Literature Analysis of Tuina in Regulating Subhealth Status in Recent 10 Years

Lei Long-ming, Wu Gui-fen, Qiu Shi-yuan

1 Tuina Department, First Hospital Affiliated to Guangxi University of Traditional Chinese Medicine, Nanning 530023, China

2 Guangxi University of Traditional Chinese Medicine, Nanning 530001, China

LITERATURE REVIEW

Literature Analysis of Tuina in Regulating Subhealth Status in Recent 10 Years

Lei Long-ming1, Wu Gui-fen2, Qiu Shi-yuan2

1 Tuina Department, First Hospital Affiliated to Guangxi University of Traditional Chinese Medicine, Nanning 530023, China

2 Guangxi University of Traditional Chinese Medicine, Nanning 530001, China

Author: Lei Long-ming, M.D., professor, chief physician.

E-mail: leilongming@126.com

The literatures of the recent ten years about tuina (massage) therapy in traditional Chinese medicine (TCM) for regulating and treating the subhealth status were searched and analyzed to understand the current thought and methods for the regulation and treatment of subhealth status by tuina. The results showed that tuina had a better regulatory effect for subhealth status. In the selection of the position for tuina application, tuina was predominantly applied to the whole body, guided by the holistic viewpoint and meridian theory of Chinese medicine, especially on the Governor Vessel and Bladder Meridian of the back and on the area the patient felt uncomfortable. In terms of tuina techniques, the routine relaxing technique, tendon-regulating technique and acupoint-pressing technique were used in predominance. In terms of the therapeutic time and course, although the reports were different in various literatures, it was believed in most reports that 50 min and 2-4 sessions per week were appropriate. The therapeutic aim could be achieved by 15-20 sessions. Without pain from the needles and suffering in taking drugs, tuina has a better psychological regulatory effect, therefore it has a better prospect for popular application. But, the basic study on the explanation of its functional mechanism by modern medical theory and means needs to be intensified.

Tuina; Massage; Subhealth; Preventive Medicine

As early as inHuang Di Nei Jing(Yellow Emperor’s Classic of Internal Medicine), the concept of ‘treating the unformed diseases’ was mentioned. The concept of ‘treating the unformed diseases’ is coincided with modern preventive medicine. The physiological status of the human body can generally be divided into health, disease and subhealth status. Subhealth is a middle status between health and disease, also termed a gray, latent morbid, sub-clinical, and sub-morbid status. But, scholars generally term it as the subhealth status. The subhealth belongs to the scope of ‘unformed diseases’ in traditional Chinese medicine (TCM). The positive regulation and treatment of subhealth are beneficial to prevention of diseases, and have important clinical significance[1-3]. Tuina therapy (massage) in TCM is one of the effective methods to regulate and treat subhealth and has currently been the first choice for prevention and healthcare and for the regulation and treatment of subhealth[4]. In order to learn about the current thought and methods of tuina in regulation and prevention of subhealth, the author searched the literatures about regulation and treatment of subhealth status by tuina from CNKI database, VIP full-text journal database and Wanfang database. Now, the analysis is given as follows.

1 Inclusion Criteria of Literature

1.1 Literature types

Those articles of clinical observation (with or without control group) and theoretical discussion of tuina in treating and regulating the subhealth status.

1.2 Research population

The group of subhealth status was included, but the group of chronic fatigue syndrome was excluded.

1.3 Intervention measure

The intervention measure is tuina (massage), including acupressure.

1.4 Indexes of clinical observation

The indexes of clinical observation include the changes in the symptoms and quality of life.

2 Effect of Tuina Therapy for Subhealth Status

It has been indicated by more and more clinical observation that tuina has the affirmative effect for subhealth. For instance, Peng SX[5]treated 65 cases of subhealth with chiropractic tuina. The results showed 37 cases were cured, 25 cases improved, 3 cases failed and the total effective rate was 95.38%. No reoccurrence was reported in the follow-up observation of the cured subjects for half a year. It was indicated in the clinical observation of Lun SF, et al[6], that the regulatory effect of tuina for subhealth was mainly showed in improvement of sleep and elimination of fatigue, so as to relieve the body symptoms of the subhealth group. At the same time, tuina could also improve somatic symptoms of psychological subhealth, depression, anxiety, mental and other symptomatic factors. Gao S[7]treated 60 cases of the subhealth with routine herbal therapy in combination with the psychological and behavior advice plus tuina, with the control group by routine herbal drugs and the psychological and behavior advice (n=60). The results showed that the indexes for fatigue, sleeping disorder, poor memory, poor concentration, muscular aching pain and anxiety were improved better in the observation group than those in the control group. In the clinical research method designed with randomized, double-blind (surveyor, statistician) and blank parallel control trial by Tang HL, et al[8], the results showed that tuina had affirmative effect for painful subhealth of the body.

Herbal medicine, acupuncture and tuina are the three major means of TCM in treating diseases. In regulating and treating subhealth, tuina has the similar and even better clinical effect than acupuncture and oral administration of herbal medicine. Luo RH, et al[9], treated 68 cases of insomnia under the subhealth status with massage therapy (treatment group), in comparison with 52 cases treated by ordinary needling method (control group). The results showed that the differences between the treatment group and the control group were statistically significant (P＜0.05). The therapeutic effect was better in the treatment group than that in the control group. Li ZH, et al[10]treated 30 cases of subhealth by tuina, in comparison with 30 cases treated by oral administration of herbal medicine. The therapeutic effects of the two groups were statistically different (P＜0.05). It was indicated in the clinical observation of Huang TY, et al[11], the difference of the total effective rates between tuina on the whole body and oral administration of herbal medicine based upon pattern differentiation was not statistically significant (P＞0.05), but tuina therapy was more advantageous than oral administration of herbal medicine in regulating the symptoms of fatigue, lassitude, headache and muscular aching pain (P＜0.05).

3 Thoughts and Methods of Tuina for Subhealth Status

The clinical effects of tuina in treating diseases or regulating subhealth were related to the functional state of the subjects and also were directly and importantly related to the functional areas, manual techniques and therapeutic time.

3.1 Operating area

3.1.1 To select the operating area guided by TCM theories of meridians and acupoints

It is believed in TCM that the meridian system plays a linking and communicating role in the tissues, Zang-fu organs of the human body, enabling the human body to be an organic entirety. The meridians are pathways between internal organs and body surface, can circulate qi and blood, communicate with Zang-fu organs and limbs, as well as link the interior with the exterior, and upper body with the lower body. The meridians are the pathways to transport qi and blood and also the channels to transmit diseases. The physiological functions of the human body and changes in diseases are directly or indirectly related to the meridians. Therefore, like acupuncture, the operating areas in tuina therapy are selected based upon the theory of meridians and acupoints. So does tuina therapy for subhealth status.

Guided by the meridian theory, Li JS, et al[12], found out that this method could obviously enhance the psychological regulatory ability under the subhealth status, by stimulating the running courses of the twelve regular meridians on the body surface and the Conception Vessel and the Governor Vessel. Zhu G, et al[13], pressed the running courses and distributionof the meridians on the head, face, neck, shoulder, back and low back, and abdomen based upon the theory of the meridians for regulating and treating subhealth and the therapeutic effects were satisfactory. Wang Y[14]emphasized and stressed the application of ‘spots, lines and surface’ in accordance with the theory of meridians and acupoints in TCM, for realizing the comprehensive effect. The ‘spots’mainly refer to the application of the acupoints in particular, such as Baihui (GV 20), Danzhong (CV 17), Qihai (CV 6), Zusanli (ST 36), Mingmen (GV 4) and Yongquan (KI 1). He believed that those seven acupoints are the important acupoints for healthcare. The ‘lines’ mainly meant to emphasize the meridians, such as the running courses of the Governor Vessel, the Conception Vessel, the Bladder Meridian, the Stomach Meridian and the Gallbladder Meridian on the body surface. The ‘surface’ meant to emphasize the application of the cutaneous region in the theory of the meridians in TCM. Wang YQ, et al[15], held that the Governor Vessel manages yang qi of the whole body and communicates with the five Zang organs and six Fu organs, and has the effect to protect the health of the human body and resist the invasion of the pathogenic factors. Moreover, the Governor Vessel is adjacent to the Bladder Meridian and their meridian qi are linked. Therefore, the running courses of the Governor Vessel on the midline and its bilateral Bladder Meridian are used as the operating areas of tuina therapy for regulating and treating subhealth. The therapeutic effects were better. Our previous study showed[16-17]that the therapeutic effects were satisfactory, if the back was used as a sole operating area for subhealth status. The theoretical foundation of the running courses on the back for regulating and treating the psychological subhealth status is that the psychological subhealth status is closely related to the heart, liver and brain. The Governor Vessel meets with the Liver Meridian at the vertex and the Governor Vessel enters the brain and its branch communicates with the kidney and pertains to the heart. The Governor Vessel links with the Bladder Meridian of Foot Taiyang laterally and the Bladder Meridian enters to communicate with the brain. Moreover, Back-Shu acupoints of the five Zang organs and six Fu organs are all distributed on the Bladder Meridian. Therefore, the back is related to the five Zang organs and six Fu organs, most closely with the heart, liver and brain in particular. So, the back is selected as the operating area in tuina therapy for regulating and treating the psychological subhealth status. Wei MQ[18]treated subhealth status of status insomnia by massaging the meridians and acupoints of the legs and feet and the therapeutic effects were better. Wei MQ[18]believed the pathogenesis of insomnia in subhealth status was mostly in pattern of yin deficiency and yang excess. There are three yin meridians of foot and three yang meridians of foot on the leg and foot of the human body. The Kidney Meridian of Foot Shaoyin is on the sole. Yin deficiency and yang excess of the human body are mostly related to the kidney deficiency. Therefore, the effects can be achieved to nourish yin and suppress yang by pressing the acupoints on the leg and foot. Sun Y[19]believed that self-massage on Yongquan (KI 1) could obviously relieve the symptoms of poor appetite and poor sleep under subhealth status.

3.1.2 To massage the whole body by holistic viewpoint of TCM

The subhealth is similar to ‘unformed diseases’ in TCM, related to preponderance or decline of yin or yang but not obvious. Therefore, tuina treatment in TCM should be guided by the holistic viewpoint of TCM, and the holistic massage on the whole body should be adopted to regulate and harmonize qi, blood, yin and yang of the whole body. This tuina method for whole body healthcare has been extensively applied to regulate and treat subhealth[6,10,20-22].

Zhou GP, et al[23], and Zhang HS[24]just did tuina operation on the running courses of the twelve regular meridians, the Conception Vessel and the Governor Vessel in treating subhealth status caused by fatigue. Judging from the literature and materials, although many medical practitioners emphasized the whole body massage, they mostly emphasized the operation on the Governor Vessel and Bladder Meridian of the upper back and low back in their application of the whole body massage. Luo RH, et al[9]emphasized the operation on the back in particular, by pressing and kneading the dorsal midline and bilateral lines (3-9 cm lateral to the midline of the spine) from the upper part to the lower part for ten times with the palm, and pressing Xinshu (BL 15), Ganshu (BL 18), Pishu (BL 20) and Shenshu (BL 23) respectively for 5 min. Li ZH, et al[10],emphasized to use the pressing method (by the finger, palm or elbow) to function on the bilateral lines and midline of the spine. Xu Y, et al[25], and Xu QE[26]also emphasized the operation on the Governor Vessel and the Bladder Meridian of the back based upon the whole body massage in regulating and treating subhealth status.

In addition to the emphasis on the Governor Vessel and the Bladder Meridian of the back, Zhao JF[27]applied the whole body massage for regulating and treating subhealth status, but the author emphasized that the massaging area should be complete, stimulating the strain area in particular.

3.1.3 To select tuina areas by pattern differentiation of TCM

Pattern differentiation is a feature, advantage andessence of TCM, but it is mainly reflected in the application of herbal medicines. Tuina by pattern differentiation is very seldom in regulation and treatment of subhealth status.

Xie HJ, et al[28], believed that tuina treatment by pattern differentiation should be combined with self healthcare massage for regulating and treating subhealth, and massage should be applied to the head and face for all patterns, but the operating areas should be different in emphasis for different patterns. In order to reinforce and benefit the heart and spleen for pattern of insufficiency of the heart and spleen, the operation was predominantly applied to the chest, two feet, abdomen and the Governor Vessel on the back. In order to nourish and reinforce the liver and kidney for pattern of yin deficiency in the liver and kidney, the operation areas were the back, low back, hypochondriac region, lower abdomen, and Laogong (PC 8) on the palm and Yongquan (KI 1) on the sole in predominance. In order to sooth the liver, get rid of depression, regulate qi and disperse accumulation for pattern of liver qi stagnation, the operation was applied in predominance by kneading Danzhong (CV 17), Zhangmen (LR 13) and Qimen (LR 14) on the chest and abdomen as well as the running course of the Liver Meridian of the lower abdomen with the fingers, and by chafing and rubbing the hypochondriac regions, in combination with the chest-dilating pulling technique on the thoracic segment of the spine (deviated spinuous process mostly palpable). In order to disperse phlegm and remove dampness for pattern of accumulation of phlegm and dampness, the treatment was emphasized to strengthen the spleen on the abdomen and to promote yang on the spine, assisted by the operation on the head to wake up the brain and open the aperture, to press Tiantu (CV 22), Yinlingquan (SP 9) and Fenglong (ST 40) for dissolving phlegm.

3.1.4 To select the tuina areas by holistic concept and pattern differentiation of TCM

By the holistic concept and pattern differentiation of TCM, Wang Q[29]pressed the head and face, abdomen, upper limb, neck and shoulder, low back and back, and lower limb by the order for massage on the whole body, plus the acupoints selected by pattern differentiation. For instance, for pattern of deficiency in both the heart and spleen, Xinshu (BL 15), Ganshu (BL 18), Pishu (BL 20), Weishu (BL 21), and Xiaochangshu (BL 27) were pressed and kneaded, for 2 min on each acupoint. Then, the Governor Vessel and bilateral Bladder Meridian of the back were chafed till warm sensation appeared. For pattern of spleen deficiency and dampness accumulation, Zhongwan (CV 12), Zhangmen (LR 13), Tianshu (ST 25), Qihai (CV 6) and Guanyuan (CV 4) were rubbed for 5 min on each acupoint. Then, Pishu (BL 20) and Weishu (BL 21) were chafed warm, and Zusanli (ST 36) and Fenglong (ST 40) were pressed and kneaded, respectively for 3 min, till aching soreness. For pattern of liver qi stagnation, the bilateral hypochondriac regions were chafed obliquely till heat sensation appeared, and Zhangmen (LR 13), Qimen (LR 14), Xingjian (LR 2), Neiguan (PC 6), Ganshu (BL 18), Danshu (BL 19), and Geshu (BL 17) were pressed and kneaded, for 1 min on each acupoint, till aching distension appeared. For pattern of yin deficiency in the liver and kidney, Ganshu (BL 18), Shenshu (BL 23) and Mingmen (GV 4) were pressed and kneaded, for about 1 min on each acupoint, and Shenshu (BL 23) and Mingmen (GV 4) were chafed crisscross till heat sensation appeared and Yongquan (KI 1) was rubbed and kneaded for 6-8 times. Pang J, et al[30]believed that the most common pattern of subhealth status in TCM was liver qi stagnation and spleen deficiency. For subhealth status in pattern of liver qi stagnation and spleen deficiency, based upon the routine tuina techniques, to soothe the liver and strengthen the spleen were added by chafing the bilateral hypochondriac regions obliquely, chafing the back crisscross and pressing and kneading Zusanli (ST 36). Zhao YK, et al[31]also believed that the selection of the acupoints by pattern differentiation and operation by pattern differentiation should be further processed based upon massage on the whole body. For instance, for those with liver qi stagnation, Zhangmen (LR 13), Qimen (LR 14) and Taixi (KI 3) were pushed additionally. For those with deficiency in the heart and spleen, Xinshu (BL 15), Pishu (BL 20) and Geshu (BL 17) were pushed additionally. For those with deficiency in the liver and kidney, Shangliao (BL 31), Ciliao (BL 32), Zhongliao (BL 33) and Xialiao (BL 34) were chafed and Yongquan (KI 1) was pressed additionally.

3.1.5 To select tuina areas by chronomedicine of TCM

It is believed in TCM that the human body is closely related to the natural world, i.e. ‘unity between the nature and human’. Therefore, the time change in the natural world is importantly influential to the physiology and pathology of the human body. The circulation and ebb-flow of qi and blood through the meridians and acupoints of the human body are different in the different time of a day. If the meridians and acupoints are selected in accordance with this theory for tuina stimulation, double effect can be achieved by half effort. The methods to select the acupoints by midnight-noon ebb-flow and Linggui Bafa are the important methods to select the acupoints by the chronomedicine theory of TCM in acupuncture medicine. In recent years, someone applied the selection of the acupoints by the time in the selection of the operating areas in regulation andtreatment of subhealth status by tuina. Huang XH[32]regulated and treated subhealth status by applying tuina based upon day and time, with the calculating method of midnight-noon ebb-flow, in accordance with the basic principle of the selection of the acupoints by midnight-noon ebb-flow. In regulation and treatment of subhealth status by tuina, Wang JH, et al[33-34]calculated respectively the major acupoints and major meridians for the treatment in accordance with the theory of the acupoint-selecting method by Linggui Bafa in acupuncture and with the visit day and time of the patients, and selected the adjunct acupoints and adjunct meridians in accordance with the choosing acupoints principles recorded inNan Jing(Classic of Difficult Issues) the combination between father and mother, wife and husband, male and female, and host and guest.

3.1.6 To massage the foot reflex zone by the principles of neuroreflexology

It is believed in principles of the neuroreflexology that there are corresponding zones of various organs and parts of the human body on the soles. Those zones reflect the physiological and pathological information of the corresponding Zang-fu organs. This is called ‘foot reflex zone’. It is also believed in the principles of reflexology that to stimulate those reflex zones by massaging techniques can regulate the functional activities of the various organs of the human body and achieve the effects to prevent and treat diseases. We treated 120 cases of the subhealth status by massaging the foot reflex zones, and the results showed that this method could relieve the symptoms of fatigue and insomnia of subhealth status[35].

3.2 Operating techniques

The routine tuina techniques are the major manipulation currently for regulating and treating subhealth. Huang TY, et al[11], regulated and treated subhealth status by the routine techniques of one-finger Tui-pushing method, Rou-kneading, Mo-wiping, An-pressing, Nie-pinching, Ca-rubbing, Na-grasping and Cuo-doing foulage methods, which were quite representative. But, there are also reports advocating that chiropractic manipulation should be added into the routine techniques[5,36]. In fact, it is still emphasized to apply the operation and stimulation on the Governor Vessel and Bladder Meridian of the back. And the chiropractic tuina method had already been recorded as early as inSheng Ji Zong Lu(Complete Record of Sacred Benevolence). Song HQ, et al[37], stressed highly the acupoint-pressing technique in the application of the routine techniques.

3.3 The combining use of tuina media

The essential oil is the collective term referring to the oily liquid that can volatile at the room temperature and cannot mix with water and exist extensively in the various parts of some herbal drugs. The healthcare and treatment of diseases by the essential oil are termed ‘aromatherapy’ in many countries and regions. The molecular structure of essential oil is smaller and can easily penetrate through the skin and body and flow through the whole body with blood.

Various tuina techniques can help the molecules of the essential oil to penetrate into the body and accelerate the absorption, so as to relax the body and mind and take care of the skin, and also to dredge the meridians, promote lymph circulation, and enhance the immunity. It has always been believed in the theory of TCM that perfume and drugs come from the same resource. In addition to the four properties and five flavors in Chinese herbal drugs, there is also an aromatic property. For over several thousand years, the aromatic components of the natural aromatic plants had been used in TCM to bring into play of the disease-eliminating and healthcare effects of those natural aromatic plants, via multiple channels of massage, bath, topical application and smells. It is also believed in TCM that the meridians are the main pathways for the circulation of qi and blood, and the essential oil mostly have the effects to travel and dredge qi activity with fragrance, and can assist the circulation of qi and blood in the meridian system and resist the exogenous pathogens. Therefore, better therapeutic effects have been achieved by using the essential oil for regulating and treating subhealth status[16-17, 38].

3.4 Time and course

There are different reports about the time and course of tuina therapy for subhealth status.

3.4.1 Therapeutic time of each session

Li ZH, et al[10], believed 30-minute manipulation was appropriate for each treatment. Luo RH, et al[9], believed 45-minute manipulation was appropriate for each treatment. Lun SF, et al[6], applied the massage to the whole body for at least 50-70 min each treatment. Zhao JF[27]applied the whole body massage for regulating and treating subhealth status, and believed that at least one hour was needed for each treatment.

3.4.2 Interval of treatments

Wang YL, et al[20], believed that 1-3 treatments per week were appropriate. Ji Y, et al[22], believed that 2-3 treatments per week were appropriate. Wang JH[33-34]believed that the treatments per week should be over 5 times.

3.4.3 Total therapeutic numbers

It was found out in clinical observation of Wang YL, et al[20], that in treatment of 76 cases with subhealthstatus by tuina therapy, the shortest treatment was 5 times and the longest treatment was 41 times, at the average of 22 times. Ji Y, et al[22]treated 54 cases with subhealth status by tuina therapy, in which the shortest treatment was 3 times and the longest treatment was 33 times, at the average of 22 times.

4 Summary

In summary, we can see that there are numerous reports about the regulation and treatment of subhealth status by tuina therapy. Tuina therapy gives a satisfactory recuperative effect for subhealth status. By analysis of the literature, we can also find out that in the treatment of subhealth status by tuina therapy, the operating areas are selected by the holistic concept and meridian theory of Chinese medicine, and massage on the whole body is in predominance. Massage is mainly applied to the Governor Vessel and Bladder Medicine of the back and on the subjective uncomfortable areas (head in headache patients, back and low back in the patients with low back pain). The tuina techniques are mainly the routine relaxing method, tendon-regulating method and acupointpressing method (pressing or pressing and kneading). They are commonly used method in the current healthcare service. In the time and course, although the results are different in the reports, generally massage on the whole body is appropriately given for 50 min each time, 2-4 sessions for each week. In general treatment, the goal can be realized by 15-20 sessions. Those data are available for clinical reference. In comparison with acupuncture and oral administration of herbal medicine, tuina therapy has lots of its own characteristics and advantages. Without pain from the needles and suffering in taking drugs, tuina has a better psychological regulatory effect, therefore has a better prospect for popular application[39]. It is pity that although the effectiveness of tuina therapy for subhealth status has been acknowledged, seldom involved is the basic study on the explanation of its functional mechanism by modern medical theory and means. This study needs to be intensified in the future.

Conflict of Interest

There is no potential conflict of interest in this article.

Acknowledgments

This work was supported by Project of National Natural Science Foundation of China (No. 81160457); Key Subject of Guangxi University of Traditional Chinese Medicine (No. ZD2010014); Self-sponsored Research Project of Administration of Traditional Chinese Medicine of Guangxi Zhuang Autonomous Region (No. gzzc1010).

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Translator:Huang Guo-qi

R244.1

: A

Date:September 25, 2013