduced.

Gua sha is performed throughout Asia, where it is especially popular in China, Taiwan, Vietnam, Cambodia, Laos and Indonesia. During the very sombre Khymer Rouge (Pol Pot) Era in Cambodia (1975–79), all traditional medical treatments, as well as biomedical practices, were strictly prohibited except for gua sha. Anyone found practising any therapy besides gua sha was executed, or if lucky sent to prison – or so a village healer, who was also a school teacher, informed me when I was in Cambodia in 2003. He himself managed to escape detection by perceiving what was in store and pre-emptively leaving the area where he was known, and travelling to the north where he acted as a homeless "idiot" during those years. He told me that gua sha was such a common practice performed by everyone that it was not considered the work of intellectuals and therefore not suspect by the Party. Even cupping and massage were forbidden.

Although experts in the method have developed a broad array of uses for gua sha treatment, for most people gua sha is used as a preventative or as a first-aid treatment for many common health conditions. The vast majority of its use is as a folk medical practice in the domestic setting. In these households, usually mum or dad or a grandparent knows how to perform it. As I have heard said by many Vietnamese Australians, "I do it for myself" or, "It's never hard to find someone who can help you with cao gio."

Knowledge of the method is passed down the generations by an oral and visual tradition, rather than from book learning. There is also no particular gender divide with its practice. Men and women both perform it, although it would be correct to say that it is done mostly by women, who adopt the role of the care-giver in most traditional households. Due to being a safe, effective and cost-effective treatment, the Chinese Government in recent times has also encouraged its practice in the broad social setting.

But gua sha is not an exclusively Asian medical practice, as a friend of mine discovered during a discussion with a 97-year-old Greek woman renowned for her skill as a village healer. When asked if she knew of the method, she replied, "Oh, that's like what I used to do back home. We'd go to the river bed to find smooth stones and rub a painful area of the body until the redness appeared – then I knew it would feel better."

Sha and the associated discolouration also contains the pathogenic factor(s) responsible for the blockage, and when it has been released, normal integrity of the area is restored.

A great 'Aussie' gua sha tale

Some 80 years ago, an eager young massage therapist in New South Wales worked so hard and deepSome 80 years ago, an eager young massage therapist in New South Wales worked so hard and deeply on his patients that he soon developed debilitating hand injuries. Unable to continue his practice, he asked an engineer friend to make a tool he could hold to allow him to resume his practice. He made an iron tool with rounded edges and to his amazement, his treatments produced sha, which he thought was his unique discovery. He interpreted sha as "digging out arthritis". Despite the great pain that his style of treatment caused, he had great success and soon had a remarkably large clientele. He was given the title "Iron Bar Bob". Things went bad again when jealous colleagues in the massage fraternity got upset about "Iron Bar" and forced his disbarment from practice.

Not to be deterred and looking for an income during the Great Depression of the '30s, he decided to put his "discovery" to work on greyhounds. So he and some mates bought retired greyhounds for next to nothing and rejuvenated their careers by getting rid of their arthritis, as it was conceived. Brought back to form, the dogs were then entered in races and bet on, to the disbelief and jeers of the bookmakers – until they had to pay out!

This was all told to me by "Iron Bar's" one and only student (Bob was very protective of his discovery) who came down to Melbourne to study with me during the '90s. He was surprised and relieved to learn that, far from being painful, gua sha can be performed to the same effect in a gentle and pleasant manner which, he agreed, makes it a much better technique.

What is sha?

Sha is the term for the small reddish dots that emerge from the superficial or deeper levels of the body to the skin surface during gua sha treatment. In biomedicine, sha is labelled petichiae by dermatologists, and understood only as a pathologic abnormality. A more dispersed pattern of redness, thought of as ecchymosis (bruising) in conventional Western medicine, is also produced, and is also seen only as abnormal. However, when these forms of discolouration appear, gua sha practitioners are pleased and assured that the treatment has been positive. In other words, with gua sha (and the same can be said of cupping), we are steered to reconstruct our usual way of thinking about "abnormal markings" and appreciate that such presentations, far from being considered "bruising", have completely different associations in practices like gua sha and cupping. In light of Western medical thinking, sha does not exist as the same body phenomenon in the East. The rationale for what produces sha is therefore best explained by how it is understood in traditional medical terms.

According to traditional Chinese medicine, sha is produced when the regular flow of qi and blood becomes stagnant or blocked. This can be due to traumatic injury or to the penetration of adverse climatic factors such as wind or internal pathogenic conditions. In Chinese there is a famous medical saying that goes: "Where there is blockage of qi and blood, there is also pain."

Qi and blood are both warm by nature, so when these two become compressed, as happens with blockage or stagnation, heat manifests and concentrates into a new substance, which is sha. Sha and the associated discolouration also contains the pathogenic factor(s) responsible for the blockage, and when it has been released, normal integrity of the area is restored due to the qi and blood being able to resume flowing smoothly.

In the case of musculo-skeletal conditions many people familiar with gua sha often have it performed as a first-line treatment, in the knowledge that ridding the body of sha takes out the irritant toxins that clog and cause pain.

From a well-informed traditional perspective, massaging the area intended for gua sha is essential to disperse any strong concentration of qi and blood that can cause painful knotting during treatment.

Qi and blood are both warm by nature, so when these two become compressed, as happens with blockage or stagnation, heat manifests and concentrates into a new substance, which is sha.

Demonstrating gua sha

It is always a fascinating time for me when I get the opportunity to demonstrate gua sha to students for the first time — to see the amazement on their faces. What does convince them of its bona fides is the way such a vivid display of sha so readily appears with just a few benevolent light stroking applications over the painful regions. They can appreciate that under "normal" circumstances, there is no way that such discolouration would appear.

What is also convincing is how the receiver will immediately report that they feel much better. A good demonstration of the efficacy of gua sha is when a person in class with a stiff and sore neck nominates themselves as a "model".

Before treatment it is always worthwhile to test their range of movement for observers to note the increase in range and comfort level afterwards.

Comments such as "intriguing" or "totally unexpected" are often heard. One of the reasons that many rural people throughout Asia enjoy gua sha is due to the immediately felt benefits. They say they can get on with their work for the day.

Vietnamese practice

In 2002 I was nominated by representatives of the Vietnamese community in western Melbourne to conduct a 12-month research project funded by the Department of Human Services (Victoria) titled Folk Medical Practices in the Vietnamese Community. I wrote a 180-page report, eventually dissected into two booklets, Vietnamese Folk Medicine Medicine: Application and Safe Practice and Folk Medical Practices in the Vietnamese Community for distribution throughout the Vietnamese community, as well as to health-care services and educational institutions. The therapies focused on were gua sha (cao gio), cupping, pinching, steaming, massage and diet. With regards to gua sha, one of the reasons why Vietnamese community leaders were so keen on this research project was to inform the community about the safe and effective manner in which it should be performed.

The very common practice of using a coin, especially when used in a forceful way (as it too often is) can cause pain, besides the chance of injury. When the skin is broken this can lead to crossinfection of blood-born diseases such as hepatitis and AIDS.

An important chapter in the report highlighted the common misinterpretation of the marks left after gua sha (and cupping) by Western health practitioners or social workers and the like. The report explained that these should not be confused as bruising due to abuse or as the outcome of a misinformed therapeutic practice.

I also had the good fortune, thanks to my contacts, to become the year-long student of a reclusive Vietnamese man who is a holder of the disappearing healing lineage known as the Buddhist Wandering Monk Medical Tradition – a topic for submission to The Lantern in the future. Some of the information in this essay comes from this source. But first here is a brief account of some of the more interesting results gathered from 360 oral questionnaires and 25 in-depth interviews conducted for this project.

According to the questionnaire results, gua sha is the most popular form of treatment used by the Vietnamese community in Melbourne, with a usage rate of 63 per cent. This means that of all the medical interventions available to the Vietnamese, including other traditional therapies as well as Western pharmacological medicine, the most popular of all was gua sha. The 63 per cent usage means that gua sha is the first contact treatment preferred by this large percentage of people.

Among the questionnaires, some of the comments in relation to gua sha (cao gio) and the question "Why do you prefer this method?" were:

Because it works and I don't need to take medicine. (Female, aged 17).
My mum likes to do it. (Female, aged 15).
This method doesn't cost money, it's effective and I can avoid waiting in a long queue to see a doctor. (Male, aged 51).
Because it has good results for many people and so the tradition is maintained. (Female, aged 67).
When I get a cold or a flu I feel like getting cao gio done for me because it opens up the points and gets the blood circulating. It makes my body feel better and relaxed straight away. (Female, aged 29).
Cao gio is effective. I have always used it. (Male aged 22).
"It seems to work every time I have a cold". (Female, aged 22).
Many times cao gio feels very effective, therefore I use it frequently. (Male, aged 67).
I believe that cao gio is good because when you take the Wind out you feel very well. (Female, aged 16)
It gives a quick result. My first preference is to treat myself before I go to see a doctor. (Male aged 61).
I don't like it because it's painful – but it's effective when I have been struck by poison Wind. (Female, aged 18).
Quick, convenient and effective. (Male, aged 18).

Gua sha instruments

While a Chinese porcelain soup spoon or a smooth-edged coin or metal top from a glass jar are commonly used to perform gua sha, nothing accomplishes the task better than a polished water buffalo horn tool made specifically for the job. These are manufactured in China. Besides having an excellent smooth edge, according to the Chinese materia medica, water buffalo horn taken internally clears heat and fire toxin in the blood. Used externally as a gua sha tool, it releases sha factors of wind and heat.

It is also good to note, as I trust my informant was correct, that the water buffalo are not killed for their horns – they are far too valuable as domestic farm animals. Instead, once they have died naturally, their horns are taken and slices are fashioned into gua sha tools. Other means, when resources are scarce, can be the knuckles of the fingers, or even as I observed in the Taiwanese countyside in the 1970s, a man using a bundle of horse mane hairs, wrapped around the index fingers of his hands to treat his neighbour's aching muscles.

Diagnosis

One way to diagnose the presence of sha is to press one's fingers on the site of pain. Under regular conditions, as soon as the fingers are taken away, the impressions left by the pressure quickly disappear. However, when sha is present the impressions of whitening or blanching remain for longer than usual and fade slowly, due to local circulation being restricted due to the clogging effect of sha.

Recommendations for gua sha

Gua sha is relatively easy to perform. It is quite common, however, to see gua sha performed with the same pressure from one person to the next. A better way depends on the strength of the person receiving treatment. If the patient is robust, then gua sha can be applied quite slowly with a degree of pressure. However, for anyone who is weak or ill, the pressure should be light and brisk to invigorate the points and clear the channels. It is most unfortunate that some practitioners use far too much pressure when they perform gua sha. I have heard many stories from people complaining that gua sha was painful, even excruciating. This is bad practice, completely unnecessary and wrecks the reputation of the treatment.

Informed consent

One of the challenges for practitioners during the process of obtaining informed consent before proceeding with the therapy, is explaining to the patient what gua sha is; and the likelihood that even with light stroking, a series of markings are likely to appear. In a nutshell, this is how I usually go about it. The explanation serves a better purpose if it is informative and brief. Let's imagine this patient has painful shoulders.

I think it would be a good idea to do some gua sha for you. It's a Chinese method for relieving sore muscles by stimulating the release of a special type of toxin called sha, which causes pain and stiffness. It is a relaxing and comfortable method using this instrument [buffalo horn tool is shown] and it will probably bring the toxin to the surface, which will temporarily cause marking to the skin. When this happens, you should feel much better. It will quickly fade within 24 hours and usually disappear within three to four days.

After checking for any contraindications (discussed next page) and inquiring whether the markings may cause social distress, you can then ask: "Does this sound fine by you?'

I find most people are receptive to this explanation. The only refusals are when the patient had received gua sha previously from a practitioner who had been far too strong with their application.

After a treatment, it is also a really good idea to have two mirrors in your practice room so the patient can see the reflected image from behind.

It can be very disconcerting for someone to see the markings later when the practitioner is not present to provide reassurance.

How to perform gua sha

Gua sha is applied primarily on the back, neck, shoulders, buttocks and limbs. A thickish oil is spread over the area to be rubbed. The instrument is held comfortably in the hand and the practitioner usually makes 10 to 30 strokes in a downward direction away from the head. A simple measure to be certain the force used is correct is to ask the person receiving if they are comfortable with the pressure. For best results, gua sha is emphasised on both local and distal acupuncture points determined by diagnosis.

Method of practice

If you are right handed then hold the gua sha instrument in your right hand. Your arm should be comfortable and relaxed.

1. Your instrument should be held at a 45-degree angle to the area you wish to treat.
2. Begin with soft scraping for the first few strokes, then apply a little more pressure if required. From this point, do not get heavier with your scraping. Remain consistent, applying a suitable strength and rhythm.
3. Try to perform long (15–18 cm or about 6–7 inches) uninterrupted strokes where possible.
4. Scrape in the same direction, ie. downwards – do not scrape downwards and draw back upwards.
5. Each stroke should be performed between 10 and 30 times before proceeding to the next area.
6. Once an area is completed, cover it up immediately with a towel to keep warm.

Note: Be extra careful not to scrape over any mole, pimple or irregular skin area. To protect a mole, place your finger over it to guard against contact. Open windows, drafts, fans and air conditioning are not recommended during treatment to avoid pathogenic wind entering the open skin pores.

After gua sha

• Allow the receiver to rest for a while and give him or her a glass of warm water.
• Instruct the receiver not to shower or bathe within one hour after treatment. A cold water shower or bath should be avoided for at least 24 hours.
• Inform the receiver it is important to keep all treatment areas covered up and warm. They should also be sure to keep away from windy conditions including fans and air-conditioning.

Cautions and contraindications

Take care to avoid pimples, moles and other skin irregularities that may be scratched or broken if an instrument is rubbed over it. Care must also be taken to rub the area with appropriate pressure. The first rule of any therapeutic procedure is DO NO HARM.

Do not apply gua sha:

1. To people who are too weak to tolerate the treatment.
2. To people with bleeding disorders.
3. To people who are taking anti-coagulant medication, eg. warfarin.
4. During pregnancy.
5. Soon after surgery.
6. Over varicose veins, skin disease or open wounds, scratches etc.
7. To a person suffering from a serious communicable disease.
8. Within one hour before or after eating.

Gua sha or cupping?

While there are some similar applications for gua sha and cupping, gua sha does a better job of removing sha. Sometimes sha can be observed when stationary cups are applied, and often even more is drawn to the surface with the sliding cup method. However, gua sha has the superior ability to thoroughly draw this toxin to the surface – where it gets ejected entirely from the body by the action of the wei qi. Gua sha is also considered better at resolving pathogenic influences from the surface, while the pulling action of cupping has the benefit of drawing pathogens from deeper levels of the body.

A simple example of the value of gua sha, especially when carried out with a water buffalo horn tool, and where cupping is impossible, is in the treatment of headache (sometimes also associated with itchiness) at the scalp level. Gua sha, (in this case without the need for the presentation of sha) that opens the yang channels throughout the head has the most effective and satisfying ability to remove wind-based pain conveniently and quickly. This is pertinent when we recall the principle from Basic Questions, chapter 5: "It is best to treat (diseases at the level of) the skin and hair."

A terrific illustration of gua sha's ability to brighten the senses and allow the clear yang to circulate can be felt by performing the following practice. Take your gua sha tool, close your eyes and for a few minutes scrape comprehensively throughout one side of your forehead (very lightly) and head to the occipital line and on down the jade column (otherwise known as the upper trapezius muscle). Allow yourself to rest briefly then open your eyes. How does that side feel compared to the other?

Case study 1

In 1998 I was conducting research in Xinjiang province in north-west China, travelling by bus to a town that was known as one of China's "three furnaces". In these shimmering desert landscapes people mostly live underground and not a soul is seen when the sun is high. On the way there, I passed "Flaming Mountain", made famous by its description in the classic Journey to the West. It was incredibly hot as I sat on the back seat of a bus for four hours with the sun beating down on the back of my neck. When I arrived, as I was getting off the bus, I felt a bit shaky and an hour later as the sun began to sink I really began to feel quite unwell and emotionally disoriented.

It was my first experience of summerheat syndrome (heat exhaustion) and luckily my hotel manager knew what to do. As I sat outdoors in the eating area shaded by grape vines, he noticed how I looked and said: "We get this all the time, let me fix you up." He did gua sha to the top of my head, beginning at the point Bai Hui (Du-20) and scraped some 6–7cm (two inches) towards my forehead. Next, from Bai Hui, he scraped the same distance to the left and right side of the point and then down the midline towards the back of my neck. He concluded by scraping from Feng Chi (GB-20) down the midlines of both sides of the trapezius muscles. The process took only a few minutes and immediately I felt like I had never had a problem.

It was truly an impressive recovery and I know of no other method that would have come close to the benefit I got in such a short time. The explanation is that the heat, which rises in the body (as heat does), was efficiently vented at and around the Bai Hui point as well as released from the neck and upper back. My scalp and trapezius were a veritable mass of sha – and I could not have been happier. Isn't it terrific when we practitioners have such an effective and insightful healing experience – and having a hotel manager cum gua sha practitioner do it on site is just one example of what I love about Asia.

Case study 2

During a tuina class, I introduced gua sha and asked for a volunteer who had a sore and stiff neck. The first hand that shot up belonged to a male aged in his 20s who worked with computers all day. Immediately after the treatment he felt much relieved and all the students witnessed a dramatic show of sha throughout the back of his neck and upper back. They also noted following a mobility test before treatment how much more movement was possible for him compared with two minutes before. He reported in class a week later that the area still felt much better. The other students of course clamoured to get a look at his neck to see whether markings remained, but true to form, all had completely faded by then.

A few months passed and I was teaching a Gua Sha Day course. I again asked for a volunteer for the first demonstration of the day. I asked for someone with a sore back and the same person as before got in first. Now, I am not making it up – I had completely forgotten I had previously performed a treatment on this guy. I began doing gua sha along his occipital line, down both trapezius and across his upper shoulders … and nothing! It is times like this as a teacher when you need to keep a brave face! Anyway, I proceeded (in desperation) and remarkably, as if a line had been drawn, a mass of sha appeared from the upper margin of the scapula and throughout the rest of the interscapular margin. Strong sha was also released from both infraspinatus regions. Whew! But I was perplexed, and remarked how strange it was for the upper area to be free of sha while the rest of the area had such a flush of the stuff.

Then my "model" perked up and said: "Don't you remember that you did the neck and shoulders in a quick demo a couple of months ago at school?" His reminder then proved to be a superlative example of gua sha. Firstly, it showed in the best way possible that only when there is a problem does sha emerge, and second, in this case at least, even though the person did the same job, the area that was first treated had maintained a good level of comfort and mobility.

By Bruce Bentley - Health Traditions

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