TuiNa Orthopedic Physiotherapy

TuiNa literally means manipulation and mobilization of soft tissue, and orthopedics is a medical specialty treating functional impairments and deformities of the skeletal system, including soft tissues such as joint capsules, cartilage, ligaments, tendons and muscles. TuiNa has a history of use and development in Traditional Chinese Medicine (TCM) as old as acupuncture and herbalism, and is combined with these treatment protocols. It is a medical specialty that is part of hospital care in China and is quickly being recognized throughout the world. TuiNa has been called 'Asian Massage' and 'Acupressure' for want of a better term in the United States, and incorporates a broad array of manual physiotherapy techniques. A better general term for TuiNa physiotherapy in the United States may be a term such as Traditional Chinese Soft Tissue Mobilization (TCSTM). Expanded use of such treatment could reduce the enormous rise in prescription narcotic addiction and chronic disability, as well as reduce the lost productivity from workers with repetitive and postural strain syndromes.

TuiNa incorporates Shiatsu (which literally means finger pressing or manual point release), myofascial release, joint mobilization, soft tissue manipulation, and other manual techniques, and traditionally may be used with topical herbal medicines, as well as patient instruction in therapeutic techniques and correction of body mechanics. The Chinese term for physiotherapy is Li Liao, and TuiNa, needle stimulation, cupping, and other modalities are all physiotherapies included under the legal scope of practice of the California Licensed Acupuncturist (L.Ac.). The science and practice of TuiNa is part of TCM and is distinctly different from the specialties of Physical Therapy, Chiropractry, and Osteopathy, but integrates well with these other medical specialties. The use of soft tissue mobilization before and after orthopedic surgery has also been found to benefit outcomes and can be easily integrated with standard medicine. The Licensed Acupuncturist may receive extensive training in TuiNa as part of the medical school curriculum, or may choose not to study this specialty, but more and more TCM physicians are opting to study this involved science. The patient needs to inquire whether the acupuncturist has received sufficient training in TuiNa.

Research in recent years has shown that deep tissue physiotherapies, such as Tui Na, also have many beneficial effects on the whole health (see the article entitled Deep Tissue Massage and it's many benefits on this website). Studies at UCLA Medical School and Cedars-Sinai have confirmed that deep tissue physiotherapies benefit hormonal balance, immune function, and neurohormonal health. The rewards of a thorough and professional holistic approach to treatment, as practiced by this physician, are many, and each year the benefits are being confirmed by sound scientific study. While study design in randomized controlled human clinical trials, designed purely to assess safety and efficacy over placebo with pharmaceutical drugs, are problematic in design to assess manual therapies such as TuiNa, the lack of such trials, due to study design, should not be used to discourage this very effective treatment modality. A wealth of clinically proven benefits are now confirmed in scientific study, and a long history of clinical effectiveness, with extensive use in Chinese hospitals, demonstrates its effectiveness and safety.

Since Tui Na is a very developed science, the techniques used may vary considerably from one practitioner to another. Much is dependent upon the level of study and background of the particular physician. You want to make sure that the Tui Na therapist has received extensive medical training and education. Almost always, TuiNa involves focus upon the deep tissues, and a thorough knowledge of anatomy and physiology is important to insure positive effects. It is distinguished from massage of superficial tissues, which is called AnMo in China. Since it works directly on injured and inflamed tissues, this therapy can be uncomfortable, but as the tissues heal and become healthy, the discomfort is replaced by a good feeling of restoration. Success can be felt on each subsequent treatment, and the outcome is usually enhanced by utilizing more frequent sessions in short courses. Here are some descriptions of pertinent aspects of TuiNa.

Myofascial Release, Neuromuscular Reeducation, Trigger Point Needling, and Active Release Technique (ART) - All Part of TuiNa, or Soft Tissue Mobilization (TCSTM)

Myofascial release is a technique used to treat a chronic contracture and/or dysfunction of the muscle caused by strain. Myo- refers to muscle and fascia is the connective tissue that joins the muscle with surrounding tissues. When a muscle suffers a strain injury, either due to trauma or overuse, it may develop a chronic syndrome of constant contracture and dysfunction. Instead of the nerves firing and then relaxing, the muscle is constantly firing. When this occurs, the chemicals that recycle in the contract and relax phases, mostly calcium and magnesium, but also ATP (adenosine triphosphate) instead build up in the tissues surrounding the point of innervation of the muscle, causing irritation and pain, usually felt as a referred pain pattern. A chronic inflammatory condition may result, as well as a pathology of the nerves, now termed a denervation supersensitivity. This condition may persist indefinitely without treatment, and stress imbalances of deep stabilizing muscles may lead to joint irritation. A chronic myofascial syndrome may spread to surrounding neurons and even cause autonomic dysfunction over time.

Release of the myofascial trigger point and resolution of biomechanical dysfunction may be accomplished by a number of therapeutic techniques. Direct manual release involves application of pressure at the trigger point, or point of innervation of the muscle, until the muscle lacks the nerve flow to maintain the constant firing and contracture, forcing the normal contract and release mechanism. Repeated release should restore normal function, as long as the patient stops the repetitive strain, which is accomplished by correction of postural mechanics and targeted stretch and strengthening of the muscle or muscles. Other techniques of myofascial release include trigger point needling stimulation, and neuromuscular reeducation, such as learned techniques of reciprocal inhibition and contract-release. Postfacilitation stretch, positional release, and movement training are also types of neuromuscular retraining (NMR) that are now grouped under “mind-body" techniques. These techniques have a long history in both Chinese TuiNa and Japanese Shiatsu practice. Electrical stimulation and muscle defeat has also long been utilized, but may not have the impact of direct trigger point therapeutics.

Satellite trigger points may also need to be released, especially at the myotendinous junction, near the joint attachment, usually accomplished by an active release technique (ART). These techniques, like acupuncture, are somewhat subtle and require some expertise and skill, with active participation of the patient. The patient needs to be instructed sufficiently in postural correction (ergonomics) and targeted stretch and exercise as well to accomplish the goals of myofascial release and sustained neuromuscular reeducation. This holistic approach is vitally important to a positive outcome.

Myofascial syndromes (muscle and connective tissue dysfunction) may be the most prevalent cause of chronic pain, as well as neuropathies. These neuropathies may be caused by mechanical impingement on the nerve as well as chronic inflammatory irritation, and are often the result of myofascial syndromes. Myofascial release is most effective when all contributing factors are addressed in therapy. For this reason, a practice that emphasizes a proactive involvement in care is most successful. Correcting the causes of chronic injury, such as posture and ergonomics, or body mechanics, and addressing the underlying health problems that may be perpetuating your condition by inhibiting proper tissue repair, are important aspects of this care. By addressing myofascial pain with direct care as well as Systemic Medicine, a greater chance of complete success is possible. Integrating Tui Na with myofascial trigger point needling, acupuncture stimulation, topical herbal medicines, and instruction in therapeutic routines and correction of postural mechanics provides a thorough and holistic treatment protocol.

Chronic pain syndromes often involve cognitive and behavioral perpetuators. Hypersensitivity to pain triggers (hyperalgesia), painful sensitivity to light pressure (allodynia), emotional pain associations, and dysfunction in the modulation of pain sensation (hypothalamic -limbic), are all hallmarks of chronic pain. Studies have shown that when the actual tissue triggers in referred pain are directly treated, that patients cognitively are able to objectify the pain triggers and causes more effectively, and with this comes a decrease in the difficult and confusing aspects of chronic pain syndromes. Patient instruction and education are also part of traditional TCM therapy and provide the means to help the patient improve both cognitively and behaviorally. Instruction in therapeutic activities helps the patient adopt a more proactive approach to their chronic pain syndromes that often provide great benefit within the holistic protocol. The behavioral aspect to treatment has also long been a hallmark of treatment in TCM, and is becoming highly touted in standard medicine again as a mind-body medicine. While the physiotherapies in Tui Na are time consuming, the benefits of this time spent in therapy can be very important. Standard medicine provides very limited time spent with the physician, and often the cognitive and behavioral aspects are not addressed. TCM thus integrates with standard medicine in an important manner.

Information Resources and Additional Information

Treatment with Complementary and Integrative Medicine (CIM/TCM) is proving very successful and well utilized in many countries, including Australia and Brazil, as well as the Asian nations, and Europe. Some of the emerging data on the practice and research support for Tui Na, or soft tissue mobilization, is listed below with links to published data, and while manual medicine has been difficult to evaluate with double blinded studies, and almost no manual medicines beside acupuncture are supported with these randomized controlled human clinical trials due to difficulties in designing manual treatment placebos, other research designs are providing valuable data. Within this body of research one can look at the study of myofascial release and neuromuscular reeducation as well, integral parts of the science of Tui na. More links to current clinical trials and laboratory evidence of effectiveness and safety are available in the article on this website entitled Deep Tissue Massage and Its Many Benefits.

  1. A 2011 survey of Australian patients revealed that manual physiotherapy was popular as a first line choice, and that the emerging practice of Tui Na physiotherapy, or TCM soft tissue mobilization and manipulation, was preferred over strong force manipulation:
  2. A 2012 study at the Shanghai Institute of Traditional Chinese Medicine, found that Tui na physiotherapy succeeded in correcting alignment of upper cervical vertebrae in patients with cervical spondylosis, as observed with 3D images provided by spiral CT scans:
  3. A 2015 meta-review of all published studies of the use of manual physiotherapies for whiplash and neck pain, by experts at the University of Ontario, the University of Montreal, and the University of Toronto, in Canada, Queen's University in the UK, and the NYU School of Medicine in the U.S.A. found that scientific evidence supports soft tissue mobilization, manipulation, and clinical massage interventions for these injuries and pain. This is called Tui Na in TCM, and may be combined with other treatment protocols to achieve a more holistic set of therapeutic goals:
  4. Finally, in 2014, human clinical randomized controlled trials to measure the effectiveness and safety of traditional Chinese physiotherapy, or Tui Na, for chronic low back pain, were started at the Chengdu University of Traditional Chinese Medicine, and the Fifth Hospital of Sichuan Province, in Chengdu, China, the old capital in the West:
  5. In 2013, randomized controlled human clinical trials were started to evaluate Tui Na, or TCM soft tissue mobiilization physiotherapy, at Charite' University, in Berlin, Germany:
  6. While clinical trials of physiotherapy are difficult to design to meet the standards of modern RCTs, many such studies have been performed. This human clinical trial in 2008, at the Nanjing University of Traditional Chinese Medicine, compared the combination of Tui Na physiotherapy and standard acupuncture to just the use of acupuncture for the treatment of menstrual cramps in 30 clinical cases. The results showed that a marked improvement in success rates occurred with the addition of Tui Na to the protocol, with over 93 percent of the women experiencing successful improvement in symptoms and pain relief:
  7. In Chinese hospitals, pediatric Tui na is a common treatment modality, and this meta-review of scientific studies showed that it was effective for treating anorexia in infants and children, showing the broad systemic benefits. Tui na is used instead of acupuncture for infants and children due to the fear of needle stimulation, and has been found effective in children for many centuries:
  8. A 2015 study at the University of Oslo, in Norway, and the Institute of Health and Society, found that the practice of acupuncture, or needle stimulation, was not widely practiced in Chinese hospitals on infants and small children, but that the traditional practice of pediatric Tui na was widely used. The use of needle stimulation in Western hospitals for infants and children is not based in TCM practice in Asia:
  9. A 2015 systematic review of all published scientific studies of treatment modalities effective for acute neck pain, such as whiplash and associated disorders, by experts at the University of Ontario Institute of Technology, and the University of Alberta School of Public Health, found that soft tissue mobilization, manipulation, and clinical massage are effective, and that evidence questions the effectiveness of relaxation massage, electroacupuncture, strain-counterstrain therapy, and some passive modalities such as cold packs. This review supports physiotherapies in the realms of TCM Tui Na, and shows that perhaps acupuncture should be just a support therapy for a more comprehensive treatment protocol by a TCM physician, or Licensed Acupuncturist. Of course, there are numerous clinical trials that also affirm that efficacy for acupuncture in the treatment of neck pain, despite the challenge of the study design in RCTs, and a treatment that combines soft tissue mobilization and joint manipulation with deep tissue clinical massage and myofascial release and trigger point needling would present the best outcomes:
  10. A 2015 meta-review of all published randomized controlled human clinical studies of soft tissue mobilization and joint manipulation for acute, subacute and chronic neck pain, by experts at the McMaster University School of Rehabilitation Science, in Ontario, Canada, found 51 RCTs, but most of them small and many of poor quality. These studies showed that mobilization and manipulation of soft tissues and joints were effective, and stated that the results of their review showed that there probably was publication bias in medical journals that prevented more quality RCTs from reaching publication. Multiple sessions in a short course of frequent treatment were much more effective, and these experts noted that soft tissue mobilization needs to be studied in comparison to manipulation, although they found that adverse events with manipulation were rare. Of course, what the modern study design does not evaluate is the outcomes of combinations of manual therapies, and types of the techniques, since these studies require a focus on one type and a one-size-fts-all dumbing down of any therapy that was designed for allopathic pharmaceuticals only. An individualized holistic treatment of various modalities that is common to CIM/TCM will need a different type of clinical study, and the Big Data approach may one day achieve this:
  11. A randomized human clinical trial at the University of Alcala Department of Physical Therapy, in Alcala' de Henares, Spain, found that both manual myofascial release and trigger point dry needling (without pharmaceuticals) were equally effective to treat chronic neck pain, with just 2 sessions. The patients receiving myofascial trigger point needling showed better outcomes with pressure pain sensitivity to the neck and spine area. Dry needling is best performed with acupuncture needles, and with acupuncture needles of a larger gauge that do not bend quite so easily. Of course, the combination of manual myofascial release and myofascial trigger point needling would achieve the best results, and can be combined with soft tissue mobilization in the same session with a TCM physician:
  12. A 2014 randomized controlled human clinical study at the University of Rey Juan Carlos, in Spain, found that a single session of myofascial trigger point needling, called dry needling since it does not use pharmaceutical injected into the trigger point, was effective in acute neck injury, such as whiplash, to decrease neck pain, pain sensitivity, and active cervical range of motion: