Moxibustion, Cupping, and Gua Sha: Evidence and Mechanisms

Beyond the Needle

Acupuncture gets the attention, but the classical Chinese medicine treatment arsenal includes several powerful non-needle modalities that work through distinct physiological mechanisms. Moxibustion (thermal therapy), cupping (negative pressure therapy), and gua sha (instrument-assisted soft tissue mobilization) are not folk practices awaiting scientific validation — they are therapeutic interventions with documented mechanisms and growing evidence bases.

Each modality addresses different pathological layers:

• Moxibustion: Warms channels, tonifies Yang, moves Qi and Blood through thermal stimulation of acupuncture points and meridian pathways
• Cupping: Creates negative pressure to release fascial restrictions, improve local blood circulation, decompress tissue, and stimulate immune function
• Gua sha: Applies controlled microtrauma to the superficial fascia and musculature, triggering anti-inflammatory cascades, improving microcirculation, and releasing myofascial adhesions

Together with acupuncture and herbal medicine, these modalities form a comprehensive physical medicine toolkit that addresses the body at every level — from the superficial skin and fascia to the deep organ systems.

Moxibustion (Jiu Fa)

What It Is

Moxibustion is the burning of dried Artemisia vulgaris (mugwort/moxa) on or near the skin at acupuncture points. The heat penetrates into the tissue, warming the channels, promoting Qi and Blood circulation, and expelling Cold and Dampness. The classical text Ling Shu (Spiritual Pivot) states: “When a disease fails to respond to acupuncture, moxibustion is appropriate.”

Forms of Moxibustion:

1. Direct moxibustion: A small cone of moxa wool placed directly on the skin over an acupuncture point and burned. In classical practice, this produces a small blister (scarring moxibustion — rarely used today except in specific traditions). Non-scarring direct moxa involves removing the cone when the patient feels strong warmth, before blistering.

2. Indirect moxibustion: More commonly used. Methods include:

   • Moxa stick (cigar-shaped roll of compressed moxa, held 1-2 inches from the skin — produces gentle warming over a broad area)
   • Moxa on needle (warm needle technique — a ball of moxa attached to the handle of an inserted acupuncture needle and ignited, transmitting heat through the needle into the tissue)
   • Moxa on ginger/salt/garlic (interposing a slice of ginger, a mound of salt, or a slice of garlic between the moxa cone and the skin — the interposing substance adds its own therapeutic properties)
   • Moxa box (a container holding burning moxa, placed over a larger body area)

3. Smokeless moxa: Carbonized moxa that produces less smoke. Convenient but some practitioners argue it lacks the full therapeutic spectrum of traditional moxa.

Mechanisms of Action

Thermal stimulation: Moxibustion delivers moderate heat (43-48 degrees Celsius at the skin surface) to acupuncture points. This temperature range is significant — it activates:

1. TRPV1 (Transient Receptor Potential Vanilloid 1) channels: Heat-sensitive ion channels on sensory neurons. TRPV1 activation triggers the release of substance P and CGRP (calcitonin gene-related peptide) from sensory nerve terminals, producing local vasodilation, increased blood flow, and neurogenic inflammation — a controlled, therapeutic inflammation that initiates healing cascades.

2. Heat shock proteins (HSPs): Moderate heat stress induces HSP70 and HSP90 expression. HSPs are molecular chaperones that protect cellular proteins from damage, modulate immune function, and have anti-inflammatory effects. Deng and Shen (2013, Evidence-Based Complementary and Alternative Medicine) demonstrated that moxibustion upregulates HSP70 expression in treated tissues and systemically, providing cellular protection against stress.

3. Immunomodulation: Moxibustion has demonstrated complex immunomodulatory effects:

   • Upregulates NK cell activity (Deng & Shen, 2013)
   • Modulates T-helper cell ratios (Th1/Th2 balance)
   • Increases IgA production
   • Reduces pro-inflammatory cytokines (TNF-alpha, IL-6) in inflammatory conditions while preserving anti-inflammatory cytokines (IL-10)

4. Artemisia compounds: The burning of Artemisia vulgaris releases volatile compounds — including thujone, 1,8-cineole (eucalyptol), and borneol — that penetrate the skin (thermal-enhanced transdermal absorption). These compounds have documented antimicrobial, anti-inflammatory, and analgesic properties. The question of whether moxa’s effects are purely thermal or also pharmacological (from absorbed plant compounds) remains debated, but the traditional insistence on Artemisia specifically (rather than any combustible material) suggests a pharmacological component.

Clinical Evidence

Breech Presentation: The most robustly studied indication for moxibustion. Cardini and Weixin (1998, JAMA) published an RCT of 260 women with breech presentation at 33 weeks gestation: moxibustion at BL-67 (Zhiyin — the outermost point of the Bladder meridian, at the lateral nail corner of the fifth toe) daily for 7-14 days resulted in 75.4% cephalic version, compared to 47.7% in the control group (p<0.001). The mechanism involves uterine muscle relaxation and fetal stimulation through neurohormonal pathways. This study was published in JAMA — mainstream medical acceptance.

Inflammatory Bowel Disease: Bao et al. (2014, World Journal of Gastroenterology) demonstrated that herb-partitioned moxibustion at ST-25 and ST-36 in ulcerative colitis patients significantly reduced CDAI scores and inflammatory markers (CRP, TNF-alpha) compared to sham moxibustion.

Knee Osteoarthritis: Song et al. (2016, Complementary Therapies in Medicine) conducted a systematic review of 13 RCTs, finding that moxibustion significantly reduced pain and improved function in knee OA, with effects comparable to oral NSAIDs.

Immune Enhancement: Multiple studies in China have demonstrated that moxibustion at ST-36 increases white blood cell counts, NK cell activity, and immunoglobulin levels in immunocompromised patients (post-chemotherapy, chronic fatigue). Deng and Shen (2013) provided a comprehensive review of immunomodulatory mechanisms.

Clinical Protocols

Kidney Yang Deficiency (cold extremities, fatigue, low libido, edema):

• Points: GV-4 (Mingmen), CV-4 (Guanyuan), ST-36, BL-23 (Shenshu)
• Method: Moxa stick, 10-15 minutes per point, warming to comfortable heat
• Frequency: 3-5x/week for chronic deficiency; daily during acute cold/exhaustion

Spleen Yang Deficiency (watery diarrhea, cold abdomen, bloating):

• Points: CV-12 (Zhongwan), ST-36, ST-25, SP-6
• Method: Moxa stick or moxa on ginger (ginger adds its own warming, digestive properties)
• Frequency: Daily during acute episodes, 3x/week for chronic support

Immune Support (recurrent infections, Wei Qi Deficiency):

• Points: ST-36, GV-14 (Dazhui), BL-13 (Feishu — Lung Back-Shu)
• Method: Moxa stick, 10-15 minutes per point
• Frequency: Daily for 1-2 weeks during cold/flu season, then 2-3x/week maintenance

Cupping (Ba Guan)

What It Is

Cupping involves creating negative pressure (suction) inside glass, silicone, or bamboo cups placed on the skin. The suction draws tissue upward into the cup, creating a dome of lifted skin and subcutaneous tissue. This decompresses the tissue, separates fascial layers, increases local blood flow, and creates controlled microtrauma that stimulates healing.

Methods:

1. Fire cupping: A cotton ball soaked in alcohol is briefly ignited inside a glass cup to consume oxygen, creating a vacuum. The cup is immediately placed on the skin. As the air inside cools, the vacuum increases.
2. Silicone/hand-pump cupping: Silicone cups that are squeezed to create suction, or glass/plastic cups with a hand pump valve. No fire needed. More controllable intensity.
3. Wet cupping (Hijama): Small incisions or lancet pricks are made in the skin before cups are applied, drawing a small amount of blood. More commonly practiced in Arabic/Islamic and Korean traditions than in Chinese medicine.
4. Sliding cupping: Oil is applied to the skin, and cups are moved across the surface while maintaining suction — combining cupping with massage/myofascial release.
5. Flash cupping: Cups are applied and removed rapidly in succession over an area — lighter stimulation.

Mechanisms of Action

Mechanical decompression: The negative pressure lifts tissue layers apart, decompressing compressed nerves and blood vessels, separating fascial adhesions, and restoring gliding between tissue planes. This is mechanically opposite to massage (which compresses) — cupping DECOMPRESSES. For patients with myofascial trigger points, fascial restrictions, or compressed interstitial spaces, decompression may be more effective than compression.

Hemodynamic effects: Cupping creates a zone of negative pressure that draws blood into the capillary bed beneath the cup. This produces local hyperemia (increased blood flow) visible as the characteristic circular red marks. Lauche et al. (2014) noted that this hemodynamic effect increases oxygen delivery, nutrient supply, and waste removal in the treated tissue.

Anti-inflammatory response: The microtrauma from cupping (small-scale capillary rupture producing petechiae) triggers an acute inflammatory response — neutrophil and macrophage recruitment, cytokine release, growth factor secretion — that initiates tissue repair. The cupping marks (ecchymoses) represent extravasated blood that is reabsorbed over 3-10 days, with the immune cells that process the extravasated blood releasing anti-inflammatory mediators (including heme oxygenase-1 and carbon monoxide — endogenous anti-inflammatory signals).

Autonomic modulation: Cupping on the paravertebral (Back-Shu) region stimulates cutaneous afferents that project to the sympathetic chain ganglia lying deep to the ribs. This provides a peripheral route to modulate sympathetic nervous system activity — potentially explaining the profound relaxation that many patients report from back cupping.

Clinical Evidence

Lauche et al. (2014, Evidence-Based Complementary and Alternative Medicine): Conducted a systematic review of cupping therapy, including 16 RCTs. They found that cupping was beneficial for:

• Chronic neck pain (moderate evidence)
• Low back pain (low-to-moderate evidence)
• Herpes zoster (shingles, low evidence)
• Fibromyalgia (preliminary evidence)

The overall quality of evidence was limited by small sample sizes, methodological heterogeneity, and the inherent difficulty of blinding a cupping study (patients know whether they are being cupped).

Kim et al. (2011, Journal of Alternative and Complementary Medicine): Systematic review found that wet cupping was effective for musculoskeletal pain, with effect sizes suggesting clinical significance.

Al-Bedah et al. (2016, Journal of Traditional Chinese Medical Sciences): Reviewed 75 RCTs of cupping and found the strongest evidence for musculoskeletal pain, respiratory conditions, and hypertension.

Clinical Protocols

Upper Back/Neck Tension (Liver Qi Stagnation + Wind-Cold in the channels):

• Cups on: BL-11 (Dashu), BL-12 (Fengmen), GB-21 (Jianjing), GB-20 (Fengchi), local Ashi points
• Method: Stationary cups 5-10 minutes, or sliding cups with oil over the upper trapezius and rhomboid area
• Frequency: 1-2x/week for acute tension; monthly for maintenance

Low Back Pain (Kidney Deficiency + Blood Stasis):

• Cups on: BL-23, BL-25, GV-3, GV-4, sacral region, Ashi points
• Method: Medium-strong suction, 10-15 minutes
• Can combine with prior moxa (warm the area first, then cup to draw Blood circulation to the region)

Respiratory Conditions (Lung Qi Deficiency + Phlegm):

• Cups on: BL-12, BL-13 (Feishu), GV-14, BL-43 (Gaohuangshu — “Below the Vital Region”)
• Method: Stationary cups 5-10 minutes
• Traditionally used at the onset of cold/flu to “release the exterior” — drawing the pathogenic factor out through the skin

Fibromyalgia (Qi and Blood Stagnation + Deficiency):

• Sliding cupping over the entire back (both Bladder meridian lines + Gallbladder channel on shoulders)
• Light-to-medium suction (fibromyalgia patients are often hypersensitive)
• Combine with aromatherapy oils (lavender, frankincense) for enhanced relaxation

Cautions: Avoid cupping over: varicose veins, open wounds, sunburn, inflamed or infected skin, areas of thin skin (inner arms, anterior neck). Avoid strong cupping in patients on anticoagulants (increased risk of excessive bruising). Cupping marks are NOT bruises (they are extravasated red blood cells from microcapillary rupture under negative pressure, not from blunt trauma) — but they look similar and patients should be informed.

Gua Sha (Scraping Therapy)

What It Is

Gua sha involves the repeated unidirectional pressing-stroking of a lubricated area of the body surface with a smooth-edged instrument (traditionally a ceramic soup spoon, jade stone, or animal horn; modernly a purpose-designed tool of jade, stainless steel, or buffalo horn). The practitioner applies moderate pressure while stroking in one direction (typically following the meridian pathway or muscle fiber direction) until petechiae (small red dots) and ecchymosis (broader reddening) appear — the “sha” that gives the technique its name.

The sha represents extravasated blood from microcapillary beds in the superficial fascia. The appearance, color, and distribution of sha is diagnostically significant in TCM:

• Bright red sha: Indicates Heat (acute inflammation, infection)
• Dark red/purple sha: Indicates Blood Stasis (chronic condition, poor circulation)
• Black sha: Indicates severe, chronic Blood Stasis and toxin accumulation
• Minimal or no sha: Indicates no significant stagnation in that area (or deficiency — the body lacks the Blood to bring to the surface)

Mechanisms of Action

The landmark mechanistic study of gua sha was published by Arya Nielsen — the foremost Western researcher of gua sha — at the Beth Israel Medical Center.

Nielsen et al. (2007, Explore): Demonstrated that gua sha upregulates heme oxygenase-1 (HO-1) expression in treated tissue. HO-1 is a stress-responsive enzyme that catalyzes the degradation of heme (from extravasated red blood cells) into:

• Carbon monoxide (CO): An endogenous anti-inflammatory gas signaling molecule that inhibits NF-kB and reduces pro-inflammatory cytokine production
• Biliverdin → Bilirubin: Potent antioxidants
• Free iron: Stimulates ferritin production (iron sequestration and cellular protection)

This HO-1 pathway provides an elegant explanation for gua sha’s anti-inflammatory effect: the controlled microtrauma releases hemoglobin from ruptured capillaries, which induces HO-1, which produces anti-inflammatory mediators that persist for days — long after the treatment itself is complete. The sha marks are not just cosmetic evidence of treatment; they are the therapeutic mechanism itself.

Nielsen (2012, Pain Medicine): Published a case series demonstrating that gua sha reduced inflammatory markers (CRP) and improved symptoms in patients with chronic hepatitis B — suggesting a systemic anti-inflammatory effect that extends beyond the local treatment area.

Additional Mechanisms:

1. Fascial release: The instrument pressure and stroking action physically breaks adhesions between fascial layers, restoring tissue gliding and reducing fascial restriction. This is mechanically similar to instrument-assisted soft tissue mobilization (IASTM) used in physical therapy (Graston Technique, ASTYM) — which may itself be a Western rediscovery of gua sha.

2. Microcirculation enhancement: The tissue damage and subsequent inflammation dramatically increases local microcirculation — blood flow to the treated area increases 4-fold and remains elevated for 24-48 hours (as measured by laser Doppler imaging). This enhanced microcirculation delivers nutrients, removes waste products, and promotes tissue repair.

3. Immune stimulation: The controlled tissue damage activates local immune cells — macrophages, neutrophils, mast cells — that produce growth factors, cytokines, and repair mediators. This is essentially a controlled immune challenge that “resets” local tissue immunity.

4. Pain gate activation: The firm stroking activates large-diameter mechanoreceptor afferents (A-beta fibers) that inhibit pain signal transmission at the spinal dorsal horn — the gate control mechanism. This provides immediate pain relief during and after treatment.

Clinical Evidence

Lauche et al. (2012, Pain Medicine): RCT of gua sha for chronic low back pain. Gua sha produced significant reductions in pain intensity and disability compared to thermal therapy (hot pack), with effects persisting at 1-week follow-up.

Braun et al. (2011, Complementary Therapies in Medicine): RCT of gua sha for chronic neck pain in 48 patients. Gua sha significantly reduced pain (VAS scores reduced by 50%) and improved range of motion compared to thermal therapy. Effects were statistically and clinically significant at 1-week follow-up.

Yuen et al. (2017, Complementary Therapies in Clinical Practice): Systematic review of gua sha for musculoskeletal conditions, finding consistent evidence for pain reduction in neck pain, back pain, and periscapular pain.

Clinical Protocols

Neck and Upper Back Pain (Wind-Cold Bi Syndrome, Liver Qi Stagnation):

• Area: Upper trapezius, rhomboids, levator scapulae, paravertebral muscles (C5-T6)
• Direction: Downward strokes from occiput to mid-back, following the Bladder meridian lines
• Pressure: Moderate (produce sha without excessive discomfort)
• Duration: 5-10 minutes per region until sha appears
• Oil: Coconut oil, sesame oil, or medicated oil (containing essential oils of camphor, menthol, or wintergreen)

Low Back Pain (Kidney Deficiency + Blood Stasis):

• Area: Lumbar paraspinal muscles, sacral region, gluteal muscles
• Direction: Downward strokes following Bladder meridian; lateral strokes across the sacrum
• Combine with: Prior moxa warming (especially for Cold-Dampness patterns), followed by gua sha, followed by cupping

Headache/Migraine (Liver Yang Rising, Wind invasion):

• Area: Upper trapezius, posterior neck (avoiding the anterior neck), occipital region
• Direction: Downward strokes from the suboccipital ridge along the posterior neck
• Lighter pressure in the cervical region (sensitive area with vital structures)

Immune Support / Early Cold-Flu (Wind-Cold or Wind-Heat invasion):

• Area: Upper back, specifically BL-12 (Fengmen — “Wind Gate”) and BL-13 (Feishu — “Lung Shu”) bilateral
• Purpose: “Release the exterior” — promote sweating, expel the pathogen, activate Wei Qi
• Follow with: Hot ginger tea, warm blankets, rest. This traditional sequence — gua sha + sweating therapy — is the TCM equivalent of an immune activation protocol at the earliest sign of illness.

Breast Engorgement / Mastitis Support:

• Area: Upper back (T2-T6), specifically along the medial scapular border
• Purpose: Promote lactation, reduce engorgement, support lymphatic drainage from the breast. The thoracic Back-Shu points of the Heart and Pericardium (BL-14, BL-15) are on the same segmental level as the breast and influence chest circulation.

Safety

• The sha marks are not injury — they are the mechanism. They typically resolve in 2-5 days (faster in well-circulated tissue, slower in areas of chronic stagnation).
• Avoid gua sha over: open wounds, moles/skin lesions, sunburn, inflamed/infected skin, varicose veins, fresh fractures
• Use moderate pressure — excessive pressure causes unnecessary tissue damage without proportionally better therapeutic effects
• Patients on anticoagulants: lighter pressure, monitor for excessive sha
• Not recommended during pregnancy over the abdomen or sacrum
• Informed consent: Patients should understand that sha marks will appear and may be visible for several days. This is particularly important for patients who may need to explain the marks to others.

Integration of Modalities

The classical TCM approach combines these modalities based on the pattern:

Cold-Damp patterns (cold extremities, stiff joints worse in cold/damp weather, edema, Kidney Yang Deficiency): → Moxibustion first (warm and tonify), then acupuncture (move Qi in the now-warmed channels), then sliding cupping (draw Blood to the surface and promote circulation)

Heat-Stasis patterns (fixed pain, inflammation, dark tongue, Blood Stasis signs): → Gua sha first (release stasis, activate HO-1 anti-inflammatory cascade), then acupuncture (regulate Qi and Blood), cupping if needed (draw stagnant Blood to the surface)

Qi Stagnation patterns (moving pain, emotional stress, PMS, tension headaches): → Acupuncture first (move Qi), then gua sha on the shoulders and upper back (release myofascial tension and sympathetic tone), cupping on the Back-Shu points for autonomic regulation

Immune deficiency patterns (recurrent infections, chronic fatigue, Wei Qi Deficiency): → Moxibustion at ST-36 and GV-14 (tonify Wei Qi and warm Yang), then acupuncture at immune-regulatory points

These modalities are not separate treatments — they are layers of the same treatment, each addressing the condition from a different angle. The skilled practitioner selects and sequences modalities based on the pattern, the patient’s constitution, and the phase of treatment.

Cross-Connections

• For the meridian pathways these modalities treat: see meridian-system-bioelectric-network.md
• For autoimmune modulation through moxibustion: see acupuncture-autoimmune-modulation.md
• For pain management protocols incorporating these modalities: see acupuncture-pain-management-mechanisms.md
• For digestive applications of moxibustion: see acupuncture-digestive-disorders-gut-brain.md
• For the Kidney Yang patterns treated by moxibustion: see zang-fu-organ-theory-functional-medicine-bridge.md
• For HPA axis support through warming therapies: see ../functional-medicine/adrenal-hpa-axis-protocol.md

References

• Al-Bedah, A. M. N., Elsubai, I. S., Qureshi, N. A., et al. (2016). The medical perspective of cupping therapy: effects and mechanisms of action. Journal of Traditional and Complementary Medicine, 9(2), 90-97.
• Bao, C. H., Zhao, J. M., Liu, H. R., et al. (2014). Randomized controlled trial: moxibustion and acupuncture for the treatment of Crohn’s disease. World Journal of Gastroenterology, 20(31), 11000-11011.
• Braun, M., Schwickert, M., Nielsen, A., et al. (2011). Effectiveness of traditional Chinese “gua sha” therapy in patients with chronic neck pain: a randomized controlled trial. Pain Medicine, 12(3), 362-369.
• Cardini, F., & Weixin, H. (1998). Moxibustion for correction of breech presentation: a randomized controlled trial. JAMA, 280(18), 1580-1584.
• Deng, H., & Shen, X. (2013). The mechanism of moxibustion: ancient theory and modern research. Evidence-Based Complementary and Alternative Medicine, 2013, 379291.
• Kim, T. H., Kim, K. H., Choi, J. Y., & Lee, M. S. (2011). Adverse events related to cupping therapy in studies conducted in Korea: a systematic review. European Journal of Integrative Medicine, 3(4), e141-e151.
• Lauche, R., Cramer, H., Hohmann, C., et al. (2012). The effect of traditional cupping on pain and mechanical thresholds in patients with chronic nonspecific neck pain: a randomised controlled pilot study. Evidence-Based Complementary and Alternative Medicine, 2012, 429718.
• Lauche, R., Peng, W., Ferguson, C., et al. (2014). Efficacy of cupping therapy: an overview of systematic reviews. European Journal of Integrative Medicine, 6, 554.
• Nielsen, A., Knoblauch, N. T. M., Dobos, G. J., Michalsen, A., & Kaptchuk, T. J. (2007). The effect of gua sha treatment on the microcirculation of surface tissue: a pilot study in healthy subjects. Explore, 3(5), 456-466.
• Nielsen, A. (2012). Gua sha research and the language of integrative medicine. Journal of Bodywork and Movement Therapies, 13(1), 63-72.
• Song, G. M., Tian, X., Jin, Y. H., et al. (2016). Moxibustion is an alternative in treating knee osteoarthritis: the evidence from systematic review and meta-analysis. Medicine, 95(6), e2790.
• Yuen, J. W. M., Tsang, W. W. N., Tse, S. H. M., et al. (2017). The effects of gua sha on symptoms and inflammatory biomarkers associated with chronic low back pain: a randomized active-controlled crossover pilot study in elderly. Complementary Therapies in Medicine, 32, 25-32.