Hong CHEN,Dongpan FAN,Jing HE,Jin ZHAO,Ling TANG

1Department of Breast Surgery,Dongfang Hospital of Beijing University of Chinese Medicine,Beijing,China;2Department of Nursing,Dongfang Hospital of Beijing University of Chinese Medicine,Beijing,China

ABSTRACT Traditional Chinese medicine scraping is a kind of natural therapy with a long history of simple and safe operation.It is easy to learn and tools are readily available,so that it has a very wide range of practical value.This paper introduces the definition and indications,function and standardization process of scraping technology,the technical operation specifications and matters needing attentions,as well as the application method of scraping technology,with a view to providing reference for clinical use of scraping technology in the treatment of cervical spondylosis,periarthritis of shoulder,lumbar muscle strain,hypertension,chloasma,and other diseases.

Keywords: Cervical spondylosis,chloasma,high blood pressure,lumbar muscle strain,nursing technology,periarthritis of shoulder,scrapping,traditional Chinese medicine

INTRODUCTION

Scraping is a kind of traditional Chinese medicine (TCM)therapy,which aims to produce petechiae through scraping the skin surface to achieve the therapeutic effect.[1,2]Petechiae are also called scrapping points or spots which are regarded as normal reactions after scrapping treatment and will generally disappear within 1 week without any treatment.[3,4]TCM is usually used to treat chronic diseases.[5]Scraping can relieve both myalgia and chronic pain and improve blood stasis and inflammation.[6]It can also be used in combination with acupuncture,cupping,puncture,and bloodletting and other therapies to strengthen the effects of promoting blood circulation and removing blood stasis,removing the pathogenic factors,and detoxifying.Modern medicine holds that scrapping is a benign surface stimulation method of stimulating neuroimmunoendocrine system to secrete neurotransmitters,to promote synthesis and secretion of vasodilatory substances by endothelial cells and subcutaneous adipose tissue,to enhance the sensitivity of endothelial cells to the substances,and thus restore the body’s blood pressure balance by adjusting the relaxation and contraction of blood vessels substances.[7]At present,there are some shortcomings in the operation procedures of scraping in the research and practice,and there is still room for research.This paper mainly explains the definition,function and standardization process of scraping technology,the technical operation specifications and matters needing attentions,as well as the application method of scraping technology,with a view to providing reference for clinical use of scraping technology.

DEVELOPMENT PROCESS OF SCRAPING TECHNOLOGY

The history of scraping can be traced back to more than 2000 years ago.AsHuangdi’sCanonofInternalMedicinestated,scraping is a kind of stone needle therapy or puncture therapy,which has been spread among the people for a long time.Traditional scraping is mainly indicated for measles.Since entering the modern times,scraping treatment has been already applied in 400 kinds of diseases in internal medicine,gynecology,andrology,pediatrics,surgery,dermatology,orthopedics,ophthalmology,etc.

In order to promote the continuous development of the TCM medical technology-related work,the department of medical administration of State Administration of TCM set up TCM medical technology cooperation group who sorted out and standardized more than 100 mature TCM technologies and drafted the technical operation plan,including scraping technique among them in 2012.In order to facilitate the publicity and promotion of TCM technologies,theMedical TechnicalManualofTCM(Universal Edition) was issued in 2013.[8]In the same year,the General Administration of Quality Supervision,Inspection and Quarantine of the People’s Republic of China and the Standardization Administration of the People’s Republic of China issued the technical operation standards for acupuncture and moxibustion,of which part 22 standardized the technical terms and definitions,techniques,operating steps and requirements,precautions,and taboos of scraping.[9]In 2015,in order to keep giving full play to the characteristics and advantages of TCM nursing,improve the effect of TCM nursing,and standardize TCM nursing behavior,the department of medical administration of the State Administration of TCM organized and published theTCMTechnicalManualforNursingStaff,in which the basic technical requirements,evaluation,and operation points of the techniques were explicitly stipulated.

DEFINITION AND INDICATIONS OF SCRAPING

Scraping is an external treatment method of implementing corresponding manipulations on the specific parts of human body surface,in a regular way,using blunt and smooth-edged instruments under the guidance of the theory of TCM,thus achieving the purpose of preventing and treating diseases.

According to national standards combined with clinical practice,scraping technology is indicated for neck and shoulder pain,waist and leg pain,headache,cold,cough,insomnia,constipation,and various acute diseases in summer and autumn,such as heat stroke,cholera,and dysentery.Scraping also has health-preserving and beauty effects.[10]

OPERATION PROCESS OF SCRAPING TECHNOLOGY

Basic requirements of scraping

The operation personnel of scraping technology should be registered nurses and doctors who have the relevant knowledge and skills training.Patients and caregivers should be educated about scraping.

Evaluation

Patients are evaluated in the following aspects: (1) the main symptoms,past history,bleeding disease,pregnancy or menstruation,physical fitness,and pain tolerance degree should be assessed.(2) The scraping part of the skin should be assessed and local skin infection,ulceration,and scar should be avoided.

Preparation before scraping

Preparation of materials: Treatment plate,scraping plate (e.g.horn,stone needle,and other scraping plates),medium (e.g.,scraping oil,water,skin lotion,etc.),towel,and roll paper are prepared before operation of scraping.The bath towel and screen may be prepared if necessary.

Scraping parts: The appropriate scraping parts,which are selected according to meridian circulation and pathological parts,are mainly head,neck,shoulder,back,waist and limbs,etc.The scraping parts should be exposed as far as possible to facilitate operation.

Position of the patient: Patients’ posture is decided on the characteristics of the disease,scraping parts,and their constitution.Generally,the comfortable and durable posture that is conductive to the operator’s operation of scraping is selected.

Method of scraping Scraping medium,order,and direction

Smearing scraping medium: Take proper amount of scraping medium,put it on the part to be scraped after disinfection,and smear evenly with scraping plate.

Order of scraping: The operation of scrapping plate mainly involves 12 skin areas.[11]The general principle of selecting the order of scraping parts is first head and face followed by hands and feet,first back and waist followed by chest and abdomen,and first upper limbs followed by lower limbs.

Direction of scraping: Scraping from top to bottom,from inside to outside,in single direction,with long stretch as far as possible.

Scraping manipulation

Scraping is classified into gentle scraping and heavy scraping according to strength.(1) Gentle scraping.The operator scrapes patients’ skin gently with scraping plate,with no pain and other uncomfortable feelings caused to patients.After gentle scraping,the skin only shows slight redness,no ecchymosis.This manipulation is suitable for the aged,the infirm,and the patients with deficiency syndrome.(2) Heavy scraping.The operator scrapes patients’ skin,with greater strength that can be tolerated by them.This manipulation is suitable for both sides of the lumbar spine,lower limb with rich soft tissues,young and middle-aged people with strong constitution,and patients with excess or heat syndrome.

Scraping is classified into fast scraping and slow scraping according to moving speed.(1) Fast scraping.The frequency of scraping is more than 30 times/min.This manipulation is suitable for patients with strong constitution and those with acute or exogenous diseases.The scraping parts are mainly back and limbs.(2) Slow scraping.The frequency of scraping is ＜30 times/min.This method is suitable for the weak physique and the patients with chronic and internal injuries caused by body deficiency.It is mainly used for scraping the head and face,chest,abdomen,inner side of lower limbs,and other parts.

Scraping is classified into straight-line scraping,arc scraping,and pushing manipulation according to scraping direction.(1)Straight-line scraping.The operation personnel performs this manipulation with scraping plate on the human body surface along a straight line.This manipulation is appropriate for the flat part of the body,such as back,chest and abdomen,and limbs.(2) Arc scraping manipulation.Scraping direction is arc shaped,which mainly depends upon muscle direction or bone structure characteristics.After scraping,the surface of the body shows curve scrape.This manipulation is suitable for the parts such as intercostal space of chest and back,shoulder joint,and knee joint.(3) Pushing manipulation.Scraping direction is opposite to the direction where the performer is standing.For example,it can be applied for scraping the left neck and shoulder if the operator stands in front of the right side of the subject.

Scraping is classified into rubbing manipulation,combing scraping,point-pressing manipulation,kneading manipulation,angle scraping manipulation,and edge scraping manipulation according to the part of scraping plate contacting body surface.(1) Rubbing manipulation.The operator takes scraping plate to contact the skin directly or contact through clothes,and moves it in a regular rotation,or in a straight back and forth motion,so that the skin produces heat.This manipulation is used for body parts with numbness,cold,or continuous dull pain,such as the inside of the shoulder blade,waist,and abdomen.It can also be used to make the subject relax before scraping.(2) Combing scraping.The operator uses scraping plate or scraping comb at a 45° angle to perform the manipulation in a regular single direction from the forehead hairline,bilateral Taiyang (EX-HN5) to posterior hairline.The manipulation should be gentle and slow,like combing hair,it is so-called combing scraping manipulation.It is suitable for headache,dizziness,fatigue,insomnia,and mental tension.(3) Point-pressing manipulation.The operator uses the corner of the scrapping board to directly press acupoints and lift rapidly after keeping a few seconds.The operation is repeated 5-10 times.It is noted that the strength of scraping should be gradually increased but should be tolerated by patients during pressing.This manipulation should be used for acupoints of muscle fullness,deep parts where scraping strength can’t reach,acupoints such as Huantiao (GB30),Weizhong (BL40),Dubi (ST35),and Shuigou (DU26) in bone joint depression that can’t be directly scraped,or areas in between back spines.(4) Kneading manipulation.The operator uses scraping plate first to perform point-pressing manipulation on acupoints on the body surface and then knead acupoints back and forth,or in clockwise or counterclockwise rotation,50-100 times/min.Scraping plate should be close to the skin and can’t be moved from acupoints.This manipulation is suitable for Taiyang (EX-HN5),Quchi (LI11),Zusanli (ST36),Neiguan (PC6),Taichong (LR3),Yongquan (KI1),and Sanyinjiao (SP6).(5)Angle scraping manipulation.Use angular scraping board or make scraping board edge and corner contact the skin at a 45° angle,scraping from top to bottom or from inside to outside.The technique should be flexible and avoid damaging the skin with excessive force.This manipulation is suitable for the joints of the limbs,the bilateral meridians of the spine,around the bone apophyses,and the acupoints of the shoulders such as Fengchi (GB20),Neiguan (PC6),Hegu (LI4),and Zhongfu (LU1).(6) Edge scraping manipulation.Use the long edge of the scraping plate to contact the skin at a 45°angle.This manipulation is suitable for scraping large areas,such as abdomen,back,and lower limbs.

Management and precautions after scraping Treatment after scraping

After scraping,clean paper towels,towels,or sterile cotton balls will be used to wipe the scraping medium clean.The feelings of soreness,numbness,swelling,pain,and heaviness produced in the process of scraping are normal reactions.The skin shows red or purplish red color changes,or miliary,papular spots,or flake,strip-like plaque,accompanied by local heat or slight pain sensation,which are the normal reactions after scraping,and will disappear after a few days,generally without special treatment.It is best to drink a cup of warm water and rest for 15-20 min after scraping.

If patients have a phobia of scraping,manifested as dizziness,palpitation,cold sweat,pale face,nausea,or unconsciousness,scraping should be immediately stopped.Meanwhile,the subject should be in head-low and feet-high supine position,given a cup of warm water or warm sugar water,and kept warm,and the scraping plate is used to perform point-pressing manipulation on acupoints Baihui (DU20),Renzhong (DU26),Neiguan (PC6),Zusanli (ST36),and Yongquan (KI1).

Scraping plate disinfection

Scraping plate should be timely disinfected after use,and different materials are disinfected using different disinfection methods.The buffalo horn scraping plate should be cleaned with 1:1000 new germicidal,75% medical ethanol,or 0.5%iodophor disinfection.Stone needle,ceramics,and jade scraping plates,in addition to the above wiping disinfection,can also be disinfected by high temperature,high pressure,or by boiling.

Matters needing attention of scraping

(1) Attention should be paid to indoor warmth during scraping,especially avoiding cold in winter;when scraping in summer,cool air from fans and air conditioner should be avoided to contact the scraping parts.(2) It is not suitable to eat uncooked and cold food immediately after scraping,and it is not suitable to take a cold bath within 30 min after the presence of petechiae.(3) The elderly,the infirm,children,and patients sensitive to pain should be used with gentle scraping.(4) The muscles plump (such as back,buttocks,chest,abdomen,and limbs) should be scraped with horizontal surface of scraping plate (thin or thick surface is suitable).The parts with less muscles and more concave and convex such as joints,extremities,head,and face should be scraped with the edge and corner of the scraping plate.(5) For patients with lower extremity varicose veins or lower extremity swelling,it is advisable to use reverse scraping,scraping from bottom to top.(6) The appropriate scraping time is 20-30 min,which should be appropriately shortened to ＜20 min for the infirm.The interval between two scraping should be 3-6 days,or depend upon disappearance of petechiae on the skin and painless sensation by hand pressure on the skin.

CLINICAL APPLICATION OF SCRAPING

Scraping,which has the effects of regulating Qi flow,promoting blood circulation,removing blood stasis,relaxing tendons,dredging meridians and collaterals,and detoxification,has been extensively used in the treatment of diseases in internal medicine,surgery,gynecology,pediatrics,and in beauty and health-care fields.More specifically,it is indicated for pain diseases and degenerative diseases of bone and joint,e.g.cervical spondylosis and periarthritis of shoulder.It can be combined with cupping for cold,fever,cough,and other respiratory diseases,and can be combined with acupuncture and bloodletting therapy for acne,chloasma,etc.It is also applicable to the prevention and treatment of diseases such as subhealth and chronic fatigue syndrome.

Principles of acupoint selection

The principle of acupoint selection is as follows: (1) local acupoint selection.For example,Shenshu (BL23) acupoint and Zhishi (BL52) acupoint are selected for kidney diseases.Jianyu (LI15) and Naoshu (SI10) are selected for shoulder diseases.Quanliao (SI18) and Jiache (ST6) are taken for treating cheek diseases,and Daying (ST5) and Chengjiang (RN24)are taken for treating oral diseases.(2) Distal acupoint selection: it includes acupoint selection on affected meridian and acupoint selection on related meridian.For example,Taibai (SP3) and Sanyinjiao (SP6) selected for treating spleen diseases,Weizhong (BL40) for acute lumbago,and Taiyuan (LU9) and Yuji (LU10) for pulmonary diseases follow the principle of acupoint selection on affected meridian.Zhongwan (RN12) and Zusanli (ST36) are selected for treating vomiting because vomiting is a gastric disease.However,if vomiting happens due to failure of stomach Qi to descend caused by the liver Qi upward reversal,Taichong (LR3) and Ganshu (BL18) are selected for descending liver Qi to stop vomiting,which follows the principle of acupoint selection on related meridian.(3) Selection of symptomatic acupoints:for example,Dazhui (DU14) acupoint is selected for reducing fever;Shenmen (TF4) acupoint is selected for calming nerves;Guanyuan (RN4) acupoint is selected for warming Yang,etc.(4) Selection of pressure pain point (Ashi point):the pressure pain points are selected for scraping which is effective in sprain,Bi syndrome,etc.,in clinic.[12]

Treatment of diseases Cervical spondylosis

Yaoet al.[13]carried out a systematic evaluation and showed that scraping has certain advantages in the treatment of neck and shoulder pain compared with other treatments.The scraping parts selected for the treatment of cervical spondylosis are head,neck,shoulders,and upper limbs,and the specific operation is as follows: (1) scraping the head: the head should be scraped with combing scraping manipulation,from the forehead hairline,both sides of Taiyang (EX-HN5) point to posterior hairline to do regular single-direction scraping,on which Taiyang (EX-HN5),Baihui (DU20),and Fengchi (GB20) points are mainly kneaded.(2) Scraping the shoulder and neck: the operator gently scrapes Governor Vessel and bladder meridian of foot Taiyang with straight-line scraping manipulation and scrapes gallbladder meridian of foot Shaoyang with pushing scraping manipulation,on which Fengfu (DU16),Dazhui (DU14),Fengmen (BL12),Fengchi (GB20),and Jianjing (GB21) points are mainly kneaded.(3) Scraping the upper limbs: the upper limbs should be scraped with straight-line scraping manipulation,gently scraping along large intestine meridian of hand Yangming,where Jianyu (LI15),Quchi (LI11),and Hegu (LI4) are mainly pressed with point-pressing manipulation.

Lumbar muscle strain

Yuenet al.[14]and Wanget al.[15]found that scraping had good effects in alleviating lumbago and improving lumbar function and also had a certain effect on some patients with chronic low back pain.Yang and Xu[16]showed that scrapping treatment can help inhibit Th1 immunity triggered by autologous nucleus pulposus,restore Th1/Th2 immune balance,and relieve the pain of lumbar disc herniation in rats.Wanget al.[17]conducted a randomized controlled trial of 210 patients with lumbar muscle strain,and found that scraping can effectively relieve the symptoms of low back pain.The scraping parts selected for the treatment of lumbar muscle strain are the back and waist and lower limbs,and the specific operation process of scraping technology is as follows: (1) scraping the back and waist: the gentle scraping manipulation is used for scraping the traveling part of Governor Vessel on the central part of the back from top to bottom.The heavy scraping manipulation is used for straightly scraping the bladder meridian of foot Taiyang in the back from top to bottom.The gentle scraping manipulation is used for gently and straightly scraping from Shangliao (BL31),Ciliao (BL32),Zhongliao (BL33),Xialiao (BL34) to Huiyang (BL35) in lumbosacral area.(2)Scraping the lower limbs: the straight-line scraping is used for scraping the bladder meridian of foot Taiyang and the gallbladder meridian of foot Shaoyang in the lower limbs,mainly kneading Weizhong (BL40),Chengshan (BL57),and Huantiao (GB30) points.

Hypertension

In recent years,appropriate TCM techniques such as scraping,acupuncture,moxibustion,and cupping have played important roles in nondrug treatment and intervention of hypertension.[18]Scraping therapy has an obvious intervention effect on hypertension with phlegm and blood stasis type through dredging the meridians and collaterals,promoting blood circulation,removing blood stasis,strengthening spleen,drying dampness,controlling blood pressure level,and relieving clinical symptoms,which has positive clinical significance.[19]Liuet al.[20]used scraping to treat 89 patients with essential hypertension who met the inclusion criteria based on syndrome differentiation,and found that scraping had an obvious immediate antihypertensive effect on essential hypertension.Scraping every other day is appropriate.The scraping parts selected for the treatment of hypertension are mainly the bladder meridian of foot Taiyang and Governor Vessel,with combing scraping manipulation used to radially scrape the whole head from Baihui (DU20) point,and with point-pressing manipulation to scrape Taiyang (EX-HN5),Baihui (DU20),and Fengchi (GB20) points.

Chloasma

Yaoet al.[21]found that scraping therapy has significantly better clinical efficacy than nonscraping therapy in the treatment of chloasma,with good safety and no obvious adverse reactions.In the treatment of chloasma,scraping therapy has the characteristics of simplicity and good efficacy.[22]The scraping parts selected for the treatment of chloasma with different syndrome types and the specific operation process are as follows: (1) chloasma with liver Qi stagnation:Yangbai (GB14) point and Tongziliao (GB1) point on the face,upper limb area,and hepatobiliary area are mainly rubbed.The straight-line scraping manipulation is used to scrape the spine area that the liver and gallbladder correspond to and hepatobiliary body surface projection area on the right back.(2) Chloasma with spleen deficiency: the large and small intestine area,Quanliao (SI18) point,and Yingxiang (LI20)point on the face are mainly kneaded.The straight-line scraping manipulation and rubbing manipulation are used to scrape the corresponding spine areas of the spleen,stomach,and liver and body surface projection areas of those organs on the left and right back,where Ganshu (BL18),Pishu (BL20),and Weishu (BL21) are mainly scraped using kneading manipulation.(3) Chloasma with kidney deficiency: the kidney area on the face is mainly kneaded.The straight-line scraping manipulation is used to scrape the corresponding spine area of kidney,heart,liver,and gallbladder,where Ganshu (BL18),Danshu (BL19),and Shenshu (BL23) are mainly scraped using kneading manipulation.[23]

In 2019,Yanget al.[24]conducted computer retrieval for in-depth mining of the contents of scraping technology in the core literature databases at home and abroad,and found that scraping technology in the field of nursing shows many research directions,and the key words about clinical application are mainly periarthritis of shoulder,cervical spondylosis,cold,essential hypertension,low back pain,and so on.Zhanget al.[25]found that electroacupuncture combined with scraping achieved satisfactory clinical results in the treatment of breast hyperplasia.Chenet al.[26]conducted a randomized controlled trial of treating patients with allergic rhinitis with scraping therapy,and found that the therapeutic effect of scraping treatment group was superior to Western medicine treatment group after treatment and during follow-up.In that trial,it is concluded that acupoint scraping therapy for the different syndrome types of allergic rhinitis has a definite curative effect,which is better than Western medicine treatment in short-term and long-term efficacy.Caiet al.[27]conducted a randomized controlled trial of 60 patients with knee arthritis treated with scraping combined with collateral bloodletting which showed significant efficacy in the treatment of knee pain,with feasible clinical guidance.Shanget al.[28]found that cooling and numbness in lower limbs and feet of patients with diabetic peripheral neuropathy were relieved after using warm acupuncture combined with scraping.Renet al.[29]conducted a systematic review and meta-analysis of randomized controlled trials and found preliminary evidence to support the hypothesis that scrapping therapy can effectively improve the therapeutic effect of patients with perimenopausal syndrome.More researches are needed to clarify the optimal frequency and dosage of scraping.

CONCLUSION

This paper describes the definition of scraping technology,role,and standardization process,points out the technical operation specifications and matters needing attention,and finally specified scraping technology application method.In clinical practice,scraping technology,which reflects good therapeutic effects in its application field,is more and more widely applied and recognized.In the future,animal experiments can be carried out to discuss the mechanism of scraping on different diseases.We can also try to carry out multi-disciplinary association with psychology and sociology and conduct multi-field researches,so as to ultimately promote the development of scraping technology in the field of nursing at home and abroad.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.