Advantages and Suggestions of Scraping to Promote Rehabilitation of COVID-19 Patients in Convalescence

WANGYu-yang (王雨阳), MENG Xiang-wen (孟向文), HU Guang-qin (胡广芹), SHEN Feng (沈 峰),ZHANG Yang-pu (张阳普), WANG Zhao-hui(王朝辉), SHE Yan-fen (佘延芬), HOU Zhong-wei (侯中伟),HUANG Hai-ping (黄海萍), JIA Hong-ling (贾红玲), WANG Dong-yan (王东岩)

1. Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China 2. Beijing University of Technology, Beijing 100024, China 3. Hubei University of Chinese Medicine, Wuhan 430065, China 4. Hubei Provincial Hospital of Integrated Traditional Chinese & Western Medicine, Wuhan 430015 5. Changchun University of Chinese Medicine, Changchun 130117, China 6. Hebei University of Chinese Medicine, Shijiazhuang 050091, China 7. Beijing University of Chinese Medicine, Beijing 100029, China 8. Hong Kong Academy of Chinese Medicine 9. Shandong University of Traditional Chinese Medicine, Jinan 250355, China 10. Heilongjiang University of Chinese Medicine, Haerbin 150040, China

ABSTRACT Objective:To demonstrate the advantages of scraping in helping COVID-19 patients in convalescence, popularize scraping therapy among them and provide basis for the establishment of operation speci fication.Methods : Discuss the relationship between scraping and epidemic disease by reviewing the relevant scraping theory analysis, summarize the existing clinical studies and propose reference scheme for the treatment of COVID-19 patients in convalescence with respect to the related symptoms proving effective treatment of scraping on patients in convalescence.Results : Ancient healers used scraping to treat pestilence, and there have been many clinical trials and experiments for the treatment of convalescent symptoms related to scraping. Scraping also has the effect of improving immune function and antioxidation,which is feasible for the treatment of convalescent symptoms related to scraping.Conclusion: Scraping can effectively improve the clinical symptoms of COVID-19 convalescent patients, and it can be used as one of the external treatments for convalescent patients. It is recommended to promote scraping among the patients so that they can have self-intervention treatment.

KEYWORDS COVID-19; Convalescence; Scraping; Rehabilitation; Immunity; Antioxidation

INTRODUCTION

In Coronavirus Disease-2019 (COVID-19)Diagnosis and Treatment Scheme (5thEdition for Trial Implementation), COVID-19 is defined as"belonging to the category of pestilence in traditional Chinese medicine, caused by the pestilential pathogen"[1]. There are detailed records of the pestilence inHuangdi Neijing. Among them,Huangdi Neijing•Su Wen•Ci Fa Lun Discussiondetailed the occurrence of the disease, syndrome differentiation and treatment and prognosis.Scraping and other external treatment played an important role in the treatment of epidemic disease by later generations[2]. ZHANG Bo-li, the academician of the Chinese Academy of Engineering and President of Tianjin University of Traditional Chinese Medicine, pointed out that although there was no specific medicines, there were some TCM effective solutions[3]. In the treatment of COVID-19,ZHANG Bo-li gave patients not only oral Chinese medicines or patent Chinese medicines, but also other external treatments such as scraping, which significantly reduced the transformation ratio of mild cases to severe cases. Scraping therapy is one of the external therapies byGuide and Suggestions on Rehabilitation of Convalescence of COVID-19 by Traditional Chinese Medicine(for Trial Implementation) issued by the current the National Administration of Traditional Chinese Medicine. Now the authors analyzed and demonstrated the ef ficacy of scraping theory and clinical ef ficacy of application.

THEORETICAL BASIS OF PREVENTION AND TREATMENT OF COVID-19

The "pestilence" in traditional Chinese medicine is a kind of acute infectious disease which is highly infectious, hurtful and only severe[4]. Traditional Chinese medicine believes that the disease is caused by exogenous pathogens, which invade the body through the mouth, nose or skin. The pestilence has the characteristics of rapid onset, serious illness,strong infectivity and easy to spread. It is recorded in theSu Wen•On the Feverthat "Pathogen qi is easy to invade human body when vital qi is insuf ficient." It is also mentioned in Su Wen•Legacy Essay of Ci Fa Lun Discussion that "Five epidemic diseases are easy to infect each other, and the symptoms are similar whether the illness is severe or not." Thus it can be seen that TCM has long believed that characteristics of intense infectivity and similar clinical symptoms. It is recorded inThe Origin and Symptoms of Diseases Epidemic Febrile Diseasesby Chao Yuanfang of Sui dynasty that "People get sick due to pestilential pathogen and easy to infect each other, and even the whole family died and spread outsiders, so they must take the medicines beforehand to guard against it." At this time, TCM masters have realized the severity of the disease and the importance of timely preventive measures. Ge Hong of Jin dynasty recorded the poison of sand louse "First get the poison, and it develops a red rash on the skin,such as small beans… After three days, makes the body joint be strong, and the pain is cold and hot... The worm gradually enters the bone and kills people." inHandbook of Prescription for Emergency.He documented the treatment performance and pathogenetic regularity of the "sand louse"[5]. Later,he also recorded a method similar to scraping to expel the "sand louse" from the body, "Scrape it with a bamboo leaf to make the blood come out". Guo Pu in the Jin dynasty inClassic of Mountains and Seasnotes that "It can be a needle for the treatment of carbuncle swelling". In the bookRencun Sun's Secret recipe for curing diseases of Sun Rencunof Yuan dynasty, Sun Rencun recorded the operation of the rope scraping method and the characteristics of scraping image, "The hemp rope wipes the neck and the arm, and the purple spot indicates the cure".Gong Tingxian detailed the role of scraping therapy in the cholera epidemic in his bookShou Shi Bao Yuan. Wu Shangxian'sLi Yue Parallel Prose, Chen Xiuyuan'sChen Xiuyuan 72 kinds of Medical books,and Lu Leshan'sHealth Mirrorall have records on the treatment of pestilence by scraping.

CLINICAL BASIS FOR THE TREATMENT OF POST-INFECTION SYMPTOMS

COVID-19 patients in rehabilitation period mostly have cough, fatigue, chest tightness,heartache, insomnia, abdominal distension and other clinical symptoms. Hu Qian et al[6]. divided 80 cases of post-infection cough patients into two groups: one group was treated with traditional Chinese medicine by taking decoction orally to relieve cough; the other group was treated with traditional Chinese medicine in addition to scraping on bladder meridian, lung meridian, ren vessel and governor vessel. After treatment, the cough symptom score, remission time, recurrence, TCM syndrome score, quality of life questionnaire score and substance P in sputum supernatant etc. were observed and the results showed that the curative effect was better than that of single Chinese medicine group. ZHANG Xiao-qi et al[7]. divided 72 patients with cough after cold into control group and treatment group. In the treatment group, scraping therapy was used on governor vessel (Dazhui acupoint to Mingmen acupoint),gallbladder meridian (Fengchi acupoint to the apex),lung meridian, etc. After the cough score evaluation,the curative effect of the treatment group was better than that of the control group.

Lacking in strength, fatigue and other diseases are classified as "asthenic overstrain"and "weariness and weakness" and so on in TCM.It is considered as a disease with dysfunction of multiple Zang and Fu, meridians and collaterals,and the dysfunction of Zang and Fu organs is the key to pathogenesis. Liang Hong[8]et al. divided 60 patients with chronic fatigue into two groups. Vitamin B1 was taken orally in the control group. On the basis of oral vitamin B1, the treatment group was treated with scraping therapy, and the scraping site was mainly on the back. The focus of scraping is Feishu acupoint, Xinshu acupoint, Ganshu acupoint,Pishu acupoint, Shenshu acupoint and so on. The tolerance of the patients is the degree of scraping until there are purplish red petechia and ecchymosis.In terms of face ef ficacy, FS-14 score and FAI score before and after treatment, the treatment group had better ef ficacy than the control group.

CHEN Na et al[9]. treated the patients who had a history of coronary heart disease and complained of neck pain with chest distress and palpitation by using the method of acupuncture combined with cupping, acupuncture at Neiguan, Xinshu and other acupoints, and scraping at the back. There were obvious scraping signs of stasis purple at the Xinshu and Dazhui acupoints. After four times of continuous treatment, the patients felt that the symptoms of chest distress and panic were relieved. According to the patient's symptoms and scraping image, she can judge the patient's stasis block. Unblock brings pain[10]. The cutaneous part is where the Qi of the collaterals is scattered. Operation in the cutaneous part used by scraping therapy, can mobilize the whole body viscera function, to remove blood stasis and detoxi fication.

Insomnia is highly related with mental factors and disorders of neurological system function[11]. Li Guoxiu[12]treated 30 insomnia patients with dialectical acupoint picking scraping therapy and with emotional nursing treatment, getting total effective rate of 90%.Guan Xiaodan[13]used scraping therapy for insomnia patients in the treatment group on their governor vessel and pericardium meridian and patients in the control group were given Estazolam orally. After a treatment cycle of 15 days, the result showed that the cure rate of the treatment group was 65% and that of the control group was 31.3%. Total effective rate of the treatment group was 95%, and that of the control group was 75%. Scraping therapy is better than oral administration of western medicine in improving insomnia. Yu Jianzhen[14]divided 60 cases of insomnia into two groups, which were treated with scraping and stellate ganglion block respectively. After treatment, it was observed that there was no statistical difference between the two groups in the decrease of PSQI and the increase of aMT6s level. However, due to continuous medication for insomnia, medicine tolerance exists, and withdrawal reactions such as tension, anxiety, irritability and insomnia rebound may occur when the medication is abruptly discontinued.Therefore, scraping therapy can be considered in the appropriate circumstances to replace medication for insomnia.

The symptoms of abdominal distension in convalescent patients are mostly related to the malfunction of spleen and stomach transportation and qi mechanism. ZHU Yan et al[15]. divided 60 patients with intestinal stress into control group and observation group. Patients in the control group take orally the soup of tune liver and transport spleen, and the observation group received, in addition to, oral administration of Chinese medicine decoction, scraping treatment on governor vessel, bladder meridian, ren vessel,stomach meridian, spleen meridian and liver meridian.After treatment, IBS symptom severity questionnaire and IBS quality of life table were used to evaluate the ef ficacy of the two groups. The results showed that the observation group was better than the control group in improving the symptoms of abdominal pain, diarrhea and abdominal distension, and the quality of life of the patients was improved.

SCIENTIFIC BASIS OF IMMUNE REGULATION AND ANTIOXIDATION

Function of Immunomodulatory

Modern medicine believes that subcutaneous bleeding points generated through scraping can stimulate leukocyte and interleukin factors: IL-1 and IL-6 are increased, to realize the promotion of immunity. Leukocyte is a kind of immune cells that help the body fight off infections and foreign bodies, and it plays an important role in curing body injury, resisting pathogen invasion and immunity.IL-1 (lymphocyte stimulating factor) is mainly produced by activated mononuclear macrophages,and the main forms of existence are IL-α and IL-β. It can synergistically stimulate the activation of T cells at low local concentrations, promote the proliferation of B cells and secrete antibodies.The main sources of IL-6 were mononuclear macrophages, Th2 cells, and fibroblasts etc. It can stimulate B cells to secrete antibodies; Stimulation of somatic cell proliferation and CTL activation;Participate in inflammatory response and so on.Therefore, scraping image produced by scraping can stimulate the proliferation and activation of B cells and T cells accordingly, thus improving the immune function of the body. During the scraping, mechanical pressure movement can promote subcutaneous microcirculation, and promote capillary dilatation,accelerate the release of hemoglobin, produce its own hemolysis[16]. At the same time, it can make the flow of blood and lymphatic increase, and accelerate the material exchange between blood tissue fluid and lymphatic fluid[17]. Moreover, with the production of scraping image, in filtration of subcutaneous red blood cells and platelets can cause a variety of immune and in flammatory effects.

After had experiments on rats, CUI Xiang-qing[18]finds that the lymphocyte decreased after 6 hours of scraping, but increased significantly after 12 hours.It can be considered that the effect of scraping on the lymphocyte of the body tends to be obvious with the extension of time; When on adult males and females, it was found that lymphocytes increased signi ficantly after scraping of 0.5 hour. WU Zhi-cong et al[19]. detected subcutaneous exudates and blood components of rats after scraping, and found that after scraping, the contents of IL-1 and interferon γ in subcutaneous tissues decreased signi ficantly, and the leukocyte in the blood increased significantly.It shows that scraping can effectively mobilize the immune function of the body and cause the immune response of the body. By scraping rats and mice respectively, Jian Li[20]found that the effect of scraping not only exists in the local, and scraping can produce a systemic response, and several hours after that, the whole body immunity is still in a state of improvement. CHEN Hua et al[21]. divided 50 rats into sham operation group, blank group, scraping group and medicine group. In the scraping group,scraping was taken on Dazhui acupoint to Houhai acupoint, and in the medicine group, azathioprine was dissolved in normal saline and gavage was performed. The study found that after treatment,the IgG both in the scraping group and medicine group decreased significantly, and there was no statistical difference between the two groups, and suggested that scraping and the medicines had a good inhibitory effect on the autoimmune response in vivo after mold building. The scraping group and the medicine group curative effect may be equal.

Antioxidation Effects of the Scraping Method

Studies have shown that[22]scraping can increase the content of antioxidants such as nitric oxide (NO), nitric oxide enzyme (nNOS) and superoxide dismutase (SOD) in the blood. NO can dilate blood vessels and increase blood flow. SOD is an intuitive index of cell senescence and death,and the primary material for scavenging free radicals in living organisms. It can catalyze superoxide anion radical disproportionation to produce oxygen or hydrogen oxide, and plays an important role in maintaining the balance of oxidation and antioxidant in the body. SOD can also repair damaged cells,and repair the damage caused by free radicals to the body, and its vitality can re flect the ability of the body to remove oxygen free radicals. Other studies have confirmed that scraping can significantly increase the catalase (CAT) and glutathione peroxidase(GSH-Px) in endurance training rats, and reduce the malondialdehyde (MDA) content in liver and the activity of serum glutamate aminotransferase(ALT). Therefore, scraping can reduce the oxidative damage caused by long-term fatigue by reducing the oxidative substances produced by long-term fatigue and increasing the antioxidant substances. Bilirubin also has antioxidant effect, can inhibit linoleic acid and phospholipid oxidation[23]. Heme oxidase (HO-1)is an antioxidant defense enzyme[24], which can fight in flammation, oxidation, apoptosis and proliferation[25],and has a protective effect on cell stress.

CUI Xiang-qing[18]divided the rats into four groups (blank group, 2ndgroup (0.5 hour after scraping), 3rdgroup (6 hours after scraping) and 4thgroup (12 hours after scraping) for blood collection and detection. The results showed that direct bilirubin in the rats showed an increasing trend within 12 hours after scraping. Wang Ke found that the total bilirubin was signi ficantly higher in rats 6 hours after scraping than before, and compared with the control group.The lymphocytes in the 2ndgroup and the 3rdgroup were decreased and that of the 4thgroup signi ficantly increased than the control group. Liu Ronghua et al.[26]observed the antioxidant ability of rats by endurance training after meridian scraping, and it was found that scraping could improve the activity of SOD, CAT and GSH-Px, and at the same time eliminate MDA and inhibit the activity of ALT. It is suggested that scraping can improve the antioxidant capacity of the liver and remove free radicals produced by the liver tissue of exercise training rats. Kwong K K et al.[27]observed the gene expression of HO-1 in mice after scraping with fluorescein imaging method, and found that the gene expression was up-regulated, suggesting that scraping had an antioxidant effect.

ADVANTAGES IN FACILITATING RECOVERY OF COVID-19 PATIENTS IN CONVALESCENCE

Prof. ZHOU Zhong-ying[28], the master of Chinese medicine, found that most of the patients have fever,fatigue and dry cough, accompanied by headache,myalgia, poor appetite, diarrhea, thick and greasy coating on the tongue and other clinical symptoms,("Warm disease enters from the mouth and nose,passing from the nose to the lungs and starting from the hand-Tai Yin.", "for people with more dempness demp, the demp is heavier than the heat, and the disease is mainly occurred in the Tai Yin-lung and Tai Yin-spleen."). Therefore, Dr. ZHOU summarized the pathogenesis of the disease as demp interior and exterior, spleen and stomach with the disease.The demp poison turbid gas initially enters by the surface, blocks the lung health gas. XUE Bo-shou[29]characterized the disease as "Cold and Demp Plague", because it occurs in the winter and invades the lung, and will get worse in the cold and demp.Since all sorts of disease in the nature pathogen,epidemic gas invades the transmute way of human body to enter for the surface, from shallow into deep.So from the perspective of the overall concept of Chinese medicine, the treatment of exogenous fever,the priority is to force the pathogen outside. Xiong Jibai[30]summed up three characteristics: 1. Infectious and rapid onset; 2. The main syndrome is basically the same: fever, cough, asthma; 3. After the heavy snow and the winter solstice in 2019, the patient get ill.Because the pathogen spirit that invaded the human body in the 2019 was Shaoyang phase fire, that is to say, it was interfered by the hot gas, the climate was very large repeatedly, and it was easy to have infectious diseases. And Wuhan area belongs to the hot and humid zone, so it is de fined as: damp-warm.Although the etiology and pathogenesis of COVID-19 are not identical among doctors, they all believe that damp pathogen is one of the pathogenic factors. Damp pathogen has the character of entanglement, and the course of disease is longer. The National Health Commission and the State Administration of Traditional Chinese edicine jointly issuedGuide and Suggestions on Rehabilitation of Traditional Chinese Medicine in Convalescence of Corona Virus Disease 2019[31].In the appropriate techniques of traditional Chinese medicine, it is suggested that people in recovery period can adopt scraping therapy. The recommended sites for implementation are lung meridian of hand-Tai Yin, large intestine meridian of hand-Yang Ming and bladder meridian of foot-Tai Yang. This is consistent with the treatment principle[32]of "dredge upper focus,ease middle focus and permeate lower focus" in the treatment of dampness pathogen in the science of seasonal febrile diseases, promote Lung Qi in the upper part, dry and damp in the middle part, and reduce turbidity in the lower part.Su Wen•Disscussion of Cutaneous Part: "Therefore, when all diseases occur, they must first occur in the skin and hair", and"the lung governing skin and hair", so scraping and wiping the lung meridian can promote lung to dispel pathogen. The hand-Tai Yin lung meridian belongs to the lung, so the scraping and wiping of the acupoints can be used to treat lung diseases, and at the same time, according to the cutaneous part principle, to resist the role of external pathogen. The lung and the large intestine are form an exterior interior relationship, the physiological function of the large intestine is related to the lowering function of the lung, and the lung and the large intestine are related to the formation and distribution of body fluid. Scraping and wiping the large intestine meridian can consolidate the function of the lung and regulate the metabolism of body fluid in the body. The bladder meridian of foot-Tai Yang circulate on both sides of the governor vessel, the five viscera gas are injected into this, scraping and wiping bladder meridian can dredges the five viscera gas.

SUGGESTIONS

As China well controlled the epidemic, there are more and more convalescent patients. Although theGuide and Suggestions on Rehabilitation of Traditional Chinese Medicine in Convalescence of Corona Virus Disease 2019(for Trial Implementation)issued by the State Administration of Traditional Chinese Medicine point out that patients in convalescence can be treated with the scraping therapy, the lack of scraping treatment plan and unified standards cannot guarantee the treatment effect. In order to improve this situation, give full play to the unique advantages of traditional Chinese medicine, facilitate the operation of clinicians and home-based rehabilitation of patients, and accelerate the popularization of scraping therapy for COVID-19 patients in convalescence, Scraping Therapy and Cupping Therapy Professional Committee of the World Federation of Traditional Chinese Medicine organized ten experts in this field to make recommendations on the operation of scraping treatment for COVID-19 patients in convalescence[33]. In addition, after the clinical use led by ZHANG Yang-pu, the director of Hubei Integrated Traditional and Western Medicine Hospital, good effects were obtained in improving symptoms of fatigue, insomnia, chest tightness,palpitations, shortness of breath, cough and other symptoms of COVID-19 patients in convalescence.Therefore, it is recommended as follows: First, re fine the operation plan and establish the international operation specification. Convene experts to demonstrate the clinical path of scraping therapy according to the symptoms and TCM syndromes of COVID-19 patients in convalescence, including scraping indications contraindications, the choice of equipment and parts, scraping strength, speed,duration, points for attention and other key links.Second, standardize training and popularize science.Since there is few clinical medical staff proficient in scraping therapy, it is suggested to arrange the specific operation points as soon as possible,record operation videos by experts with rich clinical experience, and train doctors and nurses etc. in clinical frontline through video and remote teaching.Because scraping is a non-traumatic operation, it can also make clear simple operations to patients and their families for self-intervention treatment.Third, carry out clinical research. At present, scraping therapy for the prevention and treatment of COVID-19 has less coverage. It is suggested to focus on three elements, i.e. test subjects, intervention measures and experimental effects, conducting randomized controlled clinical studies through scientific clinical study design to provide clinical evidence of therapeutic effect of scraping therapy in convalescence, and provide theoretical basis for intervention of scraping therapy in early epidemic diseases. At present,con firmed COVID-19 patients overseas has exceeded 380,000. With the internationalization of traditional Chinese medicine, scraping therapy can help more COVID-19 patients in convalescence and bring bene fits to the people of the world.