Chuzhen Therapy as a Non-Invasive Traditional Chinese Therapy for Neck Pain

Chuzhen therapy has effectively addressed various conditions, with success in alleviating neck pain and enhancing patients' quality of life. This article presents Chuzhen as a safe and efficacious traditional Chinese method tailored specifically for the treatment of neck pain.

Neck pain (NP) is a common musculoskeletal disorder that significantly diminishes patients' quality of life. While nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently prescribed for neck pain management, their use can result in side effects, such as peptic ulcers. Consequently, non-pharmacological treatments like acupuncture and massage serve as effective alternatives. Chuzhen therapy, an adaptation of the traditional Chinese Nine Needles, is a non-invasive treatment that combines the therapeutic benefits of acupuncture and massage by stimulating meridians and acupoints through specific techniques. This approach provides a safe and effective option for neck pain treatment. This paper outlines a comprehensive method for Chuzhen therapy application in neck pain treatment, detailing acupoint selection, material preparation, treatment duration, procedural steps, and safety precautions. The Visual Analogue Scale (VAS), Neck Disability Index (NDI), and Short Form 36 Health Survey (SF-36) are employed as assessment tools to evaluate this method's efficacy. Findings demonstrate that Chuzhen therapy effectively alleviates neck pain, improves patients' quality of life, and does not produce adverse effects.

Neck pain (NP) has multiple etiologies, with cervical spondylosis being the most prevalent. Additional causes include trauma, inflammation, vascular diseases, and endocrine disorders¹. Clinically, neck pain manifests as neck and shoulder pain, stiffness, and restricted mobility, often accompanied by headaches and insomnia. According to the Global Burden of Disease database, neck pain affected over 203 million individuals globally in 2020, with an anticipated increase of 32.5% by 2050². In China, 87.3 million people are affected, which is the third largest cause of disability burden³. Neck pain adversely impacts patients' quality of life and mental and physical health and imposes a significant economic burden on individuals and society. While most neck pain patients choose conservative treatment, often with NSAIDs, these carry risks such as peptic ulcers and gastrointestinal bleeding. Traditional Chinese Medicine (TCM) methods, including acupuncture and massage, have demonstrated positive effects in alleviating neck pain^4,5. However, acupuncture needs to puncture the skin, some patients can not cooperate with the treatment due to pain, and massage cannot be done to effectively stimulate the acupoints.

The history of Chuzhen therapy has a far-reaching origin, deeply rooted in TCM theory. As a part of non-invasive acupuncture, Chuzhen therapy integrates theories from the Zhou Yi (Book of Changes) and the Yin Fu Jing (Hidden Talisman Classic), merging acupuncture and massage to enhance qi and blood circulation, producing effects similar to traditional acupuncture. Animal studies further indicate that Chuzhen therapy increases pain thresholds by modulating central monoamine neurotransmitter levels⁶. Chuzhen therapy has shown promising results in pain management^7,8,9. It is available in four types (see Figure 1), each designed for targeted techniques and treatment purposes; pressing and rubbing points or meridians in the body regulate the activity of qi, blood, and meridians in treating diseases. Compared with acupuncture, there is no need to break the skin; compared with Tuina, the acupoint stimulation is more significant. Developed by Professor Zhongyu Li from the Hospital of the Chengdu University of TCM, Chuzhen therapy combines the principles of acupuncture and massage, offering high safety, broad applicability, and noninvasiveness¹⁰. Evidence-based studies confirm the safety and efficacy of Chuzhen therapy for neck pain treatment^11,12.

Currently, there are no guidelines regarding the application of Chuzhen therapy in the treatment of neck pain. Nevertheless, our team has developed local standards for Chuzhen therapy procedures¹³. This article's objective is to present a standardized Chuzhen method tailored for patients with neck pain in cervical spondylosis, thereby providing practitioners with a reliable reference.

This study is a self-controlled, retrospective trial analyzing medical records of 74 patients with neck pain treated with Chuzhen therapy at the outpatient clinic of the Hospital of Chengdu University of TCM from March 2023 to June 2024. The cohort consisted of 48 females and 26 males, aged 18 to 82 years (43.22 ± 15.30 years), with neck pain duration ranging from 4 days to 8 years. All patients provided informed consent for this study. The clinical research protocol was reviewed and approved by the hospital's ethics committee (KY2022031).

1. Patient assessment

1. Use the following inclusion criteria: Diagnosis of cervical spondylosis¹⁴; primary complaint of neck pain persisting for > 24 h; age over 18 years; gender not restricted; patients who receive the Chuzhen therapy in the hospital; VAS score > 3; patient and family provided consent, and an informed consent form was signed.
   NOTE: On the VAS scale, a score of less than or equal to 3 is considered to be mild pain, which can be tolerated by the patient. The clinical significance of a VAS score of >3 is that it transitions pain from tolerable to requires intervention. Therefore, in clinical trials, VAS scores greater than 3 are often used as inclusion criteria^15,16.
2. Use the following exclusion criteria: Acute trauma (e.g., fractures, dislocations) or spinal cord conditions requiring surgery; the presence of malignant tumors or severe systemic diseases affecting outcomes; infected or damaged skin, scars, lesions, or masses in the treatment area; mental illness or cognitive impairments affecting cooperation; patients using pain medications during the treatment period; pregnant or breastfeeding women.

2. Preparation before the procedure

1. Prepare the following materials: Chuzhen instrument set (standardized DB51/T 3179-2024): No.1 Chuzhen (Qiyao Hunyuan Chuzhen), No.2 Chuzhen (Wuxing Santai Chuzhen), No.3 Chuzhen (Jingang Chuzhen), and No.4 Chuzhen (Kuixing Pen; see Figure 1 for details); medical disinfectant and blanket.
2. Prepare a clean, quiet, well-lit treatment room at a comfortable temperature to ensure patient comfort.
3. Patient preparation: Position the patient either in the prone or seated position. Ensure patients have eaten within the hour to avoid hunger. Clean the treatment area (the entire neck to the outside of both shoulders) with a warm towel, saline-soaked cotton balls, or 75% alcohol.
4. Practitioner preparation: Wear clean attire and a mask; disinfect hands with water and sanitizer.

3. Chuzhen therapy procedure

1. Positioning: Position the patient either in the prone or seated position, allowing comfortable access to acupoints.
2. Acupoint selection: Select common points, including Fengchi and Jianjing; select specialized points, including Fengfu Bazhen, Dazhui Bazhen, and Heche Road (from Naohu to Dazhui; see Figure 2 and Table 1). Select acupoints based on the National Standard of the People's Republic of China: Nomenclature and Location of Meridian Acupoints (GB/T 12346 - 2021)¹⁷ and Therapeutics of Chuzhen¹⁸.
3. Tap the no. 2 Chuzhen on Dazhui Bazhen and Fengfu Bazhen with the tapping technique 49x in 1 min. For the tapping technique, repeatedly perform point-knocking which is fast, applies low pressure and is shallow. For smaller regions, perform knocking slowly, with high pressure and deep.
4. Press the tool's head against the skin at the No. 1 Chuzhen along Heche Road (Naohu to Dazhui) point, moving horizontally and vertically 21x in 2 min.
5. Press and lift 21x in 1 min at the No. 3 Chuzhen on Fengfu Bazhen and Dazhui Bazhen site. To do this, press the Chuzhen tip on the acupoint to be treated. Then, gradually transmit force to the Chuzhen tip and advance it downward. Ensure the degree of advancement can be tolerated by the patient, aiming to disperse the qi and blood in all directions. Following this, slowly lift the Chuzhen upward, but ensure the Chuzhen tip does not leave the skin of the treated acupoint.
6. Perform circular motions 7x in 3 min at No. 3 Chuzhen on Dazhui Bazhen and Fengfu Bazhen. During the application, press the tail of the Chuzhen closely against the skin of the treatment area and perform circular motions from inside to outside, and then from outside to inside (taiji running). Keep the force as much as the patient can tolerate. Continue the application until the skin becomes flushed.
7. Press and lift 21x in 2 min at the No. 4 Chuzhen on Fengchi and Jianjing site as described in step 3.5.
8. Repeat steps 3.3-3.7 2x. Continue each step until the skin flushes or reaches the patient's tolerance threshold.
9. Post-procedure, assist the patient to a comfortable position, clean and disinfect the Chuzhen tools with 75% alcohol, and store them in a designated container.
10. Perform the procedure for 2 weeks with five sessions per week, each lasting approximately 30 min.
    NOTE: Clinical studies have confirmed that 2 weeks can achieve the therapeutic effect, so 2 weeks are used. The treatment time can be added or subtracted according to the patient's condition^19,20.

4. Precautions during the procedure

1. Communicate with patients to alleviate anxiety. Maintain a warm room to ensure seasonal comfort.
2. Ensure practitioners are skilled in the technique for smooth application. Monitor patient reactions (e.g., complexion, blood pressure, heart rate) to prevent adverse effects.

5. Post-treatment care and data collection

1. Allow patients to rest for 15-20 min post-treatment. Mild skin redness, warmth, or millet-like papular spots are normal reactions that do not require special care. In case of skin damage, sterilize the area of the skin lesion and suspend further treatment.
2. Obtain patient basic information (age, gender, disease duration, and intervention methods) through the hospital's electronic medical record HIS (Hospital Information System) system. Collect clinical efficacy indicators (VAS, NDI, and SF-36) before treatment, at the end of treatment, and 1 month after treatment through outpatient visits, with some data collected through telephone follow-ups. Two researchers independently enter and extract the data for analysis.
   1. VAS score: Ask patients to mark their perceived pain intensity on a 10 cm line, where 0 indicates no pain and 10 indicates the most severe pain. Record the position of the patient's mark in cm as their VAS score. The nurse then measures and enters the data.
   2. NDI index: Use the Neck Disability Index (NDI) to evaluate the patients' neck function and quality of life. Ask patients to fill out a questionnaire consisting of 10 questions covering pain, personal care, lifting, headache, reading, work, driving, sleep, recreation, and concentration. Score each question from 0 to 5, with a total score of 50, where a higher score indicates more severe neck dysfunction.
   3. SF-36 scale: Use the Short Form Health Survey (SF-36) to assess the patient's overall health status and quality of life. This scale consists of 36 questions divided into eight dimensions: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. Score each dimension from 0 to 100, where a higher score indicates better health status and quality of life.

6. Statistical analysis

1. Clean the collected data, only retain cases that have completed the three stages of assessment and exclude cases with missing data at key time points. Conduct data analysis using SPSS 25.0 Normal distribution data are presented as mean ± standard deviation, with intra-group comparisons made using a paired t-test. Comparing the efficacy results before and after treatment, as well as the efficacy results at 1 month after treatment and at the end of treatment, with statistical significance set at p < 0.05.

Based on a comparison of pre-and post-treatment data, significant improvements were observed in the Visual Analogue Scale (VAS) scores, Neck Disability Index (NDI), and Short Form 36 Health Survey (SF-36) for the 74 patients treated (p < 0.001; see Table 2). The results presented here strongly prove the effectiveness of Chuzhen therapy. Further analysis revealed continued improvement in NDI and SF-36 scores 1-month post-intervention (p < 0.001), suggesting that Chuzhen therapy provides sustained therapeutic effects, effectively ameliorating patient conditions. However, no significant change was observed in the VAS score 1 month after treatment compared to the score at the end of the intervention (p > 0.05), which may relate to the brief duration of the intervention. In general, Chuzhen therapy has been demonstrated to be an efficacious method for alleviating the symptoms of neck pain associated with cervical spondylosis. Furthermore, it has been shown to enhance the life quality of patients as measured by SF-36 scale analysis, with the total score rising from 48.64 ± 10.97 to 72.74 ± 11.13 at baseline (p < 0.001) and maintained at 76.66 ± 10.49 at 1-month follow-up (p < 0.001) after treatment.

Figure 1: Typical design of Chuzhen tools. Different parts of the Chuzhen are labeled enabling practitioners to select the appropriate part for operation accurately. (A) No.1 Chuzhen (Qiyao Hunyuan Chuzhen); (B) No.2 Chuzhen (Wuxing Santai Chuzhen); (C) No.3 Chuzhen (Jingang Chuzhen); (D) No.4 Chuzhen (Kuixing Pen). Please click here to view a larger version of this figure.

Figure 2: Chuzhen therapy manipulation of acupoints diagram. (A, B) Heche Road trajectory in the head and neck. (C) The structure of Bazhen acupoints. *The sky, wind, snake, cloud, earth, dragon, bird, and tiger represent eight different directions on the Bagua Zhen, with the Sky usually considered to be above. (D) The Bazhen acupoints in the cervical (Fengfu Bazhen, Dazhui Bazhen). (E, F) Clinical application scenarios of the acupoints. Please click here to view a larger version of this figure.

Table 1: Detailed information on acupoints in this study. The name, serial number, distribution, localization, and treating diseases are described. *The Fengfu Bazhen is based on the Fengfu point as the central point, a set of 8 points formed by the radius 1,2 and 3 cun lateral to GV 16 and on both sides. It is the same with Dazhui Bazhen. # is a set of 7 lines, including the line between GV 17 and Dazhui GV 14 at 0.5, 1.5, and 3 cun lines lateral to the spine on both sides, respectively.

Table 2: Scores of VAS, NDS, SF-36 before, after, and 1 month after treatment. Data are reported as mean ± SD or [95% confidence level]. ^a The p values were obtained by paired t-tests. *Compared to the end of treatment, there was no significant difference 1 month after treatment.

In Traditional Chinese Medicine, neck pain is referred to as cervical bi syndrome, characterized by posterior neck pain, rigidity, and restricted movement, presenting a significant public health issue with greater impact than conditions such as alcohol use disorder²¹. TCM attributes neck pain to factors such as blocked qi and blood flow, invasion by cold and dampness, or liver and kidney deficiencies. For chronic cervical pain management, conservative treatments have shown greater efficacy compared to other approaches²². Neck pain lasting more than 3 months is classified as chronic²³. TCM therapies-such as acupuncture, Tuina, and herbal medicine-are effective alternative treatments that unblock meridians and alleviate pain^5,24,25. Chuzhen has demonstrated considerable efficacy in pain relief^8,26 and offers therapeutic benefits comparable to traditional methods of managing various conditions.

Chuzhen therapy primarily uses four tools and five techniques. The tools-No.1 Chuzhen, No.2 Chuzhen, No.3 Chuzhen, and No.4 Chuzhen -stimulate acupoints by pressing or scraping the skin, harmonizing Yin and Yang, eliminating pathogenic factors, promoting qi and blood circulation, and strengthening health for disease prevention and treatment. The techniques include tapping, lifting, opening, rotating, and separating. Through rotating (performing circular motions) and separating(moving horizontally and vertically) techniques, it has a similar effect to massage, which can relax the surrounding tissues of the neck, relieve nerve compression, and improve local microcirculation disorders²⁷. The tapping and opening (press and lift) techniques have a similar effect to acupuncture, achieving precise stimulation of acupoints and meridians without penetrating the skin, thus avoiding the risk of infection²⁸. Tapping uses the needle or its end to percuss the treatment site; lifting involves longitudinal movements along the body's axis; opening involves vertical pressing; rotating uses circular movements; and separating entails moving the needle to push the skin in various directions. Compared to traditional acupuncture, Chuzhen reduces discomfort and infection risks, enhancing patient acceptance. Unlike dry needling and massage, Chuzhen targets specific acupoints, increasing the precision and traceability of therapeutic outcomes^8,29. This study investigated statistically significant pre- and post-intervention changes in VAS scores, NDI, and SF-36, demonstrating the positive effects of Chuzhen therapy in relieving neck pain.

The acupoints selected include Fengchi (GB-20), Jianjing (GB-21), two Bazhen points, and Heche Road. Fengchi (GB-20), located in the upper depression between the trapezius and sternocleidomastoid muscles, is believed to dispel wind, relieve pain, and improve qi and blood flow. Recent studies have shown that GB-20 stimulation reduces microglial activation, providing anti-inflammatory and desensitizing effects useful for pain relief^30,31. Another key acupoint, Jianjing (GB-21), is traditionally used for neck and shoulder discomfort and is confirmed by clinical studies to effectively relieve pain and improve cervical mobility when combined with other acupoints^32,33. The Bazhen points, associated with Chuzhen therapy, encompass the inner, middle, and outer eight arrays around central points like Dazhui (GV-14) and Fengfu (GV-16), which are located on the Du meridian along the posterior midline of the neck. The Heche Road, a specific acupoint grouping for Chuzhen therapy, includes seven pathways integrating the conception and governor vessels, facilitating qi and blood flow in the neck region. The blunt stimulation of the Chuzhen's techniques, including tapping, lifting, and rotating, effectively stimulates qi and blood flow, enhancing analgesic effects and alleviating local pain.

This study confirms the effectiveness of Chuzhen therapy in the treatment of neck pain, but there are some shortcomings. For example, the study design was a single-arm study, resulting in no control group and potentially increasing study bias; a control group will be added to future studies to improve comparability of efficacy. In conclusion, Chuzhen therapy, as a non-invasive and painless physical therapy, demonstrates significant efficacy and ease of application. This article not only provides a noninvasive alternative to treating neck pain related to cervical spondylosis but also provides a standardized procedure for operating a pestle and mortar needle.

The authors declare no conflicts of interest.

This study was supported by the Sichuan Provincial Administration of TCM Scientific and Technological Special Project (2022zd025).