Tuina · Atlas

1. Introduction

Version followed: adult tuina as described in the WHO Benchmarks for the practice of tuina (2020) and Benchmarks for the training of tuina (2020); paediatric tuina as described in the China Association of Chinese Medicine (CACM) group standard for non-medical paediatric tuina (2023 revision, consultation draft replacing T/CACM 1081-2018). Regulatory statements follow the mainland China, Hong Kong and Australian sources listed below.

What it is. Tuina (推拿, literally "push-grasp") is the manual therapy branch of traditional Chinese medicine (TCM). WHO describes it as a manual therapy aimed at treating various disorders and enhancing health, and as one of the most commonly used modalities in traditional medicine practice [source: WHO practice benchmarks 2020; WHO training benchmarks 2020]. It is a set of hand techniques (pushing, rolling, kneading, rubbing, grasping, pressing and others) applied to acupoints, along meridians or along muscle fibres, chosen after a TCM assessment that includes "pattern differentiation" [source: WHO practice benchmarks 2020].

How change is said to happen (attributed to TCM theory, not established fact). In TCM theory as WHO's training benchmarks set it out, health depends on the balance of yin and yang and the Five Elements, and on the flow and interaction of qi, blood, essence and fluids through organ systems and a network of meridians (14 main meridians, 8 extraordinary meridians, collaterals, meridian sinews and cutaneous regions). Tuina is understood within that tradition as regulating qi and blood flow through meridians and acupoints [source: WHO training benchmarks 2020]. These are concepts of the TCM tradition; qi and meridians have no confirmed anatomical or physiological correlate in biomedicine [synthesis]. Outside the tradition, any benefit is usually discussed in ordinary musculoskeletal and touch terms, and reliable reviews rate the trial evidence as low in quality (see Evidence status, section 2) [source: Huang et al. 2023; Liu et al. 2025].

For the psychotherapist. Tuina is delivered by licensed or credentialed TCM and tuina practitioners, not by psychotherapists. This guide therefore covers (a) the method as WHO and Chinese professional bodies publish it, so you can talk about it accurately with clients, (b) who may deliver it and how they are regulated, (c) safety screening, and (d) your own role: when to suggest or discuss it, how to refer, how to prepare clients with trauma histories for touch, how to integrate body experiences, and how to recognise and pass on adverse effects and boundary violations [synthesis]. Tuina is not a treatment for cancer or any other physical disease; health claims below are attributed with their evidence status.

2. Framework

2a. Who delivers tuina and how they are regulated

Mainland China. Tuina appears in two regulated settings. Medical tuina belongs to TCM diagnosis and treatment, which may be provided only by medical institutions holding a practice licence (or filing) and by qualified practitioners such as licensed TCM physicians (中医执业医师) [source: People's Daily / China City News report, 15 May 2023, on the Medical Institution Management Regulations and NATCM rules]. Non-medical "health-preservation" (养生保健) venues may offer tuina and massage as wellness services, but under the NATCM TCM Health-Preservation Service Specification (trial) they may not diagnose or treat, may not prescribe, may not run medical qigong, may not promise treatment effects, and may not use manipulation (扳法), traction, acupuncture, invasive or hazardous methods [source: People's Daily 2023]. Paediatric tuina also exists in both settings; the CACM non-medical standard requires the operator to hold a paediatric tuina qualification [source: CACM draft standard].
Hong Kong. Under the Chinese Medicine Ordinance (Cap. 549), practising Chinese medicine includes diagnosing, treating, preventing or alleviating disease, prescribing Chinese medicines, and regulating body functions on TCM principles in general practice, acupuncture or bone-setting; only registered and listed Chinese medicine practitioners may practise Chinese medicine. Registration requires passing the Chinese Medicine Council of Hong Kong's Licensing Examination after an approved undergraduate Chinese medicine degree or equivalent [source: Hong Kong Food and Health Bureau LegCo reply LCQ20, 17 June 2015; Chinese Medicine Regulatory Office]. Tuina is not named in the statutory definition; whether a given tuina service falls inside it (for example as treatment or bone-setting) or is ordinary massage is [uncertain: not verified]. Massage premises are covered separately by the Massage Establishments Ordinance (Cap. 266), with exemptions for premises of certain registered professionals [source: LCQ20 2015].
Australia. The Chinese Medicine Board of Australia (under AHPRA) registers practitioners in three divisions: acupuncture, Chinese herbal medicine and Chinese herbal dispensing. Protected titles include "Chinese medicine practitioner", "acupuncturist", "Chinese herbal medicine practitioner", "Oriental medicine practitioner" and "Chinese herbal dispenser". Tuina is not a division of registration [source: CMBA registration FAQ]. A tuina-only practitioner therefore does not hold a tuina-specific registration but may not use a protected title unless registered [synthesis from CMBA FAQ]. Unregistered health workers such as massage therapists come under the National Code of Conduct for health care workers, with complaints to state health complaint entities, and association members (e.g. AMT) can also be reported to their association [source: HaDSCO 2022; AMT complaint page].
Elsewhere. In many countries tuina is offered by acupuncturists, TCM practitioners or massage therapists under general massage or complementary-therapy rules; check the local regulator (e.g. state massage boards in the US, voluntary registers such as CNHC in the UK) [synthesis] [uncertain: tuina-specific rules in those jurisdictions not verified].
Training standard. WHO's training benchmarks describe full training for people without a medical background at basic level (about 1,500 hours, including about 400 hours of supervised clinical practice) and advanced level (about 2,350 hours), plus adapted training for those with a traditional or conventional medical background. Advanced training includes paediatric tuina, foot tuina and cosmetic tuina as special techniques. Trainees must learn tuina's limits, precautions and contraindications, conventional medical knowledge, ethics and law, and when to refer [source: WHO training benchmarks 2020].

2b. The course of tuina care as WHO describes it

Assessment: chief complaint, medical history, physical examination, TCM pattern differentiation and a therapeutic principle [source: WHO practice benchmarks 2020].
Information and consent: the practitioner explains possible benefits and risks and obtains informed consent, orally or in writing [source: WHO practice benchmarks 2020].
Treatment: manipulations, force and duration chosen for the patient's condition and adjusted to their response; hygiene steps before and after [source: WHO practice benchmarks 2020].
Recording and follow-up: manipulations used, the patient's response, outcomes, incidents and follow-up advice [source: WHO practice benchmarks 2020].
Incident management: stop, relieve mild symptoms, refer severe cases urgently, give first aid where appropriate (section 4) [source: WHO practice benchmarks 2020].

WHO does not give a typical number of sessions [uncertain: not verified]. The CACM paediatric standard specifies session length and course structure adjusted for the child's age, constitution and condition; these parameters are for the trained practitioner and are not reproduced here [source: CACM draft standard].

2c. The psychotherapist's parallel framework [synthesis]

Phase	Goal	Move on when
1. Explore	Understand why the client is interested (pain, stress, family or cultural tradition, a doctor's suggestion)	Interest is the client's own and the goal is clear
2. Screen and refer	Medical clearance where needed; choose a properly credentialed practitioner	Contraindications checked; practitioner's credentials verified
3. Prepare for touch	Consent plan, stop signal, chaperone and clothing choices, trauma-informed adaptations	Client can name what they will and will not accept
4. Accompany the course	Brief check-ins about experience, adverse effects and boundaries	Ongoing; reviewed each session or two
5. Integrate and review	Use body experiences in therapy; decide whether to continue	Client and you agree on next steps

2d. Evidence status

Clinical practice guidelines for tuina (eight Chinese guidelines covering 35 conditions, 13 paediatric) were rated low in methodological quality, with recommendations based mostly on expert opinion [source: Huang et al. 2023, Frontiers in Medicine].
A 2023 meta-analysis of 15 RCTs (1,390 patients) in chronic nonspecific low back pain found benefit for pain and function but not clearly for quality of life; no serious adverse events were reported in the six trials that reported adverse events [source: OE summary of Yang et al. 2023, Medicine].
A 2025 meta-analysis of 13 RCTs (984 patients) for chronic ankle instability favoured tuina, but the included trials were of low methodological quality [source: Liu et al. 2025, PLOS ONE].
Spinal manipulation, especially of the upper spine, is associated with mild to moderate adverse effects and rare serious complications such as vertebral artery dissection and stroke [source: systematic review, Journal of the Royal Society of Medicine 2007, via Epistemonikos]. Tuina repertoires that include manipulation (扳法) carry this class of risk [synthesis].
Summary for clients: promising but low-certainty evidence for some musculoskeletal pain; not established as a treatment for disease; paediatric claims rest mainly on low-quality guidelines [synthesis from the reviews above].

3. Guiding principles

Attribute, do not endorse, TCM concepts. Say "in Chinese medicine, tuina is understood to move qi along the meridians", not "tuina moves your qi" [source: WHO training benchmarks for content; synthesis for wording].
Respect the tradition and its teaching authority. Teaching and clinical authority sits with TCM universities, licensing bodies (e.g. Chinese Medicine Council of Hong Kong, Chinese Medicine Board of Australia) and professional bodies (e.g. WFCMS, CACM); refer clients to them rather than to self-styled teachers [source: CMRO; CMBA; WFCMS; CACM].
Medical first. Tuina does not replace medical diagnosis; new, severe or unexplained symptoms go to a doctor first [synthesis; WHO training benchmarks require trainees to recognise limits and refer].
Screen for contraindications before referral. Use WHO's published list (section 4) as a prompt, and seek medical clearance when any apply [source: WHO practice benchmarks 2020].
Credentials matter. Check registration or qualification in the client's jurisdiction; in mainland China, treatment claims and manipulation belong in licensed medical settings, not wellness shops [source: People's Daily 2023; CMBA; CMRO].
Consent before and during touch, with the right to stop at any time. WHO requires informed consent before treatment; body-psychotherapy codes add that consent is monitored over time and the client may refuse or end any touch at any time [source: WHO practice benchmarks 2020; USABP Code of Ethics VIII].
Never sexual. Genital or other sexual touch is always inappropriate; tuina does not involve intimate areas, and any concern about pelvic or intimate symptoms goes to a regulated medical clinician [source: USABP Code VIII for the principle; synthesis for application].
Keep roles separate. You do not provide tuina in psychotherapy sessions unless your profession's code allows combined touch work and you hold recognised tuina training and any required licence. Mainstream codes (BACP, UKCP, BPS, HCPC, APA, AAMFT) contain no explicit touch clause but all require working within competence and avoiding harmful dual relationships; EABP asks therapists to consider and discuss with the client the implications of parallel services from another professional [source: compiled code extracts listed in Sources].
Children: safeguarding first. Parent or guardian consent, the child's own assent, a medical assessment for any illness, and stopping when the child resists [source: CACM draft standard for pausing when the child resists; synthesis for the rest].
Trauma-informed adaptation. Vigorous techniques (grasping, rolling, manipulation) and positions (lying face down, abdominal work) can trigger trauma responses; plan in advance [synthesis].
Cultural meaning. For clients from Chinese or wider East Asian backgrounds, tuina may carry family, cultural and identity meaning; explore this without either dismissing or overselling it [synthesis].
Report and pass on. Adverse effects and boundary violations are recorded, discussed with the client and, with consent, reported to the practitioner's regulator or association [synthesis; sources for routes in section 4].

4. Intervention inventory

The inventory has three parts. Part A describes the tuina manipulations as WHO and CACM publish them. These are delivered by the tuina practitioner; the descriptions are here so you can explain them, help clients anticipate the sensations, and recognise when something is outside the published method. They are not instructions for psychotherapists to perform. Part B covers the practitioner's safety procedures, which you can check against. Part C covers the psychotherapist's own interventions. Practitioners set frequencies, repetitions, force and duration for the individual patient; those parameters are not reproduced here [source: WHO practice benchmarks 2020].

Part A. Adult tuina manipulations (WHO practice benchmarks, 2020)

WHO describes eight manipulations, each with "key elements" [source: WHO practice benchmarks 2020]. WHO notes that tuina practice also includes further techniques not covered there, and the training benchmarks require trainees to learn basic and "comprehensive" (combined) manipulations [source: WHO training benchmarks 2020].

A1. One-finger pushing (一指禅推法)

Purpose / when used: focused, rhythmic stimulation of an acupoint or small area; in TCM terms, used on acupoints and along meridians [source: WHO practice benchmarks 2020].
Steps (as published): force comes from the tip or side of the thumb, driven by a continuous swaying of the forearm; the thumb stays on the point while the forearm swings [source: WHO practice benchmarks 2020].
Example language (illustrative): "You'll feel a steady, rocking pressure from one thumb on a small spot. It can feel quite strong. You can ask for it lighter at any time."
Watch for: sharp, burning or lingering pain at the spot; skin redness that persists (WHO lists these under skin injury) [source: WHO practice benchmarks 2020]. Working well: client describes deep but tolerable pressure that eases afterwards [synthesis].

A2. Rolling (滚法)

Purpose / when used: broad, rhythmic pressure over larger muscle areas such as the back, shoulders and thighs [source: WHO practice benchmarks 2020 for technique; synthesis for typical areas].
Steps (as published): force is applied with the back of the hand, driven by forearm swaying combined with wrist rotation, so the hand rolls back and forth over the area [source: WHO practice benchmarks 2020].
Example language (illustrative): "The practitioner rolls the back of their hand over the muscle, a bit like a wave going back and forth. Tell them if the rhythm or pressure is too much."
Watch for: bruising, petechiae or swelling after the session (WHO tissue-injury signs); for clients with trauma histories, the sustained repetitive pressure on the back while lying face down can feel confining [source: WHO practice benchmarks 2020; synthesis for the trauma point].

A3. Kneading (揉法)

Purpose / when used: gentle, circular work on soft tissue [source: WHO practice benchmarks 2020].
Steps (as published): slow, soft rotary movement using the thumb, the thenar eminence (fleshy base of the thumb) or the root of the palm; the hand moves the underlying tissue rather than sliding over the skin [source: WHO practice benchmarks 2020 for hand parts; synthesis for "moves tissue"].
Example language (illustrative): "This is a slow, circular kneading with the palm or thumb, usually one of the gentler techniques."
Watch for: usually well tolerated; it is a reasonable "starter" technique for clients anxious about touch, which the client can request [synthesis].

A4. Pushing (推法)

Purpose / when used: one-directional strokes along a meridian or along muscle fibres [source: WHO practice benchmarks 2020].
Steps (as published): a slow, one-way movement with the thumb, palm or elbow along the line of a meridian or muscle, repeated several times [source: WHO practice benchmarks 2020].
Example language (illustrative): "You'll feel slow strokes in one direction, sometimes with the elbow, which is firmer. In Chinese medicine these follow the meridian lines."
Watch for: elbow pushing is heavy; bleeding tendency or anticoagulant use makes bruising more likely (WHO lists bleeding tendency as a contraindication) [source: WHO practice benchmarks 2020].

A5. Rubbing (擦法)

Purpose / when used: producing warmth over an area through friction [source: WHO practice benchmarks 2020 for technique; CACM draft describes rubbing as friction to produce heat].
Steps (as published): a straight back-and-forth movement with the thenar eminence or palm over the skin [source: WHO practice benchmarks 2020].
Example language (illustrative): "This is a brisk back-and-forth rubbing that warms the skin."
Watch for: burning pain, persistent redness or blisters, which WHO classes as skin injury requiring the practitioner to stop [source: WHO practice benchmarks 2020].

A6. Grasping (拿法)

Purpose / when used: lifting and squeezing muscle, often on the shoulders and neck [source: WHO practice benchmarks 2020 for technique; synthesis for typical areas].
Steps (as published): lifting, pinching or clipping skin and underlying tissue between the fingers and thumb, alternating strong and gentle force [source: WHO practice benchmarks 2020].
Example language (illustrative): "The practitioner will lift and squeeze the muscle, firmer then softer. It can be intense; you can ask them to keep it on the softer side."
Watch for: grasping of the neck and shoulders is a common trigger for clients with histories of being grabbed or strangled; agree in advance whether the neck is off limits [synthesis].

A7. Pressing (按法)

Purpose / when used: sustained pressure on an acupoint or body part [source: WHO practice benchmarks 2020].
Steps (as published): downward pressure on an acupoint or area with gradually increasing strength, repeated several times [source: WHO practice benchmarks 2020].
Example language (illustrative): "They'll press on particular points and slowly increase the pressure. Say 'lighter' or 'stop' whenever you need to."
Watch for: acute local pain, swelling or loss of function afterwards (WHO tissue injury) [source: WHO practice benchmarks 2020].

A8. Palm-twisting (搓法)

Purpose / when used: often used on limbs [synthesis for typical use].
Steps (as published): the practitioner clips the region between both palms and twists swiftly while moving up and down it [source: WHO practice benchmarks 2020].
Example language (illustrative): "They'll hold your arm between both palms and roll it quickly up and down."
Watch for: joint pain or pain in a recently injured limb; WHO lists injured tendons and ligaments as a regional contraindication [source: WHO practice benchmarks 2020].

A9. Manipulation and traction (扳法, 牵引)

Purpose / when used: joint manipulation and traction are part of some medical tuina and bone-setting repertoires; WHO's 2020 practice benchmarks do not describe them [source: WHO practice benchmarks 2020; uncertain: their place in the standard tuina curriculum not verified].
Steps: not described here. In mainland China they are among the techniques non-medical health-preservation venues may not use, i.e. they belong in licensed medical settings [source: People's Daily 2023].
Example language (illustrative): "If anyone offers to 'crack' or twist your neck or back, it's fine to say no, and to ask whether they are licensed for that where you are."
Watch for: spinal, especially upper-spine, manipulation is linked to mild to moderate adverse effects and rare serious events such as vertebral artery dissection and stroke [source: JRSM 2007 systematic review]. Sudden severe headache or neck pain, dizziness, visual disturbance, slurred speech, weakness or numbness after neck work is an emergency [synthesis: standard stroke warning signs].

A10. Paediatric tuina manipulations (CACM non-medical standard, consultation draft)

Purpose / when used: paediatric tuina (小儿推拿) applies light techniques mainly to points on the hands, arms, abdomen and back; Chinese guidelines cover conditions such as recurrent respiratory infections and "spleen deficiency" (a TCM pattern) in children, but these guidelines are of low methodological quality [source: CACM draft; Huang et al. 2023].
Steps (techniques the standard names, briefly translated):
- Pushing (推法): straight, separating, combining and rotary pushing along points, one or both directions.
- Kneading (揉法): finger, palm or thenar kneading, gentle and circular.
- Pressing (按法): gradual pressure with fingertip or palm.
- Circular stroking (摩法): palm or finger-pad circles, mostly on the abdomen. The standard links the direction of circling to tonifying or reducing (补泻) in TCM theory.
- Arc pushing (运法): light arc or circular strokes on the skin surface only.
- Nail-pressing (掐法): pressing a point with the thumbnail, described for emergencies or small points.
- Palm-twisting, rotating, grasping, patting, friction-rubbing and knuckle-tapping (搓、摇、拿、拍、擦、捣法).
- Spine pinching (捏脊): lifting and rolling the skin along the spine from the coccyx upwards.
- Compound manipulations with traditional poetic names, such as "two dragons playing with a pearl" (二龙戏珠) and "phoenix spreading its wings" (双凤展翅).
- Media: powders, water, ginger or scallion juice, mint water, oils or creams, chosen by TCM pattern; powders should not be inhaled. [source: CACM draft standard]
Example language for parents (illustrative): "Paediatric tuina is mostly light stroking and pressing on the hands, tummy and back. Your child should be comfortable, and the practitioner should pause if they get upset. It is not a substitute for seeing the doctor when your child is unwell."
Watch for: the standard warns that too much force on the abdomen can cause intestinal spasm and, in severe cases, intussusception or bowel obstruction, which need immediate medical attention. It also warns against forcibly pulling the limbs and about falls from the couch. If the child resists or cries, practitioners are to pause, communicate patiently and continue only once the child trusts them [source: CACM draft standard]. Nail-pressing "for emergencies" must never delay emergency services [synthesis].

Part B. Practitioner safety procedures you can check against

B1. Contraindication screening (WHO list)

Purpose / when to use: before you suggest tuina and before the first session, as a prompt for medical clearance [source: WHO practice benchmarks 2020; synthesis for your use].
Steps: go through WHO's three groups with the client:
- Diseases or syndromes: acute heart or cerebrovascular disease; severe infectious disease; acute abdominal pain; bleeding tendency; alcohol or drug intoxication.
- Conditions: an uncooperative patient or an extremely weak constitution; the abdomen and lumbosacral region during pregnancy or menstruation.
- Treatment region: sensitive skin or skin disease; infected areas, abscesses, sepsis or malignant tumours; injured tendons or ligaments. [source: WHO practice benchmarks 2020] For children, the CACM standard adds: broken skin, burns, unexplained lumps, scars and bleeding sites; bone and joint infections (e.g. tuberculosis, osteomyelitis, septic arthritis), cellulitis, erysipelas; tumours, fractures and dislocations; severe heart, lung, liver or kidney disease; infectious diseases such as chickenpox, scarlet fever, hepatitis and tuberculosis; bleeding disorders such as thrombocytopenic purpura, haemophilia and allergic purpura [source: CACM draft standard]. Then: if anything applies, or the client takes anticoagulants, has osteoporosis, recent surgery, a suspected clot, or unexplained symptoms, ask them to consult their doctor first [synthesis; anticoagulation links to WHO's "bleeding tendency"].
Example language (illustrative): "Before you book, can we go through a short safety list? Tuina is fairly firm massage, and there are some situations where it's not advised or you'd want your GP's okay first."
Watch for: clients minimising symptoms because they want the treatment; alcohol or drug use before sessions (WHO contraindication) [source: WHO practice benchmarks 2020; synthesis].

B2. Consent, hygiene and records

Purpose: what a competent practitioner should do in every course [source: WHO practice benchmarks 2020].
Steps: explanation of benefits and risks with oral or written consent; hand cleaning before and after; clean or disposable sheets and towels; patients dressed appropriately; records of history, examination, pattern, plan, consent, manipulations, response, incidents and follow-up advice [source: WHO practice benchmarks 2020].
Example language (illustrative): "A good practitioner will explain what they plan to do and the risks, ask your consent, and keep notes. If they don't, that's worth noticing."
Watch for: no consent conversation, pressure to undress more than needed, refusal to explain techniques, treatment promises [synthesis; People's Daily 2023 on non-medical venues promising treatment].

B3. Adverse-event management (WHO)

Purpose: what should happen when something goes wrong [source: WHO practice benchmarks 2020].
Steps (as published):
- Skin injury (burning pain, persistent redness, blisters, bleeding): stop at once; large blisters drained and disinfected; keep clean.
- Tissue injury (petechiae, purpura, acute pain, swelling, haematoma, loss of function): stop at once; cold compress; immobilise if function is lost; refer if necessary.
- Bone injury (suspected fracture or dislocation): stop at once; immobilise; refer immediately. [source: WHO practice benchmarks 2020]
Example language (illustrative): "Some soreness the next day can happen. Blisters, big bruises, swelling, or pain that's getting worse aren't normal, and you should get them checked."
Watch for: WHO's benchmarks do not cover fainting or spinal manipulation injury [source: WHO practice benchmarks 2020]; treat fainting, chest pain or neurological symptoms as medical emergencies [synthesis].

Part C. The psychotherapist's interventions

All of Part C is [synthesis] built on the safety, consent and code material cited, unless a source is named.

C1. Exploring the client's interest and its cultural meaning

Purpose / when to use: when a client mentions tuina, has been advised to try it, or comes from a family where it is part of ordinary health care.
Steps: (1) Ask what draws them to it: pain, tension, a family practice, a doctor's suggestion, or a wish for touch. (2) Ask what tuina means in their family or culture, and who in their life uses it. (3) Ask what they expect it to do. Compare this with what the evidence supports (section 2d), and present the TCM concepts as the tradition's own understanding. (4) Notice whether the wish is mainly for contact or comfort; this may be material for therapy in its own right.
Example language (illustrative): "What does tuina mean to you? Is it something your family has always used?" / "In Chinese medicine it's understood to move qi through the meridians. The research mostly looks at pain, and it's still early."
Watch for: pressure from relatives the client feels unable to refuse; hopes that tuina will treat a serious illness; dismissing the tradition, which can feel like dismissing the client's background. It is working when the client can state a realistic, self-chosen goal.

C2. Medical clearance, credential check and referral

Purpose / when to use: before the client books, whenever they have health conditions, or when they are unsure whom to see.
Steps: (1) Go through the contraindication list (B1) together. (2) If any item applies, or they have anticoagulation, pregnancy, osteoporosis, recent surgery or injury, suggest they ask their doctor first. (3) Help them check credentials. In Australia, the AHPRA register lists Chinese medicine practitioners; a tuina-only practitioner will not appear unless they are also registered as an acupuncturist or Chinese herbal medicine practitioner [source: CMBA FAQ]. In Hong Kong, look for registered or listed Chinese medicine practitioners [source: CMRO]. In mainland China, treatment and manipulation belong in licensed medical institutions, not wellness venues [source: People's Daily 2023]. Elsewhere, check the relevant massage or complementary-therapy register. (4) Ask what training they hold, for example a TCM degree or a programme matching WHO's training benchmarks [source: WHO training benchmarks 2020]. (5) With consent, write a short referral letter that covers relevant health information and any trauma-related needs. It should not include psychotherapy content the client has not agreed to share.
Example language (illustrative): "Before you go, it's worth checking they're registered or properly trained. Shall we look them up together?"
Watch for: practitioners who promise to cure disease, who discourage medical care, or who offer neck manipulation in a non-medical setting. It is working when the client books with a verified practitioner after any medical clearance they need.

C3. Preparing a client with a trauma history for touch

Purpose / when to use: for any client with a history of physical or sexual abuse, medical trauma, assault, or strong reactions to touch.
Steps: (1) Map triggers together: positions (face down, lying flat), body areas (neck, abdomen, lower back), types of touch (grasping, firm pushing, rolling), the practitioner's gender, clothing and room set-up. (2) Draft a consent plan for the client to share with the practitioner. It should list areas that are off limits, techniques to avoid or keep light (kneading is often gentler than grasping or elbow pushing), clothing (tuina is commonly given through clothing or a sheet), and the right to stop at any time [source: USABP Code VIII on the right to refuse or end touch; synthesis]. (3) Agree a clear stop word, and a gesture in case speech freezes. (4) Discuss whether to bring a support person, or ask for a chaperone or an open door. (5) Rehearse saying "lighter", "skip that area" and "stop". (6) Practise a grounding skill the client can use on the couch, such as feeling the feet or naming objects in the room. (7) Suggest a shorter, gentler first session, to be agreed with the practitioner.
Example language (illustrative): "You're in charge of your body in that room. You can stop at any time without giving a reason. What would you want to say, and what would you want them to do?"
Watch for: freezing, holding the breath, going numb, or 'pleasing' the practitioner by tolerating pain; any loss of time or memory during or after the session. It is working when the client used their plan, or can describe what they would change next time.

C4. Paediatric tuina: talking with parents and protecting the child

Purpose / when to use: when a parent asks your view on tuina for their child, or the child you see in therapy is receiving it.
Steps: (1) Check whether a doctor has assessed the child's current illness; tuina is not a substitute. Red flags such as high fever in an infant, breathing difficulty, dehydration, or abdominal pain with vomiting need urgent medical care. (2) Ask whether the practitioner holds a paediatric tuina qualification, as the CACM standard requires [source: CACM draft]. (3) Explain the safety points the standard itself makes: gentle force on the abdomen, no forcible pulling of limbs, fall prevention, and pausing when the child resists [source: CACM draft]. (4) Agree that a parent stays in the room throughout, and that the child is clothed except as needed for the hands, arms, abdomen or back. (5) Seek the child's assent in age-appropriate words, and treat crying, pulling away or saying "no" as withdrawal of assent. (6) Follow local safeguarding procedures if you have concerns about rough handling, unexplained bruising or a delay in medical care.
Example language (illustrative), to a parent: "It's important your child is happy to be touched, and that you're with them. If they cry or pull away, it's okay to stop." To a child: "Someone will gently rub your hands and tummy. If you don't like it, you can say stop, and they will."
Watch for: abdominal pain, vomiting or swelling after abdominal work (the standard warns of intussusception or obstruction: seek medical care immediately) [source: CACM draft]; bruising; distress before sessions; a child's illness going untreated by a doctor.

C5. Brief check-ins during a tuina course

Purpose / when to use: at the start of sessions while the client is having tuina.
Steps: (1) Ask how it went, physically and emotionally. (2) Ask about soreness, bruising, skin changes, dizziness or new symptoms. (3) Ask whether the consent plan was respected. (4) Ask what they noticed in their body that they want to explore. (5) Keep it short unless something needs attention.
Example language (illustrative): "How was tuina this week? Any soreness or anything that didn't feel right? Did they stick to what you'd agreed?"
Watch for: symptoms that are worsening (C7); signs of a boundary breach (C8); the client feeling unable to say no. It is working when reports are open and specific.

C6. Integrating body experiences into psychotherapy

Purpose / when to use: when tuina brings up emotion, memory, relaxation or new body awareness.
Steps: (1) Invite a description of the sensation: where it was, what quality it had, and what happened next. (2) Explore the meaning it holds: safety, grief, care received or missed. (3) Link it to therapy goals, for example noticing tension patterns or learning to ask for what one needs. (4) Respect TCM explanations the client offers ('the practitioner said my qi was blocked') as their framework, and explore what that meant to them. (5) For trauma memories, use your usual stabilisation-first approach.
Example language (illustrative): "When they worked on your shoulders, you said you felt like crying. What was that like? What do you make of it now?"
Watch for: flashbacks or dissociation that arise outside sessions; turning tuina into a substitute for addressing relationships; dependence on a particular practitioner. It is working when the client can link body experience to choices in daily life.

C7. Recognising adverse effects and passing them on

Purpose / when to use: whenever a client reports physical problems after tuina.
Steps: (1) Sort what you hear using WHO's categories: skin injury (blisters, burning, persistent redness), tissue injury (bruising, swelling, acute pain, loss of function), and suspected bone injury [source: WHO practice benchmarks 2020]. (2) Urgent medical help is needed for neurological symptoms or severe headache after neck work, chest pain, signs of a clot (a painful swollen calf, sudden breathlessness), suspected fracture, or abdominal pain with vomiting in a child [synthesis; JRSM 2007 for neck manipulation; CACM draft for abdominal warning]. (3) For non-urgent problems, encourage the client to tell the practitioner and their GP. (4) Record what the client told you. (5) Discuss reporting with the client: to the practitioner's regulator or association, or to the national adverse-event route where one exists.
Example language (illustrative): "That swelling and pain getting worse isn't the usual next-day soreness. I'd like you to get it checked today."
Watch for: clients blaming themselves, or protecting a practitioner they like. It is working when the client gets assessed and decides about reporting.

C8. Recognising boundary violations and supporting a complaint

Purpose / when to use: when a client describes touch that went beyond their consent, any sexual or intimate touch, sexual comments, pressure to undress, or being told to keep something secret.
Steps: (1) Name it clearly. Sexual or genital touch is never part of a legitimate treatment [source: USABP Code VIII for the principle]. (2) Attend to safety and distress first. (3) Explain the options: police for assault; the regulator for registered practitioners (in Australia, AHPRA for registered Chinese medicine practitioners; health complaint entities under the National Code for unregistered workers) [source: CMBA FAQ; HaDSCO 2022]; in Hong Kong, the Chinese Medicine Council for registered or listed practitioners [uncertain: complaint route not verified]; the practitioner's association (e.g. the AMT Discipline Committee) [source: AMT complaint page]. (4) Support the client's decision, and follow mandatory reporting duties where children or vulnerable adults are involved.
Example language (illustrative): "What you're describing isn't part of tuina or any proper treatment. It wasn't your fault. Would you like to go through your options?"
Watch for: self-blame, minimising, and freezing at the time ('I didn't stop them'). It is working when the client feels believed and makes an informed choice.

C9. Coordinating with the tuina practitioner

Purpose / when to use: when the client consents and there is trauma-related or safety information worth sharing.
Steps: (1) Get written consent stating exactly what may be shared. (2) Share practical needs, not the trauma narrative. (3) Ask the practitioner to let you or the client know about adverse effects, with the client's consent. (4) Discuss with the client how the two services fit together, so roles stay clear [source: EABP Ethics Guidelines 6.b on parallel services].
Example language (illustrative), letter to practitioner: "My client has asked me to let you know they prefer to be clothed, would like you to avoid the neck, and may use the word 'pause'."
Watch for: the client being treated as fragile or 'difficult'; information going beyond what was agreed.

C10. If you are trained in both tuina and psychotherapy

Purpose / when to use: for clinicians who hold recognised tuina training and any licence their jurisdiction requires.
Steps: (1) Check what your psychotherapy code says. Mainstream codes require competence and avoiding harmful dual relationships, but none of those listed contains an explicit touch clause. Body-psychotherapy codes (USABP, EABP) allow touch only with assessment, informed consent and ongoing monitoring, and never for the therapist's needs [source: BACP 2018 and 2026; UKCP 2019; HCPC 2023; AAMFT 2015; USABP Code VIII; EABP 2020 Principle 7]. (2) Check whether delivering tuina is lawful in your role: in Hong Kong, practising Chinese medicine requires registration; in mainland China, treatment requires a licensed setting [source: CMRO; People's Daily 2023]. (3) The safest default is to keep tuina and psychotherapy as separate services, and to refer psychotherapy clients to another tuina practitioner. (4) If you do combine them, document the assessment of whether touch is appropriate, obtain written consent (which USABP highly recommends), review consent regularly, and seek supervision.
Example language (illustrative): "I do practise tuina, but with clients I see for therapy I keep the two separate and refer you to a colleague. That keeps our work clear."
Watch for: blurred roles; clients finding it hard to refuse touch from their therapist; dependency.

5. Handling problems

The tuina sources address only the practitioner's side: incidents, and children who resist. Everything else below is [synthesis] unless a source is named.

Client in pain during sessions but "pushing through". Tuina can be vigorous, and some clients believe it must hurt to work. Reframe: WHO expects force to be adjusted to the patient's response, and burning pain or lingering redness counts as skin injury [source: WHO practice benchmarks 2020]. Rehearse asking for lighter pressure (C3). If the client still cannot say it, explore the pattern in therapy (compliance, fear of disappointing others).
Dissociation or flashback on the couch. Before sessions, agree that the client can stop, sit up and ground themselves (C3). Afterwards, debrief the episode, stabilise, and decide together whether to pause tuina, change techniques or areas, or stop.
Overwhelm after a session (tearfulness, agitation, poor sleep). Normalise strong emotional responses to touch without attributing them to "released qi" as fact. Slow the integration work (C6) and suggest gentler or shorter sessions, to be agreed with the practitioner.
Stuck: tuina "isn't working" or the client keeps adding courses. Review the original goal and what the evidence supports (section 2d). Encourage a medical review of persistent pain. Explore whether the sessions meet a need for care or contact that could also be met elsewhere.
Using tuina instead of medical care. Particularly for serious illness, or for a sick child. State your concern plainly and support a medical assessment. Tuina is not a treatment for disease. In mainland China, non-medical venues may not diagnose, treat or promise treatment effects [source: People's Daily 2023].
Family or cultural pressure. A client may feel unable to refuse tuina that elders arrange. Respect the tradition while affirming that the client chooses what happens to their body. Role-play a respectful refusal or a negotiated compromise, for example lighter work or an agreed limit on areas.
Practitioner makes disease claims, or discourages doctors or medication. Treat these as red flags. Help the client find a different practitioner and, if they wish, report the claims to the relevant regulator or association.
Neck "cracking" or manipulation offered. Explain the risk (JRSM 2007 review). In mainland China this is restricted to medical settings [source: People's Daily 2023]. Support the client in declining, or in seeking a properly licensed clinician with medical screening.
Bleeding tendency or anticoagulants; pregnancy. WHO lists bleeding tendency as a contraindication, and abdominal and lumbosacral work in pregnancy as a condition-based contraindication [source: WHO practice benchmarks 2020]. Medical clearance first. If the client goes ahead anyway, suggest they tell the practitioner.
Intoxication. Alcohol or drug intoxication is a WHO contraindication [source: WHO practice benchmarks 2020]. Where substance use is a clinical issue, address it directly, and encourage the client not to attend sessions while intoxicated.
Boundary violation disclosed. Follow C8. Remember the client may have kept attending for some time; avoid any implication that this means consent.
Rupture: the client feels you disapprove of their tradition, or are pushing tuina on them. Acknowledge it. Separate your view on safety and evidence from the client's cultural choice. Return the decision to the client.
Non-adherence to safety advice (skipping medical clearance). Explore what makes the advice hard to follow, such as cost, access or mistrust of doctors. Problem-solve together, document the advice given, and respect the client's autonomy unless there is risk to a child.
Paediatric: the child resists or fears sessions. The CACM standard says to pause, communicate patiently and continue only when the child trusts the practitioner [source: CACM draft]. Support parents to treat persistent refusal as a reason to stop, not to persuade.
Dual-trained therapist pressured to "just do some tuina" in session. Hold the role separation (C10) and refer.
Uncertain regulatory status. If you cannot confirm how tuina is regulated where the client lives, say so. Advise choosing a practitioner who is registered in a related regulated profession (acupuncture, Chinese medicine, massage, physiotherapy), has documented training and holds insurance [uncertain: local rules not verified].

Sources

Standards, regulation and reviews:

Professional codes and complaint routes:

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