WSVMA Annual Conference

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Tui-na: Chinese Medical Massage

Spokane Convention Center Spokane, Washington October 1-3, 2010

Michelle Schraeder, DVM, MEd, FAAVA Mountain Veterinary Hospital, Bellingham, WA Michelle C. Schraeder, DVM, MEd, FAAVA Mountain Veterinary Hospital Bellingham, WA

Biography:

Dr. Schraeder graduated from The Ohio State University in 1985. Through the International Veterinary Acupuncture Society (IVAS), she is certified in veterinary acupuncture and has completed a three year course in Veterinary Chinese Herbal Medicine, and through the Chi Institute is certified in veterinary Tui-na. Dr. Schraeder became one of first two veterinarians to become a Fellow of the American Academy of Veterinary Acupuncture (FAAVA), which is an advanced acupuncture certification. She obtained a Masters of Education in College and Continuing Education from Western Washington University. Presently she is chair of the IVAS US Education and International Education Committees, an IVAS board member, and a member of the AAVA Advanced Certification Committee. Dr. Schraeder practices integrative medicine, utilizing Traditional Chinese Medicine with conventional medicine, at her clinic in Bellingham, Washington.

Contact Email:

[email protected] TUI-NA: CHINESE MEDICAL MASSAGE Michelle C. Schraeder, DVM, MEd, FAAVA Mountain Veterinary Hospital, Bellingham, WA

Tui-na, Chinese medical massage, is one of the five branches of Traditional Chinese Medicine (TCM), with the others being acupuncture, Chinese herbal medicine, Chinese food therapy, and Tai Chi & Qi Gong. All these branches of TCM incorporate the concepts of the body as an integrated whole (holistic medicine), and the theories of Yin and Yang, five element, and meridian/channel. In translation, “Tui” means push and “Na” means grasp or lift. Tui-na, through massage manipulations that stimulate acupressure points or surface regions of the body, seeks to restore physiological balance in the body via restoring flow to the channels and collaterals, promote blood circulation, and regulate Yin and Yang. By the effect of restoring balance, it increases or decreases the body’s functions to combat either excess or deficiency as appropriate. Through balancing the body, Tui-na also can used as preventative medicine, keeping Qi and blood moving freely, strengthening tendons and loosening muscle, and eliminating fatigue.

History of Tui-na and other Oriental massage techniques The earliest and classic writing on Chinese medicine was written about 2500 years ago, the Nei Jing translated as The Yellow Emperor’s Classic of Internal Medicine, and contains chapters on massage. Originally Chinese massage is referred to as An-mo, where “an” means to press and “mo” means to rub. The practice of An-mo spread via trade missions to other countries like Japan and Korea during the sixth century and became the basis of dozens of styles of Oriental bodywork that exist today. The term Tui-na was used for the first time in the Ming dynasty (1368 to 1644 AD). Japanese Shiatsu is a modern derivation (early 1900s) of the traditional Anma massage (the Japanese form of Chinese Anmo).

How Tui-na works: TCM theory Tui-na, through specific types of pressure to the meridians or acupressure points, aims to move Qi and Blood and thus bring about pain relief. Qi, in Chinese medicine, is the vital energies of the body. Pain in TCM is commonly looked upon to be from stagnation (lack of movement) of either Qi or Blood. Thus by its manipulations Tui-na tries to move Qi and/or Blood to relieve pain. Qi and Blood stagnation can have other effects on the body than just pain. Qi and Blood stagnation can bring pain, stiffness, emotional stress, anger, frustration, depression, various organ diseases, and masses. Excess emotions and life stresses can affect Qi flow, so by allowing free flow of Qi, one can achieve emotional and physical balance and relaxation for the patient.

Disease in TCM results from imbalances. Tui-na works to bring Yin and Yang into balance via tonifying moves for deficiency and sedative moves for excess. Briefly, Yin and Yang are two complementary opposites that describe how things function in relationship to each other and the environment around you. Yin-Yang theory explains the life process of continuous change and transformation, and the aim towards balance. Thus through hands-on body treatment, Tui-na aims to bring the body back into a healthy balance, and be pain-free and disease-free.

1 Tui-na individual techniques The major focus of Tui-na techniques is upon specific painful sites, acupressure points, meridians, and muscles and joints. Each of these techniques has quantity (duration and force) and quality (evenness and softness) aspects to them. The equipment needed is one’s fingers, hand, elbow, or knee. The techniques are grouped here by type of technique (Ping, 1998, 72-91) (Xie):

Gliding or Swinging Pushing (Tui fa) • Technique - Fingers, palms, or fists held in various positions are pushed over the skin. • Small Animals - Many animals will react to this technique unless it is preceded by others to relax the animal and its muscles first. Tui-fa is one of the most important techniques to help restructure connective tissue, thus allowing changes to boney alignment as well as freeing the Tendinomuscular Meridians (superficial type of meridian that follows lines of major muscles, muscle groups, tendons, and ligaments) allowing return of normal activities (Xie, 147).

Circular Rubbing (Mo fa) • Technique - Finger or palm rubs gently and loosely over the area in a circular motion at about 120 times/minute. • Small Animal - Is a good introductory and safe technique and useful for the very debilitated and geriatric animal.

Rolling (Gun fa) • Technique - Hand or wrist is rolled backwards and forward over the skin. • Small Animal - Can use LU 10 (boney point of palm/wrist at thumb base) for smaller animals. • Single Thumb (Yi Zhi Chan): • Technique – Place thumb on area and swing forearm inward and outward to cause the extension and flexion of the thumb joint. • Small Animal - Use of either a thumb or finger to apply pressure based on energy, age, size and species.

Picking Up and Squeezing: Pinching (Nie fa) • Technique - The thumb opposes a finger and pinches the treatment area deep but gently and quickly, without the palm making contact with the skin. • Small Animal - A simple technique often taught to owners to do at home on the Du channel and bilaterally on the inner Bladder meridian (Shu points), and also may be applied locally to any area of adhesion and stagnation.

Grasping/Pulling (Na fa) • Technique - Grasp forcefully skin and muscle with thumb and fingers and lift. Increase pressure gradually with repeated grasping at site.

2 • Small Animal - By grasping with the thumb and forefinger in opposition, can be used to treat any acupuncture point or Ah shi point.

Kneading: Rotary Kneading (Rou fa) • Technique - Move balls of one or two fingers or palm heel in a circular motion so that the hand/finger does not slide over the skin, but pulls it along at about 120 times/minute. Deeper and more penetrating than the circular rubbing of Mo fa. • Small Animal - Good for all species and making friends.

Broad Circular Kneading (Yun fa) • Technique - Like Rou fa but using the forearm or elbow to treat a larger area.

Warming With Friction: Friction rubbing (Ca fa) • Technique - Rub gently and rapidly back and forth over the skin until patient feels heat without moving underlying muscles. • Small Animal - Useful for Yang-deficient geriatric animals and can be easily applied by animal’s owner at home.

Piston Rubbing/Kneading (Cuo fa) • Technique – Using both hands friction rub in opposite directions going back and forth or up and down, like pistons of an engine. If done on a leg, looks like making a bread stick with hands on opposite sides of the leg. • Small Animal - Great for Wei syndrome and paresis/paralysis, and is essential for normal return to function after nervous system trauma.

Deep Pressure Strokes: Pressing (An fa) • Technique - Press deeply and forcefully with even and gentle pressure channels or points with a finger or palm. Pressure increased slowly with repetition. • Small Animal - Most Bladder Shu points, Huatuojiaji points, and the acupuncture and Ah shi points in large muscles.

Digit Pressing/Knocking (Dian fa) • Technique - Pressing depressions between joints and points with the proximal interphalangeal joint of the middle finger. Compared with An fa, it is a stronger stimulus over a smaller area. • Small Animal - This deep pressure technique is useful for Ah shi points in major muscles but needs to be preceded by preliminary techniques like An fa to determine a pressure level acceptable to the animal.

Sustained Pressing (Ya fa) • Technique - Pressing forcefully with sustained pressure with the forearm or elbow.

3 Tapotement: Patting (Pai fa) • Technique – Rhythmical and smooth slapping on surface of body with fingers or empty fist. • Small Animal - For invigoration with care that only the right amount of force is utilized.

Beating (Ji fa) • Technique – Beating on body with wrist, side of hand, fingertip, or a stick. • Small Animal – Like Pai fa but is used more than it on small animals, and can use only one digit/finger on the smallest of species.

Oscillating: Twirling (Nian fa) • Technique – Hold patient’s toe/finger between thumb, index and middle fingers and twirl back and forth gently and rapidly. • Small Animal - On all paresis/paralysis patients, it is important to apply this technique to each digit, where the Jing Well points lie. Also for lameness issues that arose from digital injury or subluxation.

Vibrating (Zhen fa) • Technique – Vibrate rapidly palm or fingers firmly on area while concentrating deeply.

Shaking (Dou fa) • Technique – Hold distal end of limb and shake up and down (vs. side to side) continuously, gently and rapidly. May need to support knee/elbow with other hand. • Small Animal - For most limb and joint disorders and can be sent as homework for the owner.

Joint Adjustments and Passive Manipulations: *Require a higher degree of skill and experience Stretching or Pull/Extend (Ba Shen Fa): • Technique – In a firm, slow, and gentle maneuver, pull and extend a joint longitudinally in its normal anatomical position. • Small Animal - Useful for the head, neck, and all four limbs, and on the tail where it can draw the CNS Qi down.

Rotating/Rocking (Yao fa) • Technique – Passive cycling through range of motion of any joint, using both hands to move and support simultaneously. • Small Animal - Post-operative and post-trauma joints can benefit from gentle Yao fa, similar to human post-op care of repaired joints where gentle manipulation of the joint is done to reduce adhesions, cartilage degradation and adverse periarticular connective tissues changes (Xie, 149).

4 Comparison of various massage techniques with Tui-na The four more common types of Oriental massage, Tui-na, Shiatsu (Japanese), Thai massage, and Indonesian massage, though each having their own philosophy and history, share some common roots including that they all look at the body at a holistic perspective of the body as a whole and disease as an imbalance in the whole, not just one part. Shiatsu is a Japanese modern variation of Tui-na. Both Tui-na and Shiatsu aim for balance of flow of “Qi” through the body. But Shiatsu has some techniques that are applied slowly with sustained static pressure, while Tui-na has many vigorous and penetrating techniques (Marceti, 1997, 11). Thai massage involves yoga-type stretches after the practitioner has pressed along energy channels and muscles they pass through. Indonesian massage is a deep oil-based massage along Chinese energy pathways and focuses on the spine.

Swedish massage and other western types of massage are more based on treating a symptom or injury. This is in contrast to the oriental perspective of looking at the entire body vs. its parts, thus forming its holistic basis of treatment of disease and aim of maintaining a healthy balanced body. But Western style massage texts refer to techniques that have similarities to various Tui-na techniques, with terms used such as effleurage (slide or glide over skin with smooth stroking hand movements frequently at the beginning and end of a treatment session), petrissage (lift, wring, or squeeze soft tissues in a kneading motion or roll tissues), frictions (superficially to create heat or deeper to stop tissue adhesions), tapotement (percussive massage techniques), vibrations (oscillating or trembling motions), and joint movements (for stretching, increase joint range of motion, relax and build muscle strength).

Western medical perspective of Tui-na and other massages Back pain is a common problem whether you are a human or an animal. The western or conventional approach would be to prescribe anti-inflammatories, rest, and possibly surgery. Back pain comes with tension of the back muscles and eventual weakening of the legs. Tui-na and other massages can help in managing chronic pain by directly relieving pain through muscle relaxation and indirectly through stress-reducing mechanisms such as the enhancement of parasympathetic nervous activity and activation of inhibitory mechanisms that suppress pain, increase relaxation, and improve sleep (Hart, 2008, 64-66). Massage, as a potent mechanical stimulus, is a particular effective trigger for the short-lived analgesia from the “pain gate” mechanism (Goats, 1994, 155). Longer lasting pain control results via the ‘descending pain suppression mechanism,” resulting in endorphin being released from the brain during massage to help in pain relief and bringing about both mental and muscular relaxation. Increased local circulation from vasodilation and increased heat all help to further reduce pain and speed healing. All this causes a feeling of vitality and wellbeing.

According to Goats review of previous research (1994), with effleurage techniques gradual compression reduces muscle tone and induces a general state of relaxation that relieves muscle spasm and prepares the patient for more vigorous treatment. Firm pressure accelerates blood and lymph flow, improves tissue drainage and thus reduces recent swelling. Rapid strokes have the opposite effect. These will increase muscle tone and may be useful during the final preparation for competition. Kneading promotes the flow of tissue fluid and causes reflex vasodilation and marked hyperemia. This reduces swelling and helps resolve inflammation. Vigorous kneading decreases muscle spasm and can stretch tissues shortened by injury. Petrissage is particularly

5 useful for stretching contracted or adherent fibrous tissue and will relieve muscle spasm. Acting more deeply than kneading, petrissage also promotes the flow of body fluids and can resolve long-standing swelling. The localized stretching and degradation of collagen caused by friction techniques can restore fibers to a more normal alignment during the remodeling phase of healing. Tapotement triggers cutaneous reflexes and causes vasodilation.

The Tui-na claim to influencing health through organ effects may be explained by activation of autonomic nervous system effect on organs via stimulation of the afferent pathways and subsequent result of efferent influence on tissues and organs.

Research on Massage Cherkin et. al. (2003), after performing a systematic review of randomized controlled trials from MEDLINE, EMBASE, and the Cochrane controlled Trials Register, concluded that initial studies (three) have found massage to be effective for persistent back pain. This study also noted that although some forms of massage involve substantial force, massage is generally considered to have few adverse effects.

Another systematic review done by Furlan et. al. (2002) discovered what they termed a “high- quality study” that compared acupuncture massage with classic Swedish massage. That study showed that acupuncture massage was superior to classic massage (irrespective of the type of exercise received) on measures of both pain and function.

Tracer experiments have been done showing effleurage, one of the least penetrating massage techniques, significantly improved blood flow over other techniques routinely used for that purpose, such as shortwave diathermy and therapeutic ultrasound. Patients with flaccid limb paralysis responded similarly, indicating the effect is not totally dependent on spinal reflexes (Goats, 1994, 153).

The effects of massage upon lymph flow and the reduction of edematous swelling has been measured experimentally. Though gentle active exercise remains the most effective method for improving tissue drainage, kneading and stroking techniques, but not others, were found to increase lymph flow (Goats, 1994, 154).

Application to animals It is advised not to perform Tui-na (Marceti, 1997, 12; Xie, 2003, 135): • Directly on inflamed or broken skin – treat these patients elsewhere on body • On brittle bones • During pregnancy on lower back or abdomen, and avoid certain acupuncture points contraindicated in pregnancy • At acute fracture sites • On very old and very weak patients • Around masses of unknown origin and recent hemorrhage • With infectious and epidemic diseases • With serious heart disease or cancer, especially of the skin or lymphatic system

6 Tui-na can support other modalities of treatment for the patient, conventional or other TCM treatments such as acupuncture and herbals. Practically, it is useful for muscle and joint pain from injury or chronic wear and tear, and stress-related disorders. It is also useful to know and practice as a veterinarian for when an animal does not like having acupuncture either through normal disposition (excessive fear of needles) or from the acupuncture point site(s) being too painful for needle insertion. Thus one can still bring about pain relief, muscle relaxation, anxiety reduction, and injury rehabilitation.

Educating the animal’s owner how to do some techniques will empower them to become part of the healing process; something every caring owner desires. The most common problem any human or animal has at one point is back pain. I have included below some handouts on back and leg techniques that I give to owners to remember what I have shown them. Often I also briefly demonstrate on the owner so they better understand the techniques. Both the competitive pet and the geriatric patient can greatly benefit from regular Tui-na from their owner or veterinarian.

Client Handouts:

TUI-NA (CHINESE MASSAGE) OF THE BACK

1. Rub along back vigorously until feel heat generated. 2. Drag a finger along each side of the spine from back of head to tail twelve times. Start lightly and each time a little harder unless the pet shows discomfort, then do not do any harder until pet is comfortable with it. 3. Along same line on both sides of back, go tail to head twelve times pinching through skin to muscles, each time a little harder. Again if pet shows discomfort, do not do any harder until pet is comfortable with it. 4. Pull on the tail twelve times.

TUI-NA (CHINESE MASSAGE) OF A LEG

1. Lay pet down on side (best in relaxed state). 2. Knead leg rapidly between palms (like making a bread stick) back and forth, up and down leg. 3. If allowed by pet, hold each toe between thumb and index finger and knead, 4. Then stretch limb with gentle traction/pulling by toe until pet pulls back on leg, then release. 5. Repeat with each toe steps 3 & 4. 6. While supporting the knee or elbow, take distal extremity in hand and gentle shake limb up and down.

7 References: Chengnan, S (ed). Chinese Bodywork: A Complete Manual of Chinese Therapeutic Massage. Berkley, CA: Pacific View Press, 1993.

Cherkin, DC, Sherman, KJ, Deyo, RA, & Shekelle, PG. A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage, and Spinal Manipulation for Back Pain. Ann Intern Med. 2003; 138(11):898-906.

Chi Institute. Application of Tui-Na in Veterinary Practice. Proceedings of 5th Advanced TCVM Seminar, 2003.

Furlan, AD, Brosseau, L, Imamura, M, & Irvin, E. Massage for Low-Back Pain: A Systematic Review within the Framework of the Cochrane Collaboration Back Review Group. Spine. 2002; 27(17):1896-1910.

Goats, GC. Massage-the Scientific Basis of an Ancient Art: Part 1 Techniques. BR J Sports Med. 1994; 28:149-152.

Goats, GC. Massage-the Scientific Basis of an Ancient Art: Part 2 Physiological and Therapeutic Effects. BR J Sports Med. 1994; 28:153-156.

Hart, J. Complementary Therapies for Chronic Pain Management. Alternative & Compementary Therapies. April 2008; 64-68.

Mercati, Maria. The Handbook of Chinese Massage: Tui Na Techniques to Awaken Body and Mind. Rochester, VT: Healing Arts Press, 1997.

Mercati, Maria. The Healing Benefits of Oriental Massage. Positive Health. May 1999; 40. Available at: http://www.positivehealth.com/article-view.php?articleid=814. Accessed on May 6, 2010.

Ping, Chen (editor). Chinese Tuina and Therapeutic Applications: Advanced TCM Series, Volume 7. Beijing: Science Press, 1998.

Tappan, FM & Benjamin, PJ. Tappan’s Handbook of Healing Massage Techniques: Classic, Holistic, and Emerging Methods, 3rd ed. Stamford, CT: Appleton & Lange, 1998.

Xu, Xiangcai. Chinese Tui Na Massage: The Essential Guide to Treating Injuries, Improving Health, & Balancing Qi. Boston, MA: YMAA Publication Center, 2002.