• 68 • Chin J Integr Med 2013 Jan;19(1):68-72

LITERATURE RESEARCH
Research Progress on the Standardization of Chinese Tuina
Therapy: A Short Review
FANG Lei (方 磊) and FANG Min (房 敏)

ABSTRACT The standardization of Chinese Tuina therapy is one of the most popular research topics in
Chinese medicine. By reviewing the literatures contributed by Chinese investigators between 1982 and 2010,
the authors summarized the progress on Chinese Tuina manipulation techniques, in particular, focusing on
the data on several key parameters (i.e., frequency, duration, and force). This summarization will benefit the
standardization of Chinese Tuina.
KEYWORDS Chinese Tuina manipulation, frequency, duration, force, biomechanics

Chinese Tuina is an important component of
Chinese medicine (CM). It falls into the category of
external treatments in CM. Tuina manipulation is
experience dependent in nature, and its therapeutic
efficacy is influenced by many operating variables,
especially frequency, duration, and force. Although
some manipulation skills are documented in
textbooks, Tuina therapy is far from standardized.
H e r e i n , w e reviewed t he Chinese lit e ra tu re s
between 1982 and 2010 and summarized the clinical
experience in Chinese Tuina, with the aim to advance
the standardization of the Chinese Tuina therapy.
METHODS
A systematic literature search was carried
out from January 1982 to July 2010 in the Chinese
National Knowledge Infrastructure (CNKI) Database
using appropriate search words (i.e., Tuina,
manipulation, biomechanics, frequency, duration, or
force). A total of 15 different journals were involved in
this search work: Journal of Medicine Biomechanics,
Shanghai Journal of Traditional Chinese Medicine,
Journal of Cervicodynia Lumbodynia, Liaoning Journal
of Traditional Chinese Medicine, Xinjiang Journal
of Traditional Chinese Medicine Pharmacology,
Chinese Journal of Information on Traditional Chinese
Medicine, Journal of Chinese Orthopedics and
Traumatology, Chinese Journal of Traditional Medicine
Traumatology and Orthopedics, Guiding Journal of
Traditional Chinese Medicine and Pharmacology,
Chinese Journal of Rehabilitation Medicine, Journal
of Tianjin University of Traditional Chinese Medicine,
Chinese Manipulatation Qigong Therapy, Journal of
Shandong University of Traditional Chinese Medicine,
Academy Journal of PLA Postgraduate Medicine
School, and Journal of Clinical Rehabilation Tissue
Engineering Research. The initial search yielded
a total of 90 relevant references. After a thorough
identification of the retrieved studies, 25 original
articles reporting experimental findings (28%) were
finally included for further analysis. The studies
lacking experimental data or sufficient novelty (72%)
were excluded.
RESULTS
Table 1 summarizes a total of nine different
Tuina manipulation techniques that were documented
in the 25 publications. Overall, these manipulation
techniques could be grouped into four distinct
categories: pushing-rolling (2 cases), squeezing
and pressing (2 cases), moving joints (3 cases), and
vibrating (2 cases).
In the past decades, the assessment method
for Tuina was greatly improved, which evolved from
a simple mechanical analysis to evaluation of mobile
dynamics, surface electromyography (sEMG), and
three-dimensional (3D) motion. A variety of analytical
instruments have been developed, such as video
camera, 3D motion analysis platform, and infrared
thermography.(1,2,3,6,15,16) Currently, studies on swinging
manipulation technique are more deep-going than
© The Chinese Journal of Integrated Traditional and Western
Medicine Press and Springer-Verlag Berlin Heidelberg 2011
Supported by the National Basic Research Program of China
(973 Program, No. 2007CB512701) and Research Program
of State Administration of Traditional Chinese Medicine
(No. 200707013)
Department of Tuina, Yueyang Hospital of Integrated Traditional
Chinese and Western Medicine, Shanghai University of
Traditional Chinese Medicine, Shanghai (200437), China
Correspondence to: Prof. FANG Min, Tel: 86-21-65161785,
E-mail: fm6505928@vip.sohu.com
DOI: 10.1007/s11655-011-0755-6
 Table 1. Characteristics of Tuina Manipulation Techniques in the 25 Assessed Studies

Manipulation technique Literature Assessment method Frequency of manipulation Duration of manipulation Force of manipulation

Rolling manipulation Shao XN, et al(1) TPA-1 type test machine for Tuina Warning limit: 118-134 Warning limit: 4.9-6.1 kg; control limit:
manipulation times/min; 4.6-6.4 kg; average value: 5.5±0.3 kg for
control limit: 114-138 the horizontal force
times/min; average value: Warning limit: 5.4-7.0 kg; control limit:
132 times/min 5.0-7.4 kg; average value: 6.2±0.4 kg for
the longitudinal force
Zhang H(2), Measurement of the blood flow volume 120 (range, 105-135) 10.00 (range, 8.75- 4.0 (range, 3.5-4.5) kg
(3) of the popliteal artery by Doppler times/min 11.25) min
Ma HS
ultrasound
Chin J Integr Med 2013 Jan;19(1):68-72

Lv J(4,5) Video camera and 3D computer force The mean frequency is The maximum vertical force is 50 N;
measuring platform about 1.7-2.5 Hz the maximum vertical force is 20 N

Chen YW, et al(6) Myotonometer 120 times/min 10 min 4 kg

Zhou XW, et al(7) Doppler ultrasound and TDZ-1 type
120 times/min 5 min 7 kg
test machine for Tuina manipulation

Wang H, et al(8) TN-2 type test machine for Tuina 128 times/min The time ratio between Force signal of manipulation is 6-peak
manipulation forward and backward and 6-valley random periodic pulsing
roll is 1.7:1; the peak width
is half the valley width

Zhou XW, et al(9); FZ-1 type test machine for Tuina The mean frequency is Heart-shaped or gourd-shaped
Xie ZY, et al(10) manipulation about 2.0-2.7 Hz trajectory for resultant force
Pushing manipulation Wang GC, et al(11) TDL-1 type test machine for Tuina Zhu Cheng-ting: 193 times/ The period of PM is 0.31, The vertical force is 1.5, 4.0,
with one finger manipulation min; Wang Bai-chuan: 45 0.42, and 0.37 s, respectively and 3.0 kg, respectively.
times/min; Wang Ji-song: The climb angle is 75°, 83°,
160 times/min and 67°-70°, respectively

Stepping lumbus Luo J, et al(12) The instrumental system of feet The frequency of wave is The period of wave is Peak value: 201.53±7.80 kg;
pressure and pressure responding 2.20±0.01 Hz 456.60±2.50 ms valley value: 10.50±1.43 kg
paper

Shaking manipulation Yang GP, et al(13) Video camera and 3D motion analysis 247-438 times/min 35 s/time Amplitude: 0.93-1.46 cm;
system minimum frequency: 247 times/min,
maximum frequency: 438 times/min
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(Continued)
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Manipulation technique Literature Assessment method Frequency of manipulation Duration of manipulation Force of manipulation

Traction manipulation (14) Elbow force: 10.18 kg; thumb force:

Fang M, et al Biomechanical measurement 5-8 s/time
8.03 kg; digitus indicis force: 6.26 kg
Vibrating manipulation Zhao Y, et al(15) Infrared thermography technology >500 times/min >1 min
Zheng JJ(16), Video camera and 3D computer
0.125 s/time 1±0.25 kg
Wang GC(17) force measuring platform

Rotation pulling Wang LH, et al(18) Soft-tissue tension analysis Pain threshold (0.22-0.30) Preload duration: 1142± Preload force: 5.42±1.85 kg; thrust
manipulation system and test machine ×3.33 kg 56 ms; force: 14.12±4.06 kg; preload force:
for rotating manipulation Pulling time: 368±20 ms; 62±1.69 kg; thrust force: 15.35±3. 85
Pain threshold (0.31-0.38) Preload duration: 1153± kg; preload force: 6.46±1.73 kg; thrust
×3.33 kg 50 ms; force: 15.66±4.12 kg
Pulling time: 373±19 ms;
Pain threshold (0.39-0.46) Preload duration: 1160±
×3.33 kg 56 ms;
Pulling time: 375±21 ms

Zhu LG, et al(19) Biomechanical materials testing system Thrust duration: 114.33± Preload force: 15.15±5.11 kg; peak
and acceleration sensor 16.98 ms force: 27.24±8.81 kg; thrust force:
14.2±5.15 kg; peak acceleration,
-0.35±0.11 g; thrust displacement,
9.3±2.67 mm; thrust impulse:
22.4±7.11 Ns
Jiang H, et al(20) Cervical spine biomechanical model Angle of axial rotation: 30°; force:
6.11±2.48 kg

Wang XJ, et al(21); Anatomical physiology and vertebral Angle of axial rotation: <45°;
Liu B, et al(22) artery hydromechanics angle range for a controlled thrust:
5°-10°
Bi S, et al(23) 3D finite element model for simulating Lumbar anteflexion: 15°; lumbar
lumbar manipulations rotation: 15°; longitudinal traction
force: 400 N

Pressing manipulation Deng M, et al(24) Ergocheck pressure detection system Pressing with finger pulp:
242.56-266.87 mm Hg/dm2;
pressing with one palm:
242.53-266.93 mm Hg/dm2;
pressing with two palms:
242.82-242.94 mm Hg/dm2; pressing
with thumb tip: 244.55-266.90 mm
Hg/dm2

Pulling and compression Zhang XG, et al(25) 3D finite element model for simulating Lumbar anteflexion: 30°; longitudinal
manipulation lumbar manipulations traction force: 400-700 N;
compression force: 0-300 N
Chin J Integr Med 2013 Jan;19(1):68-72
Chin J Integr Med 2013 Jan;19(1):68-72
the other manipulation techniques. The measurement
instruments mainly include force-measuring platform,
color Doppler ultrasound, digital camera, and sEMG.
The results of various studies on the frequency,
duration, and force of rolling manipulation were
relatively consistent.(1-10)
These studies showed that the average frequency
of rolling manipulation was 128 times/min, the average
duration was approximately 8 min, and the average
force was 5.16 kg, with a heart-shaped or gourd-
shaped trajectory for resultant force. For the pushing
manipulation with one finger, the average force,
frequency, and climb angle was about 2.8 kg, 166 times/
min, and 75.5°, respectively.(11) The operating frequency
was reduced with the increase in the strength.
Following the swinging manipulation, rotation
wrenching manipulation was well studied. Through
evaluation of fluid dynamics and anatomic changes,
a few studies were proposed a safe limit of about
15°for spine rotation. Despite the consensus in
the rotation angle, the applied force for rotation-
wrenching manipulation varied greatly in these
examined studies.(21-23) To date, very few studies were
conducted to investigate the clinical effect of the duration
of rotation-wrenching manipulation.
With regard to pressing manipulation, studies
were focused on the analysis of pressure and vertical
force(24). However, neither the duration of pressing
manipulation nor the interval was mentioned. It is well
known that the pressure is influenced by the vertical
force and the contact area. Given the difference in
the palm size of clinicians and in the contact area in
different manipulation styles, such as pressing with
thumb finger pulp, with tip of thumb, and with one
palm, it is hard to have a uniform pressure. Indeed, the
pressure value varied considerably in earlier studies,
although the actual vertical force might be identical.
Additionally, the manipulating pressure depends
on the clinical condition of individual patients. In
clinical practice, the patient's tolerance, comfort, and
safety should also be considered.
DISCUSSION
Although there is a considerable progress
made in the determination of key parameters (e.g.,
frequency, duration and force) associated with Tuina
• 71 •
manipulation, data are mainly derived from in vitro
rather than in vivo experiments. Tuina manipulation
on biological tissues is not the same as the action
on the rigid body; the latter just represents a simple
force transmission. Indeed, muscle tissues will absorb
part of the external force produced by Tuina. The
mechanical stimulation on muscle tissues will be
transmitted to the spinal dorsal horn through sensory
nerves and spinal nerve, and via a sensory-motor
feedback loop, the signal released from the central
nerve is transduced to and excites surrounding muscle
tissues of the stimulating site, ultimately initiating a
series of physiological or biochemical changes.
While excessive force will result in muscular
tension, insufficient strength fails to achieve an
effective stimulation. Prolonged action may cause an
adaptive response and thus blunt therapeutic effects.
Conversely, if the operation time is too short, no
effective stimulation can be induced.(2) Further studies
by orthogonal experiment are therefore required to
clarify the interactions among the key parameters
(force, frequency, and duration). In addition, the
frequencies for obtaining optimized effects at different
sites such as abdomen, lumbar, and back are difficult
to be unified. The biomechanical properties and
physiological condition are varied in different age
subjects, and further studies are needed in regard to
the force, duration, and frequency of manipulation.
The current instruction on the manipulating
frequency and force is applicable to new learners;
however, it does not mean a standard. Taking into
account the variations among body sites and individuals,
it is crucial to optimize the frequency, duration and force
of manipulation to maximize its therapeutic efficacy.
Ongoing attempts will be made to identify the
common features for Tuina manipulation. It is valuable to
determine the muscle groups involved and their potential
cooperation as well as the motion angle for and the
forces on various joints (e.g., metacarpophalangeal joint,
wrist joint, elbow joint, and shoulder joint) during the
process of manipulation. It is also important to quantify
the biological effects of the frequency, duration, and force
for manipulation, the resolution of which will hold promise
in developing optimal Tuina approaches. Optimization
of the angle and direction of force and its maximum
range should primarily take into account the safety of
patients and clinicians, avoiding unintended injuries.
• 72 •
In principle, the most standardized Tuina manipulation
is that having a minimum consumption but achieving
maximum therapeutic benefits. Future work should aim
to standardize Tuina manipulation approaches based on
experimental studies, especially of the biological effects
of the frequency, duration, and force of manipulation on
different tissues.
For other Tuina manipulation techniques, previous
studies focused on evaluation of therapists' action.
However, there was lack of data on the response of
patients receiving the Tuina treatment. As there are
marked differences in the biomechanical property
among anatomic sites, tissue, and populations of
different ages, it remains elusive whether the data
on Tuina manipulation in previous publications are
comparable. A more rigorous experimental design is,
thus, required to determine the important parameters
for these less-studied manipulation techniques.
Acknowledgement
The authors would like to thank Drs. YAN Juan-tao,
CHEN Ying-wu, ZHANG Shu-hui, and FANG Xiao-ming for
their invaluable assistance in data collection and analysis.
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Edited by WANG Wei-xia