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Chuna

Chuna manual therapy, also known as Chuna, is a traditional Korean medical practice that employs hands-on techniques to manipulate the spine, joints, and soft tissues, aiming to restore biomechanical balance and alleviate musculoskeletal disorders.^[1] Originating from ancient East Asian healing traditions similar to Chinese Tuina, Chuna focuses on correcting malalignments, improving joint mobility, and enhancing neuromuscular function through methods such as mobilization, traction, and muscle relaxation.^[2] It is widely used in modern Korean medicine clinics for conditions like low back pain, neck pain, and herniated discs, often integrated with acupuncture and herbal treatments for comprehensive care.^[3] Clinical studies have demonstrated Chuna's effectiveness in reducing pain and improving function, with evidence showing sustained benefits over extended periods, such as 96 weeks for chronic lower back pain when compared to conventional nerve blocks.^[4] In South Korea, Chuna is covered under national health insurance for specific indications since 2019, reflecting its recognition as a safe and evidence-based intervention, though it requires skilled practitioners to avoid risks like minor soreness or rare complications.^[5]

Definition and Principles

Core Concepts

Chuna is a manipulative therapy within Korean traditional medicine, known as Hanbang, that employs hands-on techniques to correct misalignments in the spine and joints, thereby promoting the flow of qi—the vital energy—and restoring overall bodily harmony.^[6] This approach addresses biomechanical imbalances by stimulating the meridian system, which is central to traditional East Asian medical paradigms, to facilitate the smooth circulation of qi and blood.^[6] The primary objective of Chuna is to reestablish structural and functional equilibrium in the musculoskeletal system, alleviating pain and enhancing physiological harmony through non-invasive manual interventions.^[7] The term "Chuna" derives from the Korean pronunciation of the Chinese characters 推拿 (tuī ná), literally meaning "pushing and pulling," which encapsulates the foundational actions of applying pressure and traction to manipulate tissues and joints.^[6] This nomenclature reflects the therapy's emphasis on dynamic manual adjustments to realign displaced structures and release tension, drawing from ancient practices while incorporating modern anatomical understanding.^[6] At its core, Chuna seeks to restore biomechanical function by targeting orthopedic displacements and muscular restrictions, ultimately aiming to mitigate pain and improve mobility without reliance on pharmacological or surgical means.^[5] Unlike invasive treatments, it prioritizes gentle, precise manipulations that align with the body's natural healing processes, fostering long-term balance in the musculoskeletal framework.^[8] While sharing etymological roots with Chinese Tui na—a manual therapy involving similar pushing and pulling techniques—Chuna represents a distinctly Korean adaptation that integrates traditional Hanbang principles with influences from Western chiropractic and osteopathic methods, emphasizing meridian-based qi harmonization alongside biomechanical correction.^[1] Chuna is often integrated with complementary Hanbang practices such as acupuncture or herbal medicine to enhance therapeutic outcomes.^[9]

Theoretical Foundations

Chuna manual therapy is underpinned by the philosophical principles of traditional Korean medicine (TKM), which emphasize individualized treatment through the integration of Sasang constitutional typology and the yin-yang balance. Sasang typology classifies individuals into four constitutions—Taeyang (greater yang), Taeeum (greater yin), Soyang (lesser yang), and Soeum (lesser yin)—based on biopsychosocial traits, allowing practitioners to tailor manipulations to a patient's inherent physiological and psychological predispositions for optimal therapeutic outcomes. This typology, rooted in Confucian and Taoist influences, aligns with the broader East Asian concept of yin-yang harmony, where treatments aim to restore equilibrium between opposing forces to address imbalances manifesting as musculoskeletal dysfunction.^[10]^[11] Physiologically, Chuna focuses on neurophysiological mechanisms to enhance joint mobility and alleviate dysfunction, drawing from both traditional and modern biomedical understandings. Techniques in Chuna stimulate proprioceptive neuromuscular receptors, particularly through trigeminal nerve fibers in facial applications or spinal structures, facilitating neural feedback to the central nervous system and promoting muscle re-education and symmetry. Additionally, end-range mobilization—applying controlled movements slightly beyond the normal physiological range—improves joint function by addressing restrictions in motion, akin to high-velocity, low-amplitude adjustments that enhance proprioception and reduce nociceptive input. These effects underscore Chuna's emphasis on biodynamic principles, integrating anatomy and physiology to correct structural imbalances without invasive interventions.^[12]^[13]^[6] Central to Chuna's theoretical framework is the concept of malalignment, analogous to subluxation in chiropractic influences, where osteoarticular displacements disrupt normal biomechanical function and contribute to pain and systemic dysfunction. Evolving from bonesetting traditions and Western chiropractic methods, Chuna posits that such malalignments impede the flow of vital energy (qi) and create pathological cascades, including neurovascular compression and altered proprioception. Correction of these misalignments is viewed as essential for restoring homeostasis, reflecting TKM's adaptation of chiropractic principles to emphasize preventive and holistic realignment. Recent advancements include functional dynamic radiographic assessments to quantify malalignments, enhancing precision in biomechanical corrections as of 2025.^[14]^[6]^[15] In its holistic orientation, Chuna operates within a broader East Asian medical paradigm that addresses meridian pathways and the circulation of qi, positioning manual therapy as a non-invasive means to harmonize the body's energetic network. By stimulating acupoints and soft tissues along meridians, Chuna facilitates qi flow, mitigating stagnation that underlies conditions like chronic pain, while avoiding surgical or pharmacological disruption. This integrative approach views the musculoskeletal system not in isolation but as interconnected with visceral and energetic functions, promoting overall vitality through balanced meridian activation.^[6]

History and Development

Origins in Traditional Medicine

Chuna's historical roots lie in ancient East Asian medical traditions, particularly those outlined in the Huangdi Neijing (Yellow Emperor's Inner Canon), a foundational Chinese text compiled during the Warring States period (475–221 BCE) that emphasized manipulation techniques for balancing qi and treating bodily disharmonies. This canon profoundly influenced Korean traditional medicine by providing core principles of health preservation and physical therapy, which were transmitted through cultural exchanges and adapted into local practices.^[16]^[6] During the Joseon Dynasty (1392–1910), these influences manifested in early Korean medical records, where manual therapies were documented for addressing musculoskeletal issues. Key texts such as Eui-Bang-Yoo-Chui (1445), Hwal-In-Sim-Bang (1550), and Dong-Eui-Bo-Gam (1610)—the latter authored by the prominent physician Heo Jun—describe techniques like Tao Yin (guiding and pulling exercises), Anma (pressing and rubbing), and Angyo (joint manipulation) as methods to restore bodily alignment and function. These works represent adaptations of Chinese techniques to Korean contexts, incorporating indigenous understandings of anatomy and meridians while prioritizing preventive and holistic care.^[6]^[17] Chuna further evolved through shared East Asian heritage, drawing from Korean traditional bone-setting practices, alongside Chinese Anmo (a precursor to Tuina involving meridian-based massage) and Japanese Seikotsu (bone-setting manipulation). In the 17th century, physicians like Heo Jun played a pivotal role in synthesizing these elements, refining them for practical application in treating joint and spinal disorders amid Korea's conservative medical environment. Amid Japanese colonial rule (1910–1945), Chuna practices were suppressed and limited primarily to blind practitioners and folk remedies, despite restrictions on techniques like Anma. Following liberation in 1945, Chuna entered a period of further suppression from 1945 to the 1980s, where it remained marginalized and passed down informally.^[6]^[18]

Modern Integration in Korea

Following the Korean War, traditional Korean medicine, encompassing manual therapies such as Chuna, experienced a significant revival amid a shortage of medical personnel after the departure of Japanese practitioners. In 1951, the South Korean government reintegrated hanbang (traditional medicine) practitioners into the national medical system, reopening a dedicated medical college to train Oriental medicine doctors and addressing the urgent healthcare needs of the population.^[19] Chuna emerged as a formalized manual therapy within this revitalized system during the 1990s, integrating elements of traditional Korean techniques with influences from Chinese tuina and Western chiropractic methods. The Korean Society of Chuna Manual Medicine (KSCMM) was founded in 1991 to standardize practices, followed by official legalization by the Ministry of Health and Welfare in 1994, marking its recognition as a legitimate component of Korean medicine.^[6] Educationally, Chuna was incorporated into the core curriculum of Korean medicine colleges starting in 1995, with all 12 such institutions now offering dedicated courses ranging from 4 to 8 credit units, often mandatory. The Korea Institute of Oriental Medicine, established in 1994 as a national research body, supported this integration by advancing evidence-based standards for traditional therapies, including Chuna, through clinical guidelines and training programs. Supplementary specialized courses, initiated in 1996, provide over 126 hours of annual instruction to ensure practitioner competency.^[6]^[20] Key milestones in Chuna's institutionalization include its approval as a reimbursable nonpayment item under the National Health Insurance in 2002 and full coverage for specific conditions like neck and back pain starting in March 2019, which expanded access and utilization. This period also saw the proliferation of specialized clinics, notably Jaseng Hospital of Korean Medicine, founded in 1999, which has grown into a network of 21 branches emphasizing non-invasive Chuna-based treatments for spinal disorders and conducting high-impact clinical trials.^[6]^[21]^[22]

Techniques and Methods

Manipulation and Mobilization

Chuna techniques are broadly classified into subtypes such as Fascia Chuna, which emphasizes gentler mobilization and soft tissue work, and Bonesetting Chuna, involving thrust manipulations like high-velocity low-amplitude (HVLA) techniques.^[23] Manipulation and mobilization form the cornerstone of Chuna manual therapy, focusing on restoring alignment and function to the spine and joints through targeted hands-on interventions. These techniques aim to correct biomechanical imbalances by applying controlled forces to the musculoskeletal system, particularly the vertebral column. Chuna practitioners assess joint mobility and restrictions before selecting appropriate methods, ensuring interventions are tailored to the patient's condition.^[6] High-velocity low-amplitude (HVLA) thrusts represent a primary manipulative technique in Chuna, akin to chiropractic adjustments, where a rapid, controlled force is delivered to specific spinal segments to induce joint cavitation and improve mobility. These thrusts are commonly applied to the cervical, thoracic, and lumbar regions to address subluxations or hypomobilities, with the practitioner positioning the patient supine, prone, or side-lying for optimal access. The HVLA maneuver involves a short lever arm and precise localization to minimize extraneous forces, typically producing an audible "pop" from synovial fluid release within the joint.^[23] In contrast, mobilization techniques in Chuna employ gentler, oscillatory movements graded according to the Maitland concept, adapted to emphasize spinal and joint restoration without high-velocity thrusts. Grades I and II involve small- to large-amplitude oscillations within the pain-free range to reduce muscle guarding and enhance proprioception, while Grades III and IV apply deeper, end-range movements to stretch capsular tissues and increase joint play. These passive mobilizations are sustained or rhythmic, progressing based on patient tolerance to progressively restore range of motion in restricted areas like the facet joints.^[23] Specific maneuvers in Chuna manipulation include rotational adjustments for cervical issues, where the practitioner rotates the head and neck to target upper cervical vertebrae, promoting decompression and alignment in cases of restricted rotation. For lumbar concerns, extension-distraction techniques are utilized, involving prone positioning with gentle traction and extension to separate vertebral segments and alleviate disc pressure, often combined with side-lying corrections for facet dysfunction. These maneuvers prioritize directional specificity to match the diagnosed restriction pattern.^[24]^[25] Occasionally, Chuna incorporates specific tools to deliver precise force in sensitive areas, allowing for enhanced control during mobilization or distraction without relying solely on manual contact.^[26]

Soft Tissue and Adjunctive Approaches

In Chuna manual therapy, soft tissue approaches emphasize non-thrust techniques to target muscles, fascia, and connective tissues, aiming to alleviate tension and restore function without direct joint correction. Myofascial release involves sustained, gentle pressure applied by the practitioner's hands to stretch and release restrictions in the fascial network, reducing adhesions that contribute to pain and restricted movement.^[6] Deep tissue massage, a related method, employs firmer strokes and kneading to penetrate deeper muscle layers, promoting improved blood flow and tissue pliability in areas affected by chronic strain.^[1] Stretching techniques in Chuna are integrated to elongate shortened muscles and enhance overall flexibility, often guided by the patient's functional assessment to avoid overextension.^[6] Proprioceptive exercises, such as controlled resisted movements or balance-oriented tasks, are incorporated during sessions to retrain neuromuscular coordination and support long-term stability in the musculoskeletal system.^[6] Adjunctive methods complement these manual techniques, particularly for chronic pain management. Cupping therapy, involving the application of suction cups to the skin, is frequently combined with Chuna to draw out stagnation and enhance circulation in affected soft tissues, as demonstrated in treatments for conditions like frozen shoulder.^[27] Moxibustion, the burning of herbal cones near specific points, pairs with manual work to warm and stimulate underlying tissues, aiding pain relief in persistent cases by improving local energy flow.^[6] A typical Chuna session begins with soft tissue preparation, such as myofascial release or massage, to relax muscles and minimize discomfort before progressing to mobilization or other interventions, ensuring a safer and more effective overall treatment. Sessions typically last 20-30 minutes.^[1]

Clinical Applications

Common Conditions Treated

Chuna manual therapy is primarily indicated for a range of musculoskeletal disorders, with a strong emphasis on spinal conditions that cause pain and functional impairment. Common spinal disorders treated include cervical and lumbar disc herniations, spondylosis, and nonspecific low back pain. These conditions are addressed through targeted manipulations to restore joint alignment and alleviate nerve compression or inflammation. For instance, lumbar disc herniation often presents with radiating pain, while cervical spondylosis involves degenerative changes leading to stiffness and discomfort.^[28]^[29] Extremity-related issues also form a significant portion of Chuna applications, particularly those involving joint dysfunction and soft tissue strain. Shoulder impingement syndrome, characterized by restricted movement and pain during overhead activities, knee osteoarthritis with its progressive cartilage loss and joint instability, and ankle sprains resulting from ligament damage are frequently managed using Chuna techniques to improve mobility and reduce swelling. These treatments focus on mobilizing affected joints and surrounding muscles to support recovery.^[28]^[1] In addition, Chuna is applied to headache and radiculopathy presentations linked to spinal misalignment. Tension-type headaches, often originating from cervical tension or misalignment, and sciatica, which involves radicular pain from lumbar nerve root irritation due to disc issues or stenosis, benefit from Chuna's corrective approaches to relieve pressure on neural structures.^[28]^[29] Chuna is most commonly utilized in outpatient settings for chronic pain management, where musculoskeletal complaints account for approximately 68.9% of visits to Korean traditional medicine clinics. This prevalence underscores its role as a cornerstone therapy for persistent musculoskeletal issues in clinical practice.^[30]

Treatment Protocols

Chuna therapy begins with an initial assessment to evaluate the patient's musculoskeletal status and identify any imbalances. This typically involves posture analysis in standing and sitting positions to detect asymmetries, such as spinal alignment and pelvic tilt, along with range-of-motion tests for flexion, extension, lateral bending, and rotation to assess joint mobility and pain provocation. Palpation of spinous and transverse processes is used to identify malpositions or restrictions through tactile feedback on tissue tension and bony landmarks.^[31]^[32] A standard Chuna session lasts 20-40 minutes and occurs 1-3 times per week for 4-8 weeks, depending on the condition's severity. The structure starts with a brief reassessment of symptoms and physical findings, proceeds to targeted manipulative techniques, and concludes with patient education on posture maintenance and self-care strategies to reinforce therapeutic effects.^[32]^[33] Patients are positioned supine, prone, or seated based on the targeted region, with practitioners emphasizing relaxation techniques such as deep breathing to minimize muscle guarding and enhance treatment efficacy. For instance, supine positioning is common for cervical and lumbar manipulations, while prone allows access to thoracic and pelvic areas.^[34]^[35] Follow-up care includes prescribing home exercises, such as gentle stretching or strengthening routines, and recommending lifestyle modifications like ergonomic adjustments to sustain improvements in mobility and reduce recurrence risk. These are tailored to the individual's needs and integrated after the initial treatment course.^[32]

Evidence Base

Key Clinical Studies

A randomized controlled trial published in 2021 evaluated the efficacy of Chuna manual therapy compared to usual care for patients with nonspecific chronic neck pain. Involving 108 participants, the study found that Chuna therapy led to significantly greater reductions in pain intensity, as measured by the Visual Analog Scale (VAS), and improvements in functional disability at 5 weeks post-randomization, with these benefits persisting at the 1-year follow-up.^[7] A 2024 analysis of nationwide Korean National Health Insurance claims data examined the utilization patterns of Chuna manual therapy, confirming its frequent application for musculoskeletal conditions but noting a need for more diverse international applications to address potential regional biases.^[36] A 2025 randomized controlled trial demonstrated the long-term efficacy of Chuna manual therapy for chronic lower back pain, showing sustained pain reduction and functional improvements over 96 weeks compared to conventional nerve blocks.^[4]

Systematic Reviews and Meta-Analyses

A systematic review and meta-analysis published in 2023 evaluated the efficacy of Chuna manual therapy (CMT), also known as Tuina, for chronic nonspecific low back pain, finding low-quality evidence for short-term pain relief based on 15 randomized controlled trials (RCTs), with a standardized mean difference (SMD) of -0.82 (95% CI -1.12 to -0.53) compared to control interventions; however, the review highlighted limited high-quality RCTs due to methodological inconsistencies and small sample sizes.^[37] An umbrella review of systematic reviews published in 2023 summarized evidence for CMT on various musculoskeletal disorders, including knee osteoarthritis. For knee osteoarthritis, one included meta-analysis (6 RCTs, 359 patients) reported non-significant pain reduction (MD -0.38, 95% CI -1.35 to -0.19). Overall, these reviews indicate promising but preliminary evidence for CMT in musculoskeletal conditions, with consistent benefits in pain and function when compared to pharmacological or usual care options, though evidence quality remains low. Despite these findings, significant research gaps persist, including the need for larger-scale international trials to enhance generalizability, as the majority of studies are conducted in Korea and China, potentially introducing bias from funding sources tied to traditional medicine institutions.^[38] In comparison to Western manual therapies, CMT demonstrates similar short-term outcomes to physiotherapy in pain relief and functional gains for conditions like low back pain, but it may offer advantages through better integration with holistic elements such as acupuncture or herbal medicine in comprehensive care protocols.^[38]

Safety and Regulation

Potential Risks and Contraindications

Chuna manual therapy, like other forms of spinal manipulation, is associated with common minor adverse effects, including post-session soreness, headache, and fatigue, which typically resolve within 24-48 hours. These transient reactions occur in approximately 30-50% of patients undergoing spinal manipulative therapies, though reported incidences in large-scale Chuna studies are lower due to underreporting of mild events.^[39]^[14] Serious adverse events are rare. In a retrospective analysis of 289,953 patients receiving over 2.6 million Chuna sessions for musculoskeletal disorders, the overall incidence of adverse events was 1.86 per 100,000 sessions, with mild to moderate events at 1.83 per 100,000 and severe events at 0.04 per 100,000; no cases of vertebral artery dissection or spinal cord injury were reported. However, cervical manipulation in Chuna carries a theoretical risk of vertebral artery dissection, estimated at approximately 1 in 1-8 million manipulations based on data from similar manual therapies.^[14]^[40] Absolute contraindications for Chuna therapy include acute fractures, severe osteoporosis, active infections or inflammatory arthritis, vertebral dislocations, and cerebral aneurysms, as these conditions increase the risk of exacerbation or serious injury. It is also contraindicated in pregnancy, particularly the third trimester, due to potential risks to the fetus from manipulative forces, and in patients with pre-existing vascular conditions such as hypertension or known arterial vulnerabilities.^[29]^[41]^[42] To mitigate risks, practitioners should conduct thorough pre-treatment screening, including patient history and, when indicated, imaging such as X-rays to rule out contraindications like fractures or malformations. Graded, low-force techniques are recommended for at-risk patients, such as the elderly or those with osteoporosis, to minimize potential complications.^[14]

Professional Standards and Training

In Korea, practitioners of Chuna manual therapy must complete a 6-year Doctor of Korean Medicine (KM) program at one of the accredited KM colleges, which integrates Chuna-related coursework such as Chuna manual medicine, oriental rehabilitation medicine, and neuromusculoskeletology into the curriculum.^[6] This training encompasses 120 to 225 hours of class time, including lectures and practical components, with additional clinical rotations during the program's internship and residency phases to build hands-on expertise in applying Chuna techniques.^[43] To supplement the foundational education, the Korean Society of Chuna Manual Medicine (KSCMM) provides specialized annual training courses totaling approximately 126 hours, focusing on advanced Chuna applications for licensed KM doctors.^[6] Certification for Chuna practice is tied to general KM licensing, requiring graduates to pass the national Korean Medicine Licensing Examination administered under the oversight of the Association of Korean Medicine.^[44] Licensed KM doctors (KMDs) are authorized to perform Chuna as part of their scope, with no separate Chuna-specific certification needed, though KSCMM endorses additional qualifications for complex techniques through its training programs.^[6] Practitioners must engage in ongoing continuing medical education (CME), including KSCMM workshops, to maintain licensure and proficiency in evolving Chuna standards, ensuring risks such as procedural errors are minimized through rigorous preparation.^[45] Chuna regulation falls under the Ministry of Health and Welfare (MoHW), which legalized the therapy in 1994 and has since integrated it into national health policies.^[6] In 2012, KSCMM established standardized protocols by classifying Chuna into simple, complex, and special categories, requiring at least 100 hours of targeted training for providers of advanced forms.^[46] National Health Insurance reimbursement, implemented fully in 2019 following a 2017 pilot, mandates adherence to these protocols to ensure quality and safety in clinical delivery.^[46] Internationally, Chuna practice remains limited and is not independently regulated, necessitating adaptation to local healthcare laws where KMDs or equivalently trained professionals integrate it into complementary or integrative medicine settings.^[21] In the United States, for instance, Chuna has been offered as continuing medical education for MDs and DOs since 2011, often within holistic clinics, while in Europe, it appears sporadically in multidisciplinary pain management programs under broader manual therapy guidelines.^[21] MoHW supports global expansion through initiatives targeting markets like North America, promoting standardized Korean training for overseas application.^[47]

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