Thursday, February 10, 2011
Researchers in Germany conducted a first-of-its-kind randomized, controlled trial of the traditional East Asian healing technique Gua sha in patients with chronic neck pain. While favorable pain-relief results were observed, there are questions about whether healthcare providers should recommend this therapy for their patients.
During Gua sha — sometimes referred to as “spooning” or “coining” — a lubricated section of the body surface is pressure-stroked with a smooth-edged instrument to intentionally raise a millet-like skin rash, or petechiae, representing extravasation of blood in subcutaneous layers. Gua sha (pronounced ‘gwa shah’) may be loosely translated from Chinese to mean “scraping away disease by allowing it to escape as sandy-looking objects through the skin.” Shortly after the scraping, petechiae become ecchymotic (reddish or purplish) patches or streaks that fade away during a period of several days. It also might be noted in passing that there are some similarities of Gua sha with traditional “cupping therapy,” which also involves that application of treatment to the body surface causing transitory petechiae.
Writing in an advance online edition of the journal Pain Medicine, researchers report enrolling 48 outpatients with chronic, painful restriction of cervical spine mobility (average duration of symptoms 8.25 years; mean age 49.5 years; 85% female; non-obese, mean BMI=23) [Braun et al. 2011]. At the start of the study subjects were randomly assigned to either Gua sha applied to the upper back and entire neck (n=30) or to a control treatment with local application of a thermal-heat pad (n=24). The single-treatment session lasted up to 30 minutes and subjects were then followed for 7 days posttherapy. The primary outcome measure was a change of neck-pain severity after 1 week as assessed by a 100 mm visual analog scale. Secondary outcomes included pain at motion, the neck disability index (NDI), and the short-form quality-of-life health survey (SF-36).
Neck pain severity after 1 week significantly improved in the Gua sha group compared with the control subjects group (group difference = −29.9 mm; 95% confidence interval: −43.3 mm, −16.6 mm; p<0.001). Significantly favorable treatment effects were also found with Gua sha for pain at motion, scores on the NDI, and dimensions of quality-of-life (SF-36). The use of adjunctive oral analgesics was comparable but rare in both groups during the one-week observation period. No serious adverse events were reported and minor adverse effects included slight muscle aches or soreness in the area of treatment in both groups.
CLINICAL COMMENT: Gua sha is an interesting and ancient therapy for musculoskeletal pain, but its physiological mechanisms of action remain largely undefined. All patients in this current study had very long-standing chronic neck pain, and following a single treatment the Gua sha group had a very meaningful 65% reduction in pain compared with only 14% in the control group. These results are impressive; however, several points need consideration…
- Although this study was sufficiently powered at the outset to detect the dramatic differences found between groups, this is still a small-scale study — less than 24 per group after accounting for 4 dropouts — and the subsequent confidence intervals for outcome measures are quite wide and variable.
- The brevity of a one-week followup period is disappointing and the persistence of benefits from Gua sha beyond that point are unknown. Certainly, any relief from long-standing pain would be welcomed by patients but, if the treatment must be frequently repeated, it could be economically, emotionally, and possibly physiologically disadvantageous.
- The authors concede that, because of the nature Gua sha, there is no ideal sham treatment to serve as a control or a way of blinding subjects to treatment condition. The relatively brief, single application of a heating pad used in this study as a control does not seem to be useful as either a placebo, a sham therapy, or a viable comparator therapy. Therefore, we do not know how Gua sha might compare with serial applications of heat (as is more typically the case), traditional pharmacotherapies, massage therapy, or other interventions for neck pain.
- Gua sha, due to its novel nature, may have powerful, albeit temporary, placebo effects that were not adequately explored or controlled in this study.
- Gua sha would be contraindicated in patients with blood clotting limitations (eg, hemophilia, taking anticoagulants, etc.), anemia, and/or the presence of skin disease in the treatment area.
There has been considerable research, of varying quality, on Gua sha reported in Chinese medical literature. This is the first randomized trial published in the Western literature and we agree with the authors’ conclusion that, according to results of their study, Gua sha appears to have beneficial short-term effects on pain and functional status in patients with chronic neck pain.
The approach may have promise, but further research is needed to assess its value in a larger population of patients, during a much longer followup period, and in comparison with other conservative treatment modalities. At the present time, there appears to be insufficient high-quality evidence for healthcare providers to specifically recommend Gua sha for patients with chronic musculoskeletal pain. What do you think? Comment below.
REFERENCE: Braun M, Schwickert M, Nielsen A, et al. Effectiveness of Traditional Chinese “Gua Sha” Therapy in Patients with Chronic Neck Pain: A Randomized Controlled Trial. Pain Med. 2011(Jan); online ahead of print [abstract here].