Preface

Much has changed since the 1995 edition of this Gua sha text. Traditional East Asian medicine has come of age as an engaged practice, an object of evidence-based and mechanism research, and the focus of study in dedicated schools, colleges and courses within universities and medical schools. Once an outlier or alternative to conventional medicine, it now leads efforts toward integrative and pluralistic care. Traditional East Asian practices, including Gua sha, are no longer isolated to the private setting but are merged in conventional clinics, hospitals and inpatient facilities.

It is good to acknowledge how far we have come. We have helped to create a regulated medical profession in the United States that did not exist forty years ago. This is no small feat given the political landscape of bias and resistance within medicine, and yet it could not have been accomplished without the support of physicians, researchers, academics, regulators and the public committed to sound options in healthcare.

We have established a safety record of 'relative risk'. That is, there is some risk with traditional East Asian medicine that is managed and greatly reduced with proper training, such that acupuncture therapies are one of the safest forms of medical intervention. We have established schools, a national board, qualifying exams that are psychometrically sound, and strong partnerships with medical, academic and regulating institutions.

My own journey is no longer defined by my acceptance to medical school (declined). I am now on faculty at a medical teaching hospital, Beth Israel Medical Center in New York City, where I also direct an Acupuncture Fellowship for Inpatient Care. My choice to study and practice traditional East Asian medicine came out of a sense that prevention is the best medicine, that physical medicine calls on a cognitive and somatic rapport that creates possibility where an informed and engaged patient is the best ally. This medicine was never meant to supplant modern medicine but to make it better, to respond to what are called 'gaps in care', to support patients who are getting care but continue to suffer.

Interest in the practice continues to mount but as a colleague recently noted: acupuncture therapy studies do little to guide or improve actual practice but continue to focus on whether acupuncture works at all. For example, acupuncture studies funded by the German Government mandated that needle insertion be used as a control. So while both real and control acupuncture treated back pain better than usual care alone, 'real' acupuncture performed only a bit better than what was situated as 'placebo'. Many researchers rebutted that, pointing out that needle insertion is not an inert control but an active form of acupuncture comparable to styles that needle 'off-channel'. In other words, if a study compared two antibiotics and found one worked a bit better than the other, but both worked much better than no antibiotic, the conclusion would not be that 'antibiotics do not work'.

This may well be how acupuncture therapies persisted over 2000 years. You did not have to be that good to have 'some effect'. The better trained and more experienced the practitioner the better the effect. Moreover, some of the studies that showed a strong placebo effect with acupuncture also found that the placebo aspect may wear off over time, i.e. real acupuncture with proper frequency and dosage of treatment is therapeutic.

There has been sufficient study of acupuncture for headache and migraine prophylaxis, neck, back, and knee pain, and for pain, anxiety, nausea and vomiting in the perioperative period as well as during chemotherapy to culminate in systematic reviews that recommend acupuncture as a safe treatment for these disorders with few side-effects. And there is positive study for many other areas and conditions that together speak well for this medicine. As of this writing, acupuncture is reimbursable by national health insurance plans in Germany and England for specific conditions.

Research into the physiology of acupuncture therapies has advanced beyond the simple endorphin effect found decades ago. Discoveries of mechanical and chemical signaling within the connective tissue are now theorized to be the 'bed' of the channel system. Brain and neurochemical studies as well as research into acupuncture's ability to regulate the autonomic nervous system each add partial knowledge as pieces to a puzzle of how this medicine works and where and when it is most useful.

While I have had a hand in shaping the practice of traditional East Asian medicine in the United States, our success has in turn shaped my priorities. I was on the first State Board for Acupuncture in New York, involved in writing New York's regulations for professional practice, and was Board Chair for two of eight years served. Those regulations allowed for practice in New York and recognition soon followed that the practices themselves needed to be researched and represented in the West. For example, there were no studies concerning Gua sha and without quantitative measures it could not begin to be situated within the science of medicine.

I wanted to research the effects of Gua sha and so entered the Academy for a research doctorate. I matriculated in a doctoral program at Union Institute and University where I received my PhD in Philosophies of Medicine with a specialty in Integrative Clinical Science and Health Care. During my doctoral study I was invited to the University of Duisburg-Essen in Germany to conduct laboratory research on Gua sha with Drs Andreas Michalsen and Gustav Dobos, who directed the Department of Integrative Medicine there as well as the Kliniken Essen, a 54-bed hospital where patients with chronic illnesses are treated with integrative therapies.

During this same period the Chinese-language database became accessible online. Now a thorough background and literature review could be done and was sorely needed to situate Gua sha in medical discourse. Together these circumstances clarified a need for revising Gua Sha, a Traditional Technique for Modern Practice. This is more than a freshening of the existing text, though some areas have stood the test of time and remain essential. It was time to advance Gua sha from a curious technique that amazes providers and patients with its curative effect while instilling trepidation in others because of the 'look' of the transitory therapeutic petechiae. It was time to fix on Gua sha with a scientific gaze and interpret what can be known, to inform practitioners and patients alike. Such a project is no longer contained in a book on theory and practice but must include evidence in addition to background and personal/archival experience.

A revised chapter on history illuminates the homogeneity of early Western medicine and traditional East Asian medicine in the application of Gua sha for the treatment of cholera. The history and theory of Hippocratic medicine connecting bloodletting with the evolution of acupuncture provides a new context for the link between Hippocrates and how his name would have been pronounced in early Chinese: 'Chih-Po' (oddly similar to the famous physician whose discourse with the Yellow Emperor is recorded as the oldest Chinese medical text). A tracing of the lineage of Dr So, the doctor from Hong Kong who taught me Gua sha, sheds light on classical practice as distinct from traditional Chinese medicine (TCM) theory that has been represented as orthodoxy from China.

Chapter 2 presents the evidence relating to Gua sha; a thorough literature review gives a current picture of medical discourse on Gua sha that until now has not benefited from such an endeavor. I find literature reviews to be extraordinarily satisfying; they set what is 'known' and become the basis for situating research inquiry. While the Chinese language database has only been available relatively recently, it is also important to note that the Chinese-language database includes articles about traditional medicine only since 1984. An abundance of the Chinese-language articles are case series with more recent randomized trials. While randomized trials remain the watermark of proof in the West, Chinese-language discourse on care and technique in the form of case series articles is worth considering in its own right. It establishes a record of use, a record of safety and lays the foundation for therapeutic relevance that can guide clinical trials.

I spent a year analysing over 600 articles in Chinese, finding over 500 to be relevant medically. I translated and organized publication types of articles in tables to provide an overview of how Gua sha has been and is being used in China.

Gua sha's register in the Western medical database is also detailed. Western medicine's first regard for Gua sha was in response to the Vietnamese version 'cao gio' as practiced by Southeast Asians who came to the States after the Vietnam War. Cao gio is described as abuse/pseudo-abuse, a religious or cultural ritual to be discouraged and pitied. Some East Asian immigrants were persecuted for using Gua sha/cao gio; a conflation of those incidents was rendered in the feature film The Gua Sha Treatment, the most popular film in China in 2001, representing intercultural misunderstanding and yet a turning tide. Science now helps us to appreciate Gua sha, like acupuncture, while its persistence over time is a credit to those engaged...