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Why are there red marks on your skin after Gua sha?

If you've ever done Gua sha and seen the distinctive red marks appear on the skin afterwards, you may have wondered what they are. Well in this episode Clive looks at exactly that and explains what happens under your skin when you do Gua sha! He explains how you deal with reactions to people seeing the sha marks and how they are not something bad but actually something very positive for your health!

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Episode Transcript

Hello and welcome to another episode of the Gua sha show. This week we look at sha - those distinctive marks sometimes left behind on the skin after someone has had Gua sha.

You know what I’m talking about, right? Even if you just do gentle movements on your face, they’re the ones which might appear on your neck or shoulders. And if you’ve never experienced sha and you do Gua sha. You and me have to have a talk because this is what it¡s all about. But anyway if you go to google and put in a search for ‘Gua sha’ and then look at the images. You should see sha somewhere on the page. If not, just add the word ‘back’ and ‘Gua sha’. Do a search and check out the images. There must be images there with these marks. I just tried it and the page was full of them. There were images with straight red lines going all the way down the back or across the shoulders. And it basically looks like they’ve just been run over or tortured or whipped or had some nasty accident. Well that’s what we’re looking at today! But hang on! Don’t disappear yet because it’s not all that it seems!

It’s common across Asia, whether it’s copper coins in Indonesia or buffalo horn in Vietnam, to scrape with the aim of extracting these red sha marks on the skin. You listened to my podcast about the origins of Facial Gua sha right? If you didn’t then go listen to it because it’s fascinating but in one part I talked about sha syndrome which is how the technique of Gua sha originated - basically it was fighting serious febrile diseases like tuberculosis. If you’re treating someone with what is considered to be a viral infection like a cold, considerable amounts of sha can appear. So when that infection is something more serious, so the treatment has to be. That’s sometimes behind these images. But not always.

I recall reading about a series of lectures by well known Chinese Gua sha experts from mainland China who while visiting Taiwan were emphasizing the fact that a good Gua sha treatment doesn’t necessarily mean the whole body is covered in what looks like a nasty red rash. They were insinuating that practitioners were a little too eager in trying to extract sha on the skin and they were potentially causing problems because of this. This was partly due to a lack of training and regulation and also more than a few people looking like those painful looking images on google. Of course, there is a time and a place for treating like this but one has to adapt to the people you treat.

Sha is actually quite deceptive because it looks like something horrific but it’s actually something generally positive. It’s like your body’s way of telling you that it’s dealing with something right now. One of the reasons I don’t use images of sha in my clinic because if I were in their place and I go and see someone for help and that person says they’re going to scrape my skin and it might look like this (this is where I dramatically lift up an image of sha and raise my eyebrows like a madman). Then of course I’m going to do what any of you would do and I’m going to get the hell out of there. I’m not even going to wait. I’m just going to stand up, apologize and swiftly leave.

So I get that. It’s only after you’ve had Gua sha and sha has come out onto the skin that you get to understand what it’s all about. That it doesn’t usually hurt. It isn’t normally a strong technique. I usually take a photo of the sha afterwards and show them. And it’s always the same reaction. “Oh Wow! Is that my back! That’s crazy!” and that’s it. It’s a positive experience and one that they want to repeat.

Of course there are some people who don’t want to have Gua sha just like there are some people who don’t want massage and a whole lot of people who don’t want needles. Some people just don’t respond to physical contact too well but that’s okay. But for the vast majority of people Gua sha is comfortable and the appearance of sha is absolutely fine.

So before we go any further let’s just look at what’s actually happening when sha appears on the skin.

Well when you do Gua sha, there are a variety of techniques. Some of these techniques are designed to not produce sha on the skin such as the sweeping techniques on the face. But other techniques can and often do produce marks on the skin. So this is what happens. The pressure of the tool digs into the tissue as you scrape along and this causes friction within that tissue area. Normally this wouldn’t cause anything other than a temporary flush of the skin but if there is a particular type of restriction in the tissue (which I’ll come on to in a minute), then the tissue bed leaks blood cells. Now when I say tissue bed, don’t think of a bed. Think of a collection of tiny blood vessels like candyfloss sitting in the tissue. So this leaked blood then gets caught in the extra-vascular space under your skin. So that’s the bit of tissue without the vessels in them. And you get the distinctive collection of small red dots (each up to 1 mm) that make up the appearance of sha. The closest way to describe sha in Western medicine terms is petechiae (pe-tee-kiya) which has the same appearance but is normally due to things like straining (coughing or weightlifting), a side effect of a medication (like penicillin) or a symptom of a nasty disease like sepsis or scarlet fever.

If we were just to use the word petechiae (pe-tee-kiya) though, it’s not quite what sha is, as it doesn’t do justice to the long history behind it and the varied meanings related to the Chinese character used. You can’t just put that into one medical word. Sha is both the thing causing the appearance of red dots and the red dots themselves. It takes some explaining in words!

Sometimes you can see sha with the slightest touch and sometimes you can scrape strongly with no sha at all. This can be confusing if you don’t know what’s happening. If Gua sha is done properly, the sha marks aren’t the result of the pressure of the tool but on the state of the tissue structures beneath the skin. It’s all about what’s happening under the skin. Sha is a sign of a pathological restriction of blood flow. But there are certain conditions which must be there in order for sha to appear on the skin. As to what the certain conditions are - there are no short cuts to this. It’s something you have study and understand. When you do, it’s so simple and elegant. But for the purposes of this podcast, it’s essentially an obstruction in the tissue caused by an internal or external pattern. Which is sitting there either causing problems or with the potential to cause problems with blood circulation.

When people show me sha I don’t look at it horrified as you would at those google images but I appreciate it like it’s some precious skillful artwork and I look through it in my mind to try and understand it. I don’t diagnose why the sha is there as without knowing what is happening in the body as there can be many reasons for it to be there. It could be due to a local feature in the muscle or tissue where you are scraping or perhaps it’s being caused by a situation in a totally different part of the body. For example, the sha on the front of your thigh could easily be due to or is causing a digestive disorder. Actually, when you have some time go ahead and scrape down the front of your thigh and see if some part of your leg shows sha. It’s pretty common. That’s part of the stomach area.

How other people react to sha is something you have to deal with. When my children were growing up, we would often use Gua sha on them. Remember when done appropriately Gua sha is a great treatment for children. One of my sons was fine with it but the other hated it and you really knew when he was sick when he agreed to have it. Both would sometimes arch their backs and giggle not out of laughter but because Gua sha can sometimes reach that weird place which is both comfortable and uncomfortable at the same time! The giggle is half laughter because it tickles and half despair because it hasn’t finished yet. We treated all kinds of typical childhood health problems in this way! It was especially useful in the remote places we lived (on our island in the East China sea for example). But whenever they were treated, I made sure that they had a note to their teacher at school, to explain the treatment as it’s easy to misunderstand. There’s actually a movie called the Treatment or Gua sha which came out in 2001 which looks at what can happen when this misunderstanding occurs to an immigrant family in New York. And it isn’t nice!

It’s a similar thing in my clinic. If someone is going to react strongly to Gua sha it’s going to be after treatment on the neck area. That’s my experience. If someone has dizziness which is related to the tension of the muscle-fascia group over the neck, then sometimes the dizziness can get temporarily stronger. Over the years I’ve had patients in the ER on the day of treatment (who didn’t actually need to be in ER but went anyway) and I could just imagine what the physician was thinking when they looked at all those red marks. Who did that to you again? Here we go waiting for the call. But it never came. Because it was a predictable event and you’ve got to plan for predicable events. My grand strategy for times like those is the very patient who is in the ER in the first place. They can explain what happened, how it happened and why and throw in a surprising amount of enthusiasm in the process. So it actually turns out to be an educational event. And anyway this wasn’t such a rare thing. We treated lots of people over many years with sometimes quite severe symptoms.

There are certain places that seem to show the presence of sha more than others - the neck or back for example and other places which are very rare such as your hand. And there are certain places that you definitely don’t want sha to show such as your face. That’s a sure way to cause a major rupture in the patient-therapist relationship. Get a bruise or sha marks on the face and you’ll certainly know about it. It’s a bit like bruising someone with a needle or even worse, leaving the needle in the skin and forgetting about it (but not in the face). You’re not the flavor of the month. Actually between you and me, acupuncturists do that more often than they like to admit! It once horrified me and I was so embarrassed but now I’m like, if you find one, you can keep it for free!

So, don’t be put off by those scary pictures online. Sha is a natural part of Gua sha and is a therapeutically important event which tells you that something is or was present in the tissue and that your body is trying to deal with it. All you’ve got to remember is to adjust how you do Gua sha according to who you’re treating and why you’re treating.

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©2021 Clive Witham