“Gua Sha Massage: How to Do It; Why It Works”
“Gua Sha Massage: How to Do It; Why It Works”
Untold Secrets of China’s Most Powerful Massage Technique ©2013
By Dr. Harvey Kaltsas, A.P. , Dipl. Ac. (NCCAOM)
“Those who give their bodies a good cure (first) treat their skin and hair; their next treatment concerns itself with the muscles and the flesh…”
Physician Ch’i Po in the Nei Ching (the oldest book in the history of traditional Chinese medicine)
When it comes to treating painful afflictions, most Chinese grandmothers have it all over Western physicians. They know how to make most pain go away (without expensive surgery or the use of potentially addictive drugs laden with unhealthy side effects) by using a simple massage technique known as gua sha. This article will teach you the technique, but more importantly it will teach you the how, when, and why to do gua sha massage. Practicing techniques without understanding can be dangerous – hence the length of this article.
My own understanding of gua sha all started one cold, blustery day in December, 1974 when I was putting a Selkirk™ stainless steel chimney through the roof of my farmhouse in Saskatchewan, Canada. The temperature was 20 below zero Fahrenheit with a stiff wind that knifed through my overcoat as I wrestled with this cumbersome contraption, trying to maintain my balance on the slanted, slippery roof.
I was hoisting the chimney pipe into place while my friend Lew pushed it up from below. Somehow we got our signals crossed, and the entire weight of the chimney was suddenly left to me. As I struggled to keep the chimney from plummeting down below, it pulled, stretched, and tore most of the attachments of my rhomboids to my left shoulder blade.
Even though I was then an invincible and immortal twenty-seven years of age, it hurt like hell, and every time the weather turned damp or cold or windy, which is virtually everyday in Saskatchewan, I would writhe in agony from sporadic fits of pain, which extended from my shoulder blade all the way down the backside of my arm to my baby finger.
On occasion I would lean up against a door jump and rub it to gain some relief, but basically I was miserable for a year. The pain humbled me and left me despairing that
I would always be subject to its whims, never knowing when it would flare up.
A year later I moved back to Boston and had the very good fortune to intern as an acupuncture apprentice with Dr. John Ho Fen Shen at his clinic in Everett. After a few days of watching him perform miracles with patients, I dared to broach the subject of my own malady. In short order he diagnosed me with a wind cold invasion of the triple warmer, small intestine, and urinary bladder musculo-tendino meridians and inserted a few appropriately placed needles, at Triple Warmer 3 being one I can distinctly remember.
Then he uttered words I will never forget: “You need gua sha massage to release the wind.” Like most North Americans, I had never heard of gua sha, even though unlike them I had been studying macrobiotics with Michio Kushi since 1970 and had studied at the North American College of Acupuncture in Vancouver from 1973 to 1975.
Dr. Shen approached me with a jar of Tiger Balm™ and a plastic spoon left over from the Chinese take-out food which we’d had for lunch. He smeared the Tiger Balm™ on and started scraping the back of my left arm, shoulder, and shoulder blade.
To my amazement, the reservoir of pain which had been pent up in those pathways drained out of me like a dam had burst, and soon I was pain free for the first time in a year. Over the next few weeks Dr. Shen gave me a few follow-up treatments – to my relief with a proper porcelain spoon – and I was able to resume a relatively pain free life, with only occasional flare-ups when the weather turned bad. Those times were relieved by more gua sha massage.
During my year of apprenticeship with Dr. Shen, gua sha became my specialty, and I was called upon to do it to many, many patients, most of whom experienced dramatic relief. It is the single most effective massage technique I have ever used.
Dr. James Tin Yau So became my other mentor at Dr. Shen’s clinic, and together they taught me their underlying theories of how to do gua sha and why it works. Dr. Shen and Dr. So both instructed me that if a patient has pains in the neck, arms, back, and joints, or even on the abdomen and intercostally, if the pain is intermittent, and especially if the pain varies with changes in the weather, then the patient probably suffers from a condition known as sha.
If the doctor assumes the patient simply has rheumatism and treats him/her for that only with herbs, acupuncture, and/or moxa, the symptoms will probably come back in a couple of days. If the doctor treats with gua sha massage, the patient will get much better.
Gua is Chinese for scraping. Sha is a Chinese medical term which lacks an accurate English translation, but the word sha in Chinese means sand; and sharks, which have a sandy like appearance to their skin, are called sand fish. When one performs gua sha massage, scraping the skin, the skin develops petechiae or little bruises which give it this sand like appearance.
Is Gwa Sha a Form of Detox?
I have read some explanations that sha is a condition “in which the waste products of cellular metabolism (the burning of glucose in the cells for energy) become trapped in the muscle fibers, often as the result of major trauma such as whiplash but sometimes from accumulated smaller traumas from daily wear and tear and exercise.”
However neither Dr. Shen nor Dr. So ever mentioned toxins to me in relationship to sha, and it is probably an insufficient understanding of what is really going on to think that sha represents an accumulation of toxins, at least in the Western sense.
When too many toxins are released into the bloodstream all at once, the patient often experiences a Herxheimer reaction. “The Herxheimer reaction (also known as Jarisch-Herxheimer or herx) occurs when large quantities of toxins are released into the body as bacteria (typically Spirochetal bacteria) die, due to antibiotic treatment.
Typically the death of these bacteria and the associated release of endotoxins occur faster than the body can remove the toxins via the natural detoxification process performed by the kidneys and liver. It is manifested by fever, chills, headache, myalgias, and exacerbation of cutaneous lesions. Duration in syphilis is normally only a few hours but can be much longer in other diseases. The intensity of the reaction reflects the intensity of inflammation present.”
The Herxheimer reaction also happens when candida die off from anti-fungal treatments. Patients get tired, achy, and even groggy during die off reactions when their eliminative organs cannot process the sudden onrush of newly released toxins.
However, this does not occur when one does gua sha, even though there is a dramatic, obvious reaction if sha is present. Upon scraping, the skin can turn various colors, from pink to bright red if the condition is new or to purple with little black spots if the blood has been stuck a long time.
Something is obviously being released, upwards to the surface, but patients do not feel tired or achy afterwards. If anything, they feel relieved, refreshed, and free of pain and discomfort, often remarkably so. This is uncharacteristic of a release of toxins as others have assumed. Certainly some toxins are released in the process of doing gua sha, but detoxification is not the principal component in patient’s quick recovery after this therapy.
What is Sha, Really?
What is happening then? Also, why do fried or sugary foods contribute to sha? Why does traumatic injury contribute to sha? Why do changes in weather aggravate this condition, and are there any special groups of patients on whom you should not perform gwa sha? These are all questions the acupuncture profession in America has left largely unexamined and unanswered for decades. Until now.
Everyone in Traditional Chinese Medicine understands that sha impairs the circulation of blood, but how? To comprehend the phenomenon of sha, one must first consider the physiology of the circulatory system. Wikipedia provides some help here:
“Blood flows from the heart to arteries, which narrow into arterioles, and then narrow further still into capillaries. After the tissue has been perfused, capillaries widen to become venules and then widen more to become veins, which return blood to the heart.
“Capillaries are the smallest of a body’s blood vessels, measuring 5-10 μm [micrometres (1/1000 of a millimeter) in diameter], which connect arterioles and venules, and enable the interchange of water, oxygen, carbon dioxide, and many other nutrient and waste chemical substances between blood and surrounding tissues.”
Capillaries, which are made of single layers of epithelial cells, expand or contract in diameter as an indirect function of the circulation of potent vasoconstricting hormones such as adrenaline, angiotensin II, and endothelin or the circulation of potent vasodilating hormones including prostacyclin and nitric oxide.
These hormones directly affect the metarterioles (or arterial capillaries) which are short vessels that link arterioles and capillaries. Instead of a continuous tunica media, they have individual muscle cells placed a short distance apart, each forming a precapillary sphincter that encircles the entrance to one capillary. Constriction of these sphincters reduces or shuts off blood flow through their respective capillaries and diverts blood to tissues or organs elsewhere.”
Also, endothelium derived factors play an important role in controlling local blood flow. These substances are either produced or modified in the vascular endothelium, and an accumulation of metabolites such as CO2, K+, H+, adenosine and lactate causes vasodilation.
Another factor in whether arterial capillaries expand or contract, as any arthritis or Raynaud’s patient can tell you, is weather, with its increasing or decreasing temperatures and changing barometric pressures which can affect osmotic pressures in and around the blood cells.
“When you get cold and come inside, it feels hot because your capillaries are constricting due to the overwhelming change in external temperature. The osmotic pressure is trying to increase, but the arteriole venue will not let this process to develop, and so pain and heat become evident.”
This should be a clue to us that capillary expansion or contraction is somehow related to the phenomenon of sha, since one of the common indicators of sha is that the pains vary with the weather.
Acupuncture is known to cause vasodilation by relaxing the sphincter muscles of the metarterioles. This is probably why Dr. So suggested doing acupuncture first when treating patients, because he found that makes the gua sha more effective.
“The flow of blood through the capillaries is fundamental to a feeling of well being, which is why the “…walls of capillaries are composed of only a single layer of cells, the endothelium. This layer is so thin that molecules such as oxygen, water and lipids can pass through them by diffusion and enter the tissues. Waste products such as carbon dioxide and urea can diffuse back into the blood to be carried away for removal from the body. Capillaries are so small the red blood cells need to partially fold into bullet-like shapes in order to pass through them in single file.”
Another factor affected by weather is the flow of blood. As the Physician Ch’i Po instructs in the Nei Ching, “…when the weather is warm and the sun clear and bright, the blood of man flows gently and his secretions protect his breath (vigor) and keep it volatile. Hence the blood flows easily and the breath moves smoothly.
“When the weather is cold and the sun darkened, man’s blood coagulates and does not flow, and his hitherto protected breath sinks low and perishes.”
Ch’i Po also says, “When a person is exposed to the wind, either lying down to rest or walking about, his blood will be affected. The blood then coagulates within the flesh, and the result is numbness in the hands and the feet.”
Besides their effects on dilating or contracting the capillaries, how do changes in weather such as cold and wind affect the flow of blood? The parts of the blood which concern us with respect to gwa sha are red blood cells and plasma.
Red blood cells or erythrocytes “are bi-concave disks. They are flattened and depressed in the center, with a dumbbell-shaped cross section. This shape optimizes the cell for the exchange of oxygen with its surroundings. The cells are flexible so as to fit through tiny capillaries, where they release their oxygen load into surrounding tissue… The diameter of a typical human erythrocyte disk is 6–8 µm, much smaller than most other human cells.”
Erythrocytes: (a) seen from surface; (b) in profile, forming rouleaux; (c) rendered spherical by water; (d) rendered crenate by salt. (c) and (d) do not normally occur in the body.
It is very important to note that the capillaries through which red blood cells must squeeze are 5-10 μm in diameter, and the erythrocytes themselves are 6–8 µm in diameter. This can make for can be a very tight fit in the best of circumstances. Add to this the fact that capillaries can be compressed by excess extracellular (interstitial) water, and it can be a very tight fit indeed for red blood cells to squeeze through the capillaries.
Mother nature helps out a bit here by coating the inside of the capillaries with lecithin, a teflon™type substance which makes the capillary walls smooth and slippery. Also it is good that it’s a tight squeeze, because the red blood cells, pressed up against the sides of the capillary walls, give up the oxygen they carry through osmosis to the surrounding tissue and pick up carbon dioxide in return, which is eventually exchanged in the lungs for more fresh oxygen.
When red blood cells flow through the capillaries, they do so single file, one at a time. Also, like all phenomena in nature, red blood cells have their own yin/yang nature. Part of the red blood cell, being composed of iron, carries a positive electrical charge and part of it carries a negative electrical charge. As the red blood cells line up single file, they do so with opposite polarities facing each other, positive to positive and negative to negative. In this manner, the red blood cells to some extent repel each other electromagnetically, and thus they do not stick together as they flow through the narrowest passages of the circulatory system.
But what happens when they do stick together as in figure b above? This is called a “rouleaux formation, a stack-like arrangement of red blood cells in blood or in diluted suspensions of blood in which their bi-concave surfaces are next to each other… “In large blood vessels, red blood cells sometimes occur as a stack, flat side next to flat side… and it occurs more often if the levels of certain serum proteins are elevated, as for instance during inflammation.”
Why would nature design certain molecules found during inflammatory processes to cause red blood cells to stick together? The answer is because after traumatic injury, the body is at risk of bleeding to death. When red blood cells stick together they have a much harder time passing though the capillaries and out of the body. The proteins found during inflammation serve as a localized shut off valve to keep the rest of the body alive by preventing the wounded area from spilling out too many red blood cells.
In rouleaux formation, erythrocytes can pass easily though the larger arteries and arterioles, but they have a very hard time fitting through the capillaries. Clumping together like this is also called hemagglutination, and for red blood cells, it’s like a logjam on a river. The logs (red blood cells) get stuck together, jam up against the opening of the river (the capillary mouth) and can’t flow downstream.
As a result, the tissues in that area get deprived of the vital oxygen which the red blood cells are supposed to transport to them. You know how your lungs start to scream in pain when deprived of oxygen for a few minutes? Imagine what tissues deprived of oxygen must feel like.
This, in my humble opinion, is the physiological nature of sha and the reason why it hurts.
These same tissues also have waste carbon dioxide they need to exchange for oxygen, but this is not such a big problem, because 93% of the carbon dioxide given off by tissues is carried away in plasma in the form of bicarbonates.
Fortunately, much plasma does continue to flow, since it is a thinner solution, mostly 91.5% water which acts as a solvent to carry other substances, namely proteins (7%), and salts, nutrients, enzymes, hormones, and nitrogenous waste products (1.5%). 
However, some plasma flow is restricted, and this, along with the clumping of red blood cells, causes localized edema in areas of sha.
Plasma has other qualities and functions as well:“The higher concentration of protein in [plasma] prevents water from moving from the blood into the interstitial fluid. Without this osmotic protection, water would move from the blood into the interstitial fluid, causing a rapid loss of blood volume.
“The most abundant of the plasma proteins is albumin, a protein also found in egg white. Albumin concentration is four times higher in the blood than in the interstitial fluid (the watery fluid that bathes tissues, but is located outside and between cells). This high concentration of albumin in plasma serves an important osmotic function…
“The other components of plasma are salts, nutrients, enzymes, hormones, and nitrogenous waste products. Together, these substances account for 1.5% of plasma. The salts present in plasma include sodium, potassium, calcium, magnesium, chloride, and bicarbonate…plasma contains nutrients that nourish tissues. The nutrients found in plasma include amino acids, the building blocks of proteins; glucose and other sugars; and fatty acids and glycerol, the components of lipids (fats).
“In addition to nutrients, plasma also contains enzymes, or small proteins that function in chemical reactions, and hormones, which are transported from glands to body tissues. Waste products from the breakdown of proteins are also found in plasma. These waste products include creatinine, uric acid, and ammonium salts. Blood transports these waste products from the body tissues to the kidneys, where they are filtered from the blood and excreted in the urine.”
To summarize, when red blood cells stick together and jam up at the mouths of capillaries, the tissues they were supposed to nourish are deprived of oxygen, but they do get other vital nutrients from plasma. These tissues can survive but not thrive. I suspect that when sha is present it is the lack of oxygen to the tissues and the pressure on surrounding tissues caused from excess fluid accumulating in the area which people experience as pain.
Sha, then is a situation wherein a vital component of the nutritive qi (energy), oxygen, does not flow with the blood to nourish tissues. Not coincidentally, when there is deficiency of qi in an area, qi cannot hold the blood, and there may be hemorrhages, since “Qi is the commander of Blood.”
What Causes Sha?
What causes this clumping together of red blood cells? One factor is the presence of proteins associated with inflammation, as occurs after a traumatic injury. Everyone who treats sha knows that it often develops after trauma.
Another well known fact is that certain viruses can cause hemagglutination. Evil winds and viruses are often synonymous in traditional Chinese medicine.
A third factor is that trauma can depolarize magnets and the magnetic qualities of red blood cells, causing them to stick together rather than repel each other.
High levels of sugar and/or fats in the blood also cause red blood cells to stick together, especially if the surface of the nearby skin under which the sugar and fat rich blood flows is exposed to a cold wind. The blood is 98.6 degrees Fahrenheit. A cold wind can be 40, 30, 20 degress or less Fahrenheit, which can cause the blood to gel up, like oil in a car motor on a very cold winter day or water in a frozen stream.
As the Nei Ching says, “When Heaven is cold and the earth is icy (frozen), the then main arteries of water are stiffened and frozen.”
The following drawing from Wikipedia show the effects that weather, which has a direct impact upon intracellular and extracellular osmotic pressure, has on red blood cells themselves. If the osmotic pressure is too great, the erythrocytes look like those in the hypertonic picture; if just right, they look like those in the isotonic picture; and if too little, they look like those in the hypotonic picture. Does this remind anyone else of the Goldilocks story?
osmotic pressure on red blood cells
All these Western physiology understandings of the blood and circulatory systems fit in well with what my Chinese masters said about sha. Drs. Shen and So taught me that sha is created from an internal condition of overheating in the body, and it is aggravated by the consumption of overheating foods such as a diet rich in sugars, fried food, or starchy, baked goods. The qi and blood get stuck, don’t flow, and pain ensues.
Also, as they often said, since “the wind is the cause of 100 diseases,” a cold wind can get into the body and become trapped. The patient, they told me, interprets as pain the struggle between the wei qi (defensive energy) trying to push the evil wind out of the body and the evil qi trying to penetrate deeper. The Vietnamese term for gwa sha literally means “scratch the wind.”
Dr. So once recounted that he would often eat fried rice at night which led to overheating of his intestines while he was asleep. Since he was sleeping, he couldn’t drink appropriate teas to counter the overheating, and this led to severe pain in his spleen area.
Dr. So’s father suggested the problem was sha. He scratched Dr. So’s abdomen, and this resulted in a cure. For one week thereafter Dr. So abstained from rice and ate potato and soybeans instead. The pain did not come back.
Drs. Shen and So also explained that sha can result from traumatic injuries, and from my years of observation, I know this also to be true.
They advised me that to diagnose if sha is present, press down firmly on the skin and underlying tissue with the thumb or fingertips. If the skin turns white and stays white for more than a few seconds, leaving a vestigial image of the thumb or fingers after taking them away, then a condition of sha exists.
In Western medicine, this is referred to as “capillary refill - when pressure is applied to skin or a finger nail, it goes white. When the pressure is released, the colour rapidly returns within 2-3 seconds. This is capillary refill, and is prolonged when the peripheral circulation is poor.”
“Sometimes if the sha has been there many years,” Dr. So would say, “it sinks down so deep that you can’t see it, even when pressing on the skin. If needling or moxa don’t improve the patient’s condition, then gua sha might still be indicated.”
Gua Sha Precautions and Prohibitions
To treat sha by doing gua sha massage, traditionally the Chinese applied cooking
oil to the skin and then rubbed the skin with a coin, spoon, or other smooth-edged instrument. For the rubbing tool, I do not use the cap of the Tiger Balm™ jar or Vicks Vapo-Rub™ jar as do some practitioners. I’m concerned that reuse without proper sterilization will make the cap a vector for transmission of blood-borne diseases, especially since the cap is metal, has a lip that curves inward, and is much harder to clean than a porcelain spoon. Instead, I prefer to use Tiger Balm™ and a porcelain spoon with its smooth round edge.
Although gua sha is recognized correctly in the acupuncture community as being one of the safest and most effective tools we have to get patients well, it is not a therapy without risks and harmful side effects. These should be understood before commencing treatment.
It is very important first to learn if the patient is either a diabetic and/or on blood thinning drugs such as coumadin. Do NOT perform gua sha on diabetic patients unless you are sure their blood sugar has been in normal range for an extended period of time.
Why is this? Because if there is a great deal of sugar in the blood, there will be hemagglutination everywhere. Sha will be everywhere, and it will not drain away readily once rubbed. It will just hurt, unlike after doing gua sha to patients with normal blood sugar levels, and the bruises will last a long time.
Conversely, if patients are on coumadin or other blood thinning agents, their normal tissues which are not affected by sha will often hemorrhage and bleed when rubbed. It can be a problem getting this bleeding to stop.
Also, the skin of elderly women who are very low in estrogen can become very thin, with little fat beneath the layer of epidermis, in the hypodermis level, so that it can be almost like paper. Please be careful when considering doing gua sha to them, as you can literally scrape their skin off and cause significant gashes in the upper level of skin.
The same holds true for people who have been on prednisone for extended periods of time. Their skin becomes quite thin and fragile, and they are not good candidates for gua sha massage.
The drawing below is from Wikipedia and shows the various levels of skin and their components.
An equally important precaution to take before doing gua sha is to warn the patient that a reddish or even purplish bruise may develop. Otherwise they may freak out. This has happened to me too often to want to go through that again. Also, advise them to tell their spouse that the treatment was gentle, did not hurt, despite appearances, and the bruises will go away in a few days. I’ve had more than one husband threaten to inflict bodily harm on me when their wives forgot to explain before taking off their clothes what had happened at my office.
Tell your patient that you will be applying Tiger Balm™, some other balm, or oil to their skin to make it slippery and that you will then be rubbing on their skin with a porcelain spoon. Explain that although you will be rubbing several areas with the same moderate intensity, not all of them will bruise – only those areas where the blood had been stuck and causing them pain.
The redness and reddish purplish spots which look like sand represent old red blood cells which had formerly been stuck together but now have been broken up into smaller particles. Now the capillaries will be unclogged and fresh red blood cells will be able to flow though, bringing fresh oxygen to the tissues and often near immediate relief. With that communicated, your patient will receive the treatment much more comfortably.
How to Do Gua Sha
1. Again, apply Tiger Balm™ or some other oil liberally to the surface of the afflicted area.
2. Take a porcelain spoon and face the hollow side towards the patient’s skin.
3. Rub downward and outward with moderate intensity (more on intensity later) along the various acupuncture meridians associated with the patient’s pain:
a. on the back, go downwards one inch lateral to the spine;
b. on the neck, go downwards from below the earlobe cleft to along the top of the shoulder on the Gall Bladder meridian;
c. stroke downwards along the urinary bladder meridians on the neck and back, along both the inner and outer U.B. meridians;
d. stroke downwards along the medial aspects of the shoulder blades, that is along the rhomboid attachments to the shoulder blades;
e. stroke between the ribs in the intercostal spaces, from the center of the chest outward;
f. stroke down the center line of the chest, gently as there is little subcutaneous fat there;
g. stroke downwards along the acupuncture meridians (triple warmer, large intestine, small intestine) of the posterior aspect of the arms;
h. stroke downwards along the acupuncture meridians (urinary bladder, gall bladder, stomach) of the lateral and posterior aspects of the leg; and
i. only occasionally stroke downwards along the medial aspects of the acupuncture meridians of the arms (heart, pericardium, lungs) and legs (spleen, liver, kidney).
4. Also important: avoid rubbing over moles and areas of broken skin.
5. Do not rub over the vertebrae, bump, bump, bumpety, bump, bump; rub downwards alongside them. Gua sha strokes should be smooth and firm, but gentle.
6. Do not rub over the ribs, bump, bump, bumpety, bump, bump. Rub laterally, between the ribs from the center of the chest and abdomen outward to the sides.
7. Keep reapplying Tiger Balm™ or oil to the skin after you have wiped it off with your spoon. You can scoop out the Tiger Balm™ which has accumulated inside your spoon.
8. Use about four pounds of pressure - maximum - when making your strokes. You can ascertain what five pounds of pressure is by pressing down with your thumb or fingers on a bathroom scale. Stroke, don’t fan the skin, in one direction – downward. Your level of pressure should not hurt the patient. I have seen one colleague produce deep dark reddish bruises wherever he rubs because he uses too much pressure. He rubs as if he’s digging for gold with that porcelain spoon. He’s not releasing sha; he’s actually breaking otherwise healthy capillaries. Don’t do that!
9. Rub general areas at first till you see redness appear in some areas.
10. Then concentrate your rubbing in the reddened areas.
11. Continue rubbing these reddened areas till little red or back dots show up or till the redness doesn’t get any redder – that is, stop rubbing once the redness has leveled off and doesn’t get any redder.
12. After you’re done with the massage, wipe the residual Tiger Balm™ or oil off your patient to prevent clothing from getting stained.
13. Advise your patient to avoid fatty and sugary foods and to keep out of cold drafts. This is very important. Explain that you’ve opened the skin for the body to push out the evil qi, but the door is also now open for cold wind to enter. So tell them to keep warm and out of drafts. This holds true even in Florida, where air conditioning both at home and in the car can penetrate and make a patient’s condition worse.
14. Remember: gua sha is very good for treating muscle spasms, especially in conjunction with acupuncture, after needles have been inserted and withdrawn from around the perimeter of the muscle. The acupuncture needles relax the sphincter muscles around the ends of capillaries, allowing for easier blood flow.
15. Expect to hear reports of miraculous recoveries.
16. Wait till all the redness goes away before performing gua sha again. This usually takes three or four days. The next time you do it there will probably be less sha appearing. Eventually, after a few treatments, there will hardly be any sha appearing at all. This does not mean you are doing the technique incorrectly. It means that the patient has recovered, and there is little if any sha left. Congratulations. I’m sure your patient will be thanking you by then.
 Huang Ti Nei Ching Su Wen, p. 123, translated by Ilza Veith, University of California Press, Berkeley and Los Angeles, 2002
 Dr. So founded the New England School of Acupuncture in Massachusetts and Dr. Shen founded what would later would become the National College of Oriental Medicine in Orlando.
 By Jim Martin, Licensed Acupuncturists; http://newconnexion.net/article/05-01/gwasha.html
 Huang Ti Nei Ching Su Wen, p. 217, translated by Ilza Veith, University of California Press, Berkeley and Los Angeles, 2002
 Ibid., p. 42
 Kathleen Scogna, The Gale Group Inc., Gale, Detroit, Gale Encyclopedia of Nursing and Allied Health, 2002
 The Foundations of Chinese Medicine, 1989, Giovanni Maciocia, p.52, Churchill Livingstone, New York
 Huang Ti Nei Ching Su Wen, p. 223, translated by Ilza Veith, University of California Press, Berkeley and Los Angeles, 2002
 Physiology,” Cardiovascular Physiology,” Issue 10 (1999) Article 2: Page 3 of 4