CHAPTER 20 SHIATSU
Simple yet profound, the experience with shiatsu, whether a single session or an ongoing therapeutic relationship between therapist and client, brings the wisdom of ancient civilizations to our Western model of life, thought, and medicine. Shiatsu, which is reinforced by Western and Eastern clinical research and receives official Japanese government sanction, is regarded by many as a life-changing experience. Shiatsu’s practice as a modality for fully clothed recipients is allowing its growth not only as a therapy in the private sector, but more importantly as an easy-to-implement research tool in numerous clinical settings and hospitals.
HISTORY
The literal meaning of the Japanese word shiatsu (she-AAHT-sue) is “finger pressure” or “thumb pressure.” Over the centuries, Asian medicine, massage therapy, and twentieth-century advancements have combined to yield “modern” shiatsu.
The word massage comes from the Arabic word for stroke. The practice of massage dates back 3000 years to China. A tomb found in modern Egypt, determined to be from 2200 bc, depicts a man receiving a foot massage. In the fourth century bc, Hippocrates, known as the father of modern medicine, wrote that “the physician must be experienced in many things, but most assuredly in rubbing” (Ballegaards et al, 1996). Further support for the use of touch and massage as healing tools is noted in ancient Egyptian, Greek, Persian, Roman, and Asian manuscripts (Yamamoto et al, 1993).
During the Middle Ages, there was decreased visibility of massage as a healing tool in the West, principally because of the position of the church, which viewed the manipulation of the body as the work of the devil. Massage was often depicted as a tool of prostitution, a prejudice that still lingers today among uninformed people. In the thirteenth century the German emperor Frederick II seized a number of newborns and did not allow caretakers to cuddle or talk to the infants. All died before they were able to talk. The historian Salimbene described this “experiment” in 1248 when he wrote, “They could not live without petting” (Colt et al, 1997).
People instinctively recognize the need for human touch and contact. From the rubbing of a painful shoulder to the physical act of intimacy, connection and human touch not only feel good but yield many physical and psychological benefits. These benefits are gaining increased recognition among laypeople and are enjoying a substantial increase in support from scientific studies that document numerous broad-based positive effects (see later section on research). The University of Miami Medical School’s Touch Research Institute (TRI) is gaining widespread acceptance as a pioneer of research supporting the medical benefits of massage therapy. TRI has published numerous studies and review articles, with more in progress (Colt et al, 1997). Evidence presented in these studies supports the clinical use of massage therapy for a wide range of ailments. Massage therapy has been shown to facilitate weight gain in preterm infants, reduce stress hormone levels, alleviate symptoms of depression, reduce pain, positively increase measurable immune system functions, and alter electroencephalogram readings in the direction of heightened awareness. Research studies also suggest benefits for patients with conditions such as Alzheimer disease, arthritis, cancer, depression, fibromyalgia, job stress, and premenstrual syndrome (PMS), while in addition documenting benefits related to maternity and labor (Colt et al, 1997; Touch Research Institute, n.d.).
Shiatsu’s history lies within the antecedents of Asian medicine, as was clearly stated 2000 years ago in The Yellow Emperor’s Classic of Internal Medicine, a text discussed in The Art of Shiatsu (Cowmeadow, 1992). Others suggest that Chinese medical practice was derived from techniques originally developed in India and adapted to China.
Shiatsu has evolved within the genre of touch and massage therapies, as well as within Asian medicine’s juxtaposition of ancient and modern Japanese culture. As a healing art or treatment, shiatsu grew from earlier forms of anma in Japan (anmo or tui na in China) (Lundberg, 1992). An denotes “pressure” and “nonpressure,” and ma means “rubbing” (Yamamoto et al, 1993). This method, which was well known 1000 years ago in China, found its way to Japan and was recognized as the safest and easiest way to treat the human body (Masunaga et al, 1977). In Japan, shiatsu was used and taught by blind practitioners who relied on their hands to diagnose a patient’s condition (Cowmeadow, 1992). Anma was recognized by the medical authorities in Japan in the Nara period (ad 710-784) but subsequently lost its popularity before gaining more widespread use in the Edo era (1603-1868) (Yamamoto et al, 1993), during which doctors were actually required to study anma. During the Edo period, most practitioners were blind and provided treatments in their patients’ homes. An extensive handbook on anma was published in 1793, and anma was considered one component of the Asian healing arts, a reputation it enjoys today. Anma’s “understanding and assessment of human structure and meridian lines” were and are believed to be important distinctions that separate shiatsu therapy from other healing models and massage therapies (Yamamoto et al, 1993). One author states that European physicians and missionaries from the sixteenth century onward introduced Western anatomy and physiology to Japan (Young, 2004), whereas others suggest that Western massage was introduced into Japan in the late 1880s, when the many vocational schools that taught anma were dominated by blind instructors. However, this very limitation stopped the further development of anma and led to the evolution of what we recognize today as shiatsu therapy (Yamamoto et al, 1993). The practitioner Tamai Tempaku is credited with developing shiatsu as a separate therapy in the early 1900s (Young, 2004).
Modern shiatsu, as noted previously, is therefore a product of twentieth-century refinements and evolution that produced the form of therapy used today. Shiatsu began its modern evolution in the 1920s (the Taisho period) when anma practitioners adopted some of the West’s hands-on techniques, including those of chiropractic and occupational therapy (Yamamoto et al, 1993), as well as with the merging of ampuku (abdominal massage), do-in (breathing and self-massage practices), and Buddism. Tamai Tempaku is credited with establishing shiatsu in Japan and worldwide. The Shiatsu Therapists Association was formed in 1925 (Annussek, 2004).
The practice of shiatsu received much attention from studies conducted after World War II, as described in the following quotation from Saito, and these studies also sparked its growth:
After World War II, U.S. General Douglas MacArthur directed the Japanese Health Ministry. There were more than 300 unregulated therapies in Japan at that time. MacArthur ordered all 300 to be researched by scientists at the Universities, to document which ones had scientific proof of merit; and which did not. At the end of eight years, the Universities reported back; and “Shiatsu” was the only one therapeutic practice which received scientific approval. (Saito, 2001).
In 1955 the Japanese parliament adopted a bill on “revised anma,” which gave shiatsu official government endorsement. This endorsement allowed shiatsu to be legally taught in schools throughout Japan (Yamamoto et al, 1993). Shiatsu received further official Japanese government recognition as a therapy in 1964 (Harmon et al, 1999) through the efforts of Tokujiro Namikoshi and his son Toru, who emphasized the application of pressure on neuromuscular points to release pain and tension (Young, 2004). In the early 1970s, shiatsu began spreading to the West and rapidly gained widespread acceptance (Cowmeadow, 1992). Although shiatsu and its distant cousin acupuncture are considered medically sound and are “accepted methods of treatment for over one-quarter of the world’s population,” the United States and many other Western nations consider both techniques experimental (Yamamoto et al, 1993). This is interesting, considering that these “experiments” have been conducted successfully for more than 2500 years (Cowmeadow, 1992). However, several U.S. hospitals now allow the use of acupuncture, and medical and nursing students are beginning to be taught the theory and practice of acupuncture, shiatsu, and macrobiotics. These gains suggest that an environment has been established for rapid, ongoing change in the West. There is a growing acceptance and use of these practices among Western-trained physicians and health care providers.
Shiatsu can be described as a synthesis of Eastern and Western medicine, quickly gaining recognition for its success as an adjunctive healing therapy. “The foundations for modern ideas and techniques in the healing realm come from ancient civilizations. In the West it was Greece and Rome. And in the East it was China, India, and Persia. These foundations are the basis of present scientific methods [of healing]” (Yamamoto et al, 1993). Shiatsu’s foundations, and therefore shiatsu itself, are a part of the growing trend and movement toward complementary and alternative medicine.
PRINCIPLES AND PHILOSOPHY
Many followers of Eastern traditions believe that the natural state of humanity is to be healthy. Yamamoto and McCarty (1993) describe it this way:
With observation we can see that there is a definite and distinct order in nature. Nature’s power guides all things. When we do not follow nature’s order we can become sick. We are often reminded of nature’s order by the presence of sickness. Sickness can be our teacher. From a traditional point of view the specific name of an illness is not so important. Physical ailments such as headache, gallbladder pain; emotional states such as anger, depression, irritability; and mental conditions such as paranoia, lack of concentration, and forgetfulness; are all various states of disequilibrium or disease. Theoretically there is no disease that is incurable, if we are able to change the way we think, eat, and live. Of course this is easier said than done.
They also write, “The simple understanding that humans are equipped to heal themselves and that [they] can also help others, [forms] the underlying foundation of Shiatsu. Shiatsu [simply] acts like a spark or catalyst to the human body [and] the combination of treatment and way of life suggestions form the basis of total care” (Yamamoto et al, 1993).
The major underlying principle of shiatsu, derived from the tenets of Asian medicine, is actually a reflection of scientific thought. Simply stated, “Everything is energy.” When considered in the context of molecular structure, all matter is a manifestation of energy. Shiatsu interacts directly with this energy, and therefore with life itself.
From the perspective of classic Asian medicine, energy moves along 14 distinct pathways in the body; these pathways are called meridians or channels (kieraku in Japanese, jing in Chinese) (Yamamoto et al, 1993). The meridians were discovered by accident when certain acupoints (specific locations along the meridians) were stimulated and beneficial results were observed. For example, asthmalike symptoms caused by certain types of battle wounds were relieved when the corresponding acupoint was touched, and menstrual pain was reduced when a heated rock from a fireplace accidentally brushed against a point on the inner thigh (Schlager et al, 2000). Although many in the West may attempt to deny or discount the existence of the meridian network, modern research conducted by biophysicists in Japan, China, and France has documented its existence. Yamamoto and McCarty (1993) describe some of this research in the following excerpt from Whole Health Shiatsu:
Many studies have been conducted by biophysicists in Japan, China, and France. They postulated that a measurement of acu-point electricity would be a biophysical index that would illustrate the objective existence of the meridian system. They discovered that acu-points have a lower skin resistance. When an electrical current is passed through a classical acu-point, it has a higher electrical conductance, which is a lower resistance, than the surrounding area. They also discovered that when disease or illness is present, pathological changes take place in the body while changes are found in the resistance of relevant meridians and acu-points. Similar internal changes are also reflected by the acu-points. In other words, imbalance in the organs affect the acu-points, imbalance in the acu-points affect the organs. Researchers also found that the external environment, such as temperature, season, and time of day, changed the resistance of acu-points.
In the Lanzhou Medical College in China a test of the acu-points of the Stomach meridian showed significant variations in conductance when the stomach lining was stimulated by cold or hot water, either before or after eating. In Beijing, ear acu-point research learned that low resistance points on the outer rim of the ear were elevated either in the presence of disease or following long-term stimulation of a corresponding internal organ.
In addition to the scientific support developed thus far, support for the benefits of shiatsu comes from the experiences of clients and practitioners alike. Asthmatic clients experience volatility (pain and sensitivity) along the lung meridian. Clients with lower digestive track symptoms such as constipation experience this same sensitivity along the large intestine meridians. Women with PMS symptoms are sensitive on the lower leg along both the bladder and the kidney meridians, which, according to Shiatsu theory and literature, are associated with reproductive energy. When clients experience these connections, which are common in shiatsu, they are quick to convert or more readily accept the principles of Asian medicine and to accept the validity of the meridian network. Not only has research documented scientific evidence to support the theory behind shiatsu, but the body’s own level of pain along related organ meridian lines makes clients’ enlightenment regarding the existence of meridians, based on their own personal experience with shiatsu therapy, difficult to deny.
It is believed that meridians evolved from energy centers in the body called chakras (SHOCK-ras) and that our organ systems subsequently evolved from the meridian network. There are 10 meridians directly related to internal organs, two indirectly related, and two related to systems not recognized by Western medicine.
Along the meridian lines are points called tsubos (SUE-bows), or acupuncture points, of which there are believed to be about 600 (Annussek, 2004). Yamamoto and McCarty (1993) describe tsubos in the following excerpt from Whole Health Shiatsu:
The word Tsubo or acu-point derives from the Oriental characters meaning hole or orifice, and position—the position of the hole. Traditionally, the word hole was combined with other terms such as hollow, passageway, transport, and Ki [KEY, or energy, also described in other cultures as chi, qi, and prana]. This suggests that the holes on the surface of the body were regarded as routes of access to the body’s internal cavities. The acu-points are spots where Ki comes out.
There are three phases in the historical development of the concept of these holes or acu-points. In the earliest phase people would use any body location that was painful or uncomfortable. Because there were no specific locations for the points, they had no names.
In the second phase, after a long period of practice and experience, certain points became identified with specific diseases. The ability of distinct points to affect and be affected by local or distant pain and disease became predictable. . . .
In the final phase, many previously localized points, each with a singular function, became integrated into a larger system that related and grouped diverse points systematically according to similar functions. This integration is called the meridian or channel system.
Although the analogy is not completely accurate, shiatsu is often called “acupuncture without needles.” To alter a client’s internal energy system or pattern, an acupuncturist inserts needles in the same tsubos that are used by a shiatsu practitioner. The most significant difference between the two disciplines is that whereas acupuncture is invasive and is performed by extensively trained doctors, shiatsu is noninvasive and can be practiced by either a professional therapist or a layperson. Shiatsu is also a whole-body technique versus one that is limited to the insertion of needles at specific tsubos. Acupuncture is generally considered more symptom oriented, in that people are much less likely to go to an acupuncturist without a specific complaint, whereas clients often equate shiatsu with health maintenance and go for treatments in the absence of particular “problems.” Although some consider shiatsu a cousin to acupuncture, others suggest a “distant cousin” relationship. The distinctions between the two disciplines are worth noting (Table 20-1). It is also important to note that simple shiatsu can be practiced with little or no understanding of the underlying principles. The practitioner does not have to agree with the principles or understand them to provide shiatsu; however, the techniques are part of a more complicated healing system that, when adhered to and studied, provides more effective results.
TABLE 20-1 Distinctions Between Shiatsu and Acupuncture
| Category | Shiatsu | Acupuncture |
|---|---|---|
| Movement | Free flowing | Systematic |
| Focus | Intuitive | Adheres to laws |
| Theoretical inclination | Daoist | Confucian |
| Quality | Feminine | Masculine |
| Tools | Practitioner’s body | Needles |
| Treatment goal | Balance by becoming whole | Balance by alleviating symptoms |
| Patient interacts with treater | Yes | No |
| Encourages independence | Yes, immediately | Yes, after treatment series |
| Physically strengthens | ||
| Receiver | Yes | Sometimes |
| Treater | Yes | No |
Although not all acupuncturists agree with all these distinctions, they form a basis for comparison. All shiatsu practitioners and acupuncturists practice according to their own interpretations and belief systems, so Table 20-1 should not be interpreted as a rigid, fixed framework.
A simple and accurate analogy for understanding the meridian pathways and tsubos in relation to the body’s internal organ systems is that tsubos are similar to a system of volcanoes on the earth’s surface. We know that a volcano’s real energy is not at the surface, but rather is found deep inside the earth. A volcano is a superficial manifestation of the underlying energy. Similarly, a tsubo can be thought of as a manifestation of the underlying energy of the organ system. This does not imply that the therapist should ignore the area of pain a shiatsu client may describe. However, a classically trained shiatsu practitioner looks past sore shoulders, ligaments, and tendons (unless the cause of the pain is trauma to these structures) and focuses on the related organ system through the meridian network. Philosophically, shiatsu practitioners would have a tendency to relate health to the condition of the related “vital” organs (i.e., those associated with the meridian system). Although shiatsu is noninvasive and appears to deal with external or surface pain, according to shiatsu theory and the experience of those who practice and receive the art, it stimulates, sedates, and balances energy inside the body as a way to address the root causes of surface and bodily discomfort.
The principles of Asian medicine evident in shiatsu theory and practice state that two types of energy exist in the universe. These two types of energy, called yin and yang, exist side by side and are considered both complementary and opposing. Unlike Western medicine, which uses more dualistic terms such as “good and bad,” Eastern or Asian medicine looks at health more as a manifestation of balance between yin and yang and considers that an imbalance may allow infection or disease to become manifest. An effective way to comprehend this internally is to apply the principles of yin and yang to diet through macrobiotics. When a person’s health and metabolism adjust to what Eastern medicine and macrobiotic practitioners consider universal guidelines, natural harmony occurs “from the inside out.” Varying states of yin and yang are experienced by the body but are not necessarily comprehended by the mind. This experience can be made manifest by dedication (not necessarily lifelong) to the practice of using food according to the various energetic principles long understood by the Chinese, Japanese, and followers of macrobiotic theory.
In defining yin and yang, one should bear in mind that a continuum exists between the extremes of each. In shiatsu, major organs are paired together under one of the five major elements. Each pair includes both a yang and a yin organ. One organ is more compact and tighter (yang), whereas the other is more open and vessel-like (yin). The five elements—wood (tree), fire, earth (soil), metal, and water—proceed in a clockwise manner within the five-element wheel used in Asian medicine (Table 20-2).
TABLE 20-2 Five Elements of Asian Medicine
| Element | Yin | Yang |
|---|---|---|
| Wood (tree) | Gallbladder | Liver |
| Fire | Small intestine | Heart |
| Earth (soil) | Stomach | Spleen |
| Metal | Large intestine | Lungs |
| Water | Bladder | Kidney |
According to shiatsu principles, an organ is fed by its opposite energy. For the shiatsu practitioner, pressing and rubbing movements proceed in the direction that energy travels along each respective meridian. Shiatsu texts often use the term structure to describe an organ, whereas acupuncture texts may describe the same organ in terms of the energy that feeds it through the meridian. A yang organ is fed by yin energy. A shiatsu practitioner generally describes the compact kidney as yang because of its structure (compared with its paired, more hollow and open yin organ, the bladder). A classically trained acupuncturist generally describes the kidney as yin because it is fed by yin energy that flows up the body on the kidney meridian. Such differences between the two disciplines in terms of descriptive language can be confusing, although little difference in application of goals, practice, or theory really exists.
Another major principle applied to the practice of shiatsu involves the concepts of kyo (KEY-o) and jitsu (JIT-sue). Kyo is considered empty or vacant, whereas jitsu is considered full, excessive, or overflowing. A jitsu condition along the gallbladder meridian may be a manifestation of a gallbladder imbalance, resulting perhaps from recent consumption of a large pizza and two dishes of ice cream. A kyo or empty condition along the lung meridian (and within the lung itself) may exist in an individual who does not exercise and rarely expands his or her chest cavity or heart. Understanding and finding these energy manifestations is critical to diagnosis in shiatsu practice and is an ongoing, lifelong learning experience for the serious shiatsu practitioner. Although it is generally easy to find jitsu, or excess, it may be much more difficult to find emptiness or vacancy (kyo) within the meridian network. One of the keys to performing highly successful or refined shiatsu is the ability to find specific kyo within the body or the organ’s meridian network and then to manipulate it effectively.
Shiatsu practitioners may follow the practice of macrobiotics, a set of universal dietary and spiritual guidelines originally brought to the attention of the modern world by George Ohsawa. As David Sergel (1989) writes:
The ultimate goal of macrobiotic practice is the attainment of absolute freedom. The compass to reach this goal is an intimate understanding of the forces of Yin and Yang; a comprehension of an order common to all aspects of the infinite universe. The foundation of this freedom lies in our daily diet. . . . Since the same cultural soil gave form to both shiatsu and macrobiotics, we might expect to see strong possibilities of a harmonious integration between the two. In fact as we delve deeper, we see evidence that shiatsu arose from a macrobiotic mind and is thus according to this view, from its foundation, a macrobiotic practice.
It would be more accurate to state that shiatsu developed out of a society whose dietary pattern reflected the modern perspective and application of macrobiotics. Shiatsu evolved as a result of day-to-day living and thinking in terms of yin and yang, as did almost everything else in these earlier Asian societies, such as feng shui, art, and even politics.
Macrobiotics is a philosophical practice that incorporates the universal guidelines of yin and yang into daily life. With diet as its cornerstone, macrobiotic theory posits that these guidelines can be applied to all people, subject to their condition, constitution, lifestyle, environment, and, most notably, the latitude at which they live. Food choices are governed by season. Macrobiotics is not a diet; it is a philosophy that advocates cooked whole grains as the predominant staple food, to be supplemented by other yang foods such as root vegetables and occasional fish, and yin foods such as leafy greens and occasional seasonal fruit. Extreme yin foods include white sugar, honey, caffeine, most drugs, and alcohol. Examples of extreme yang foods are animal proteins such as red meat, chicken, tuna, and shellfish. Dietary choices are adjusted according to an individual’s constitution, environment, work, lifestyle, the season, and the place where the person lives (especially global latitude). When used indiscriminately, extreme yin and yang foods are more difficult to balance and affect energy, as manifested along the meridian network. For example, eating tropical fruit in Pennsylvania in January when the temperature is 10° F on a daily basis is seen as “eating out of balance.”
Macrobiotic philosophy therefore relies on nature, from which it finds ample support. Although we are able to ship foods thousands of miles from where they are grown, nature may not have intended us to consume such foods regularly in an environment that does not support their growth or cultivation. When applied in this way, the philosophies of shiatsu and macrobiotics touch on and address what is viewed as human arrogance by suggesting that when clear-cut guidelines presented by nature are ignored, health consequences can result. Nature demonstrates that the foods that grow and can grow in the latitudes where we live are the foods that support our health most fully. This philosophy also states that consumption of root vegetables (i.e., those that produce more heat in the body) is important in the winter, whereas leafy greens and occasional fruit (foods that cool the body) are needed in summer. Interestingly, we intuitively follow this practice to some extent. People who live in locations where the climate varies from season to season tend to eat more salads and fruit in the summer and more cooked and salty foods in the winter. However, macrobiotic philosophy examines this practice more closely and looks at these specific distinctions of yin and yang as being crucial to creating balance in the body, as well as the cornerstone of addressing such imbalance issues as cancer.
Shiatsu incorporates macrobiotic philosophy into its theory and philosophy regarding the movement of energy along the meridian pathways. A simple explanation of shiatsu philosophy states that the meridians can be seen as circulatory or “plumbing” channels. As long as energy moves freely (i.e., is not too weak or too strong and is not stagnant), health is maintained. If there is a blockage along the channel, the resulting disturbance can lead to minor aches and pains or a major health imbalance. It is possible to observe imbalances of energy flow in specific meridian lines and acupuncture points or tsubos. By applying pressure to a blocked meridian line or tsubo, an overactive or underactive organ system can be directly sedated or stimulated.
Shiatsu massage is not viewed by its practitioners as a panacea. Shiatsu philosophy is very clear in reinforcing the need for dietary and lifestyle guidance and changes to complement and support a shiatsu session (or series of sessions). The choices made by the recipients of treatment are their choices. Many recipients are content to stay at the level at which shiatsu is simply used for decreasing pain and for producing a “calmed sense of revitalization.” However, others who are open to the underpinnings of shiatsu philosophy may be willing to take additional steps suggested by a classically trained shiatsu practitioner regarding diet and behavior modification.
With sufficient training, the shiatsu practitioner learns to view the energy manifesting at major tsubos on the surface of the skin as indicative of the underlying condition of the organ to which the tsubo is related and connected. For example, a client may think shoulder pain is caused by how he or she sleeps or sits at a desk. A classically trained shiatsu practitioner does not ignore these factors but looks past them to the underlying organ system and the foods that affect that organ system. The practitioner attempts to change the energy pattern not just by working at the proximate points of client complaint and distress, but also by working along the entire meridian (or set of meridians). Dietary suggestions may be offered. If the concept that “everything is energy” can be accepted, it may be possible to accept not only that the specific energies of foods can have an effect on organ systems and ultimately on health, but that this effect can produce effects formerly believed to be unrelated to the internal metabolic state as well as the related surface pain or discomfort.
Shiatsu training touches on the principles of Asian medicine because the nature of the organ systems and their related energy should be understood for effective treatment to occur, although, as mentioned previously, this knowledge is not an absolute requirement to practice shiatsu. How far this education goes, particularly in relation to the underlying effects of specific foods and their yin and yang effects on various organs and the body as a whole, depends on the quality of the school, the knowledge of the instructor, and the interest of the student.
The Japanese Ministry of Health and Welfare demonstrated its support of shiatsu’s efficacy when it stated, “Shiatsu therapy is a form of manipulation administered by the thumbs, fingers, and palms, without the use of any instrument, mechanical or otherwise, to apply pressure to the human skin, correct internal malfunctioning, promote and maintain health, and treat specific diseases” (Masunaga et al, 1977).
DIAGNOSIS
The art of Asian diagnosis is a lifelong learning process in the practice of shiatsu. Subtle yet specific, Asian diagnosis is an ongoing and evolving pursuit that a practitioner is continually mastering and learning again from scratch. Modern diagnostic techniques are a relatively recent development in the history of medicine. Powerful, precise, and accurate to a large extent, the contribution of these techniques to the improvement of the human condition cannot be denied. However, diagnostic procedures in Western medicine use a disease-oriented model and tend to focus on parts (e.g., cells, tissues, organs) rather than on the whole organism. For example, Louis Pasteur (1822-1895) believed that microbes were the primary cause of disease. Although this theory has proved correct and is applicable to a large number of cases, germs are not the sole cause of disease. Although Asian diagnosis has been practiced for thousands of years, Western medicine has largely ignored its value. However, this is changing with the increased integration of Eastern and Western diagnostic methods.
In Asian medicine and shiatsu, there are two underlying levels of diagnosing humans: constitutional and conditional. Simply stated, an individual’s constitution is what he or she was born with. Along with inherited traits, the quality of life, energy, and food intake experienced by the mother while a person is in utero are all considered factors that make up a person’s constitution. A person’s condition is the sum of his or her experience, which includes diet. In classic shiatsu diagnosis, both constitution and condition are assessed according to the methods listed next.
The following four methods of observing “phenomena” are used in Asian medicine (Masunaga et al, 1977):
Each day, whether we realize it or not, we use the first three methods of observation extensively in our interactions with others and the environment. We all have experienced a funny feeling in our stomachs when we enter a room that has recently been the site of some tension related to human interaction. We choose partners based on many factors, including some innate sense of energy recognition we find compatible with our own. Although we are unaware that we use aspects of Asian diagnosis in our everyday lives, we nonetheless make assessments and judgments based on these principles. Without these “diagnostic skills,” we would not survive. Shiatsu uses the first three methods liberally, while also relying heavily on the fourth.
In a traditional shiatsu session, diagnosis begins with the first contact between client and practitioner, whether in person or on the telephone. The client’s tone of voice, speed of delivery, and choice of words give clues to the trained ear regarding the condition and constitution of the shiatsu client.
On meeting a client for the first time, constitutional and conditional assessments are made. How did the client enter the room? Did she walk upright? Did he smile or frown? Was her handshake strong or weak? Was his hand wet, damp, dry, hot, or cold? The client is often unaware that a classically trained shiatsu therapist begins work with the first contact and continues the assessment as a face-to-face meeting begins. Visual diagnosis and verbal questioning continue as the first meeting between client and therapist proceeds.
To arrive at a constitutional diagnosis, the therapist looks at various physical attributes. No single factor observed gives a total picture, but a macro assessment takes the various micro elements into account. Size of ears, shape and size of head, distance between the eyes, size of mouth, and size of hands are fundamental observations made in constitutional diagnosis before any physical treatment begins.
Factors considered in conditional assessment are slightly different but work in tandem with the overall assessment. The stated reason for the visit is a factor. In addition, tone and volume of the client’s voice, pupil size, eye color, color and condition of the tongue, condition of the nails, and response to palpation along specific points on the hands and arms may be used. Pulse diagnosis, the act of reading distinctly differently levels of heartbeats near the wrists on both hands, may be used, depending on the practitioner’s level of training. Generally, pulse diagnosis is more the tool of an acupuncturist, but it has been and can be used by a properly trained shiatsu provider.
The four diagnostic methods (observation, sound, questioning, and touch) are used to develop a singular yin-yang analysis (Ballegaards et al, 1996). At its basic level, Asian diagnosis sets out to determine whether a person is vibrationally, or energetically, more yin or more yang, because these two opposing but complementary states of energy affect each of us.
The diagnostic assessment process continues along specific lines, as follows:
Yang diagnosis: Excess body heat and desire for coolness; great thirst and desire for fluids; constipation and hard stools; scanty, hot, dark urine
Yin diagnosis: Cold feeling and desire for warmth; lack of thirst and preference for hot drinks; loose stools; profuse, clear urine; flat taste in mouth; poor appetite. (Yamamoto et al, 1993)
The key is not being able to see the yin and yang extremes described in the excerpt. The key lies in determining not only what tendency within an individual may be contributing to his or her state, but also the particular organ or organs that have a jitsu or kyo condition, and then working those organs’ meridians to change that state. This is the point at which the movement from external or initial diagnosis of constitution and condition ends and treatment begins.
At this point, the practitioner’s hands become the primary diagnostic tools. Although diagnosis is an ongoing process during treatment, traditional shiatsu first assesses by palpation of the major organs located in the client’s hara, or abdomen. Alternatively, some styles of shiatsu begin a treatment session with touch diagnosis on the upper back, an area that also yields a vast amount of information regarding a person’s condition. Assessment and diagnosis include observations through palpation that describe the following physical properties: tightness or looseness, fullness or emptiness, hot or cold, dry or wet, resistant or open, and stiff or flexible.
Diagnosis in a shiatsu session does not cease after an initial assessment. Diagnosis is an ongoing process of observation, listening, feeling, and changing focus based on continuously revealed information. The ability to make an accurate diagnosis quickly can be extremely helpful to a practitioner and client in their mutual attempt to create energetic change for the receiving partner. However, shiatsu can be effective in the hands of a relatively unskilled diagnostician. By following the simple concept of paying attention to what is going on underneath one’s hands, a layperson with relatively little training can provide an effective, relaxing, and enjoyable shiatsu treatment for family and friends in a nonprofessional setting.
PRACTICES, TECHNIQUES, AND TREATMENT
Unlike some disciplines, shiatsu is easy to learn. It is not possible for a layperson to practice chiropractic, acupuncture, or osteopathy, because medical professionals need not only training but also time and continuing education to master techniques and improve skills. Shiatsu also requires a disciplined approach, constant practice, and continuing study to develop in-depth understanding. However, the basic practice remains simple, effective, and safe. Shiatsu techniques can be learned and safely applied by anyone and typically result in positive effects for both the recipient and the provider. It can be performed anywhere, takes place with the recipient fully clothed, and requires no special tools, machines, or oils.
Sergel (1989) states, “While ki may indeed emanate from the giver’s fingertips it may not be in this way or only in this way that shiatsu works. Masunaga’s approach is to emphasize another side, that the healing ki of shiatsu lies within the quality or spirit of the touch in itself, as compared with the idea of some invisible current that emanates from the touch.” More than 150 years ago Shinsai Ota, in a book on ampuku (hara, or abdominal) shiatsu, emphasized that “honest, sincere, and simple Shiatsu is much better than merely technique-oriented professional Shiatsu” (Masunaga et al, 1977). Indeed, shiatsu training often emphasizes that the most important element is to be in touch with what is going on under one’s hands. Experts agree, indicating that when a practitioner applies pressure and stimulation, he or she should then react and follow up based on an intuitive sense of and reaction to internal changes within the recipient (Yamamoto et al, 1993). A traditionally trained shiatsu practitioner, knowledgeable in the food-energy fundamentals of yin and yang and applying those principles in his or her life, is arguably better suited to respond intuitively to the client. It is believed that intuition is enhanced by being in harmony with nature, a condition achieved by following the guidelines of living within nature’s principles—earth’s rhythms of yin and yang. Harmony in the body is achieved by being in harmony with the universe. Eating large amounts of animal protein and simple carbohydrates, which in their cultivation and processing exploit and pollute the earth, does not yield a calm and focused mind that can easily tap into human intuition. If a person is not in harmony with the natural order, the theory states, he or she is less likely to be able to tap into his or her intuition and tune in to another person’s needs and internal energies (Sergel, 1989). Experienced shiatsu practitioners would typically agree.
Although a successful shiatsu session may be based more on intuition than technical understanding, it still is necessary to outline the techniques and preparation needed for a successful shiatsu treatment. Shiatsu recipients are fully clothed. Although shiatsu techniques can be adapted to other massage styles and may be performed on bare skin, traditional shiatsu is applied to a fully clothed person. Clients should be dressed in loose-fitting cotton fiber clothing. Blends containing polyester or other synthetics are thought to block or interrupt the natural transmission of energy between the caregiver and the recipient. Static electricity builds up around synthetic fibers. Because, from an Asian perspective, everything is energy, unnatural fibers, which may produce unnatural energies, should not be worn during a shiatsu session.
Because shiatsu requires no special tools or environment, it can be performed anywhere at any time. However, traditional shiatsu is generally performed on a cotton floor futon or shiatsu mat. Shiatsu techniques may be adapted to a table, but this is considered a deviation from the classic perspective. Although shiatsu can take place at any time of day, because the energetic effects of shiatsu differ dramatically in many ways from those of other methods, practitioners may encourage new clients to schedule a session early in the day, preferably before noon. Because shiatsu can yield a “calmed sense of revitalization,” the combination of being relaxed and energized is an experience that should be savored throughout the day. Americans often equate “calm and relaxed” with an inactive state. Although shiatsu yields different results for different people, one of the most unique effects experienced by most clients is indeed this calmed sense of revitalization. When treated by a competent practitioner, a new shiatsu client may report that “I never felt this way before.”
One reason for the difference in the energetic effects of shiatsu as opposed to those of other techniques (often called regular massage by the general public) is easy to explain. In many forms of therapeutic massage a technique described as effleurage or stroking (sweeping the skin with the hands) is used. The many benefits of this type of movement on the skin include stimulation of blood flow and the movement of lymph. Although this technique is beneficial, one of its effects is often a feeling of lethargy as cellular waste is moved through the lymphatic system. Because the effects of shiatsu are realized more on the underlying blockage of energy related to the body’s organ systems than on the lymphatic system, a shiatsu session can yield a feeling of increased short-term and long-term energy. This is why chair massage using shiatsu techniques is so appropriate and considered by many superior to other techniques in the corporate setting. Employees do not experience the short-term negative energetic effects (lethargy) of effleurage, but rather the energetic boost, the calmed sense of revitalization, often associated with effective shiatsu technique. Masunaga and Ohashi (1977) described this difference in the following way:
Anma and European massage directly stimulate blood circulation, emphasizing the release of stagnated blood in the skin and muscles and tension and stiffness resulting from circulatory congestion. On the other hand, Shiatsu emphasizes correction and maintenance of bone structure, joints, tendons, muscles, and meridian lines whose malfunctioning distort the body’s energy and autonomic nervous system causing disease.
Shiatsu, like other methods, is best received with an empty stomach. This may not always be possible, and recent food consumption is no reason not to receive shiatsu. However, practitioners and recipients should bear in mind that when the body’s energies are focused inward toward digestion, a shiatsu session, with its attempt to change the body’s energies, is somewhat compromised and therefore will be less effective.
In some ways the beginning of a shiatsu session is similar to that for other massage styles. The room used should be simple, clean, and quiet. A thorough history of the client and his or her concerns should be taken. Questions may relate to sleep patterns, lifestyle, eating habits, and work history. A high level of trust should be established quickly. Often a client is seated in a chair or on a floor mat as the shiatsu practitioner observes and asks questions regarding the client’s expectations and level of understanding. Diagnostic techniques to determine the client’s constitution and condition are undertaken. The hands, eyes, tongue, and coloration along the upper and lower limbs may be examined. Several deep breaths to begin the process may be suggested. A well-trained shiatsu practitioner obtains a complete history to uncover any risk factors affecting the appropriateness of shiatsu treatment. Clinical experience and training, coupled with good references regarding a therapist’s skills and practice, should be the determining factors in selecting a shiatsu practitioner.
A shiatsu session usually begins in one of two ways. In classic shiatsu, the practitioner may use hara, or abdominal massage, to determine which organ or organ system meridians may require treatment. Because this type of probing may not be appropriate or well received by many new shiatsu clients, some practitioners start with the client seated in a chair or on a floor mat and make an initial assessment of the client’s energies from the upper back and shoulder region. This gives the practitioner immediate feedback on the client’s condition and also helps the client relax. Most people are aware of tension in their upper back, shoulder, and neck and respond rather quickly to the process of relaxation so necessary for successful shiatsu.
These early assessments of client condition, coupled with a practitioner’s best understanding and synthesis of the client’s overall constitution, dictate the direction in which the therapist moves. Classic shiatsu texts state that “kyo and jitsu must first be found in the meridian lines by touching or kneading” to allow the direction of the shiatsu to be most effective (Masunaga et al, 1977). However, even when kyo or jitsu is not accurately determined at the outset, effective treatment may still be provided; these conditions can be addressed during the session without any specific perception or awareness of these qualities.
Whether treatment begins in a chair or on a floor mat, most of the session takes place with the client lying down. Applying various techniques along the meridian network, the practitioner attempts to create a better energy balance for the shiatsu recipient. Techniques used include rocking, tapotement (pounding), rubbing, and stretching. A shiatsu practitioner employs his or her entire body to apply pressure. Feet, elbows, knees, fingers, and palms are used as appropriate. A client may be face down or face up or may lie on the side, as directed or moved by the practitioner.
Although certain techniques such as rubbing and kneading may be used at this point and throughout a shiatsu session, the application of more stationary pressure by the palms, thumbs, forearms, and elbows usually begins early in a session. The muscles at the base of the occiput may be kneaded with the fingers and thumbs. Often the head is rotated with one hand while a stationary base of support at the neck is maintained with the other hand. Although shiatsu providers generally use similar methods, every practitioner is different.
When the techniques applied to the upper back, shoulders, and neck are completed, the client generally reclines to the floor mat in a position the therapist deems most beneficial. This may be the prone, supine, or side position. Certain individuals may use the side position exclusively because of size, pregnancy, or specific issues.
If the client is placed in a prone position, the therapist may use his or her feet to rock the client’s hips or to apply graduated pressure to the legs and feet. This “barefoot shiatsu” technique is used extensively by Shizuko Yamamoto and is a very powerful adjunct to the use of the hands, knees, elbows, and forearms. The stretching of the arms and legs and their rotation at the shoulders and hips, respectively, is not uncommon.
Depending on their relative sizes, the practitioner may also walk on the client. Caution is clearly in order when using this rarely practiced technique, but it is sometimes appropriate and beneficial.
Shiatsu sessions typically take place with the provider on his or her knees next to the client. Pressure is applied along distinct meridian lines with the palms and thumbs. Knees, elbows, and forearms may also be used along these specific channels. To access the energy of the various organs through their respective meridians, the client’s position changes to side or supine as the session proceeds.
Generally, conversation is minimized or absent during a shiatsu treatment. Music may be played based on the joint needs and desires of giver and receiver. Blood pressure and breathing rates generally decrease during a session. A shiatsu recipient may feel some cold sensations as he or she begins to relax, a natural reaction of the body’s autonomic nervous system. Shiatsu can be performed through a cotton blanket, which most practitioners have available. A shiatsu session can be of any length, although a 60-minute duration is common. Sessions often end where they began, at the base of the client’s neck or head with gentle kneading or massaging of neck or facial muscles. Shiatsu recipients are generally asked to remain quiet and still for several minutes after a session.
Most people can receive shiatsu. People with sprains and sports injuries who are seeking direct treatment of specific areas of trauma are best referred to massage therapists specifically trained to address these issues. However, gentle and focused shiatsu for these types of injuries can be applied to areas not directly related to the affected area to produce positive results by removing pressure and tension that the body may have created by compensating for the injury. Shiatsu can be used during pregnancy if provided by a practitioner trained in the specific meridians and tsubos that should be avoided during a session. Shiatsu is effective during pregnancy as long as common sense and the specific training and experience of the therapist are taken into account. Both supine and side positions are typically used, as appropriate and comfortable during pregnancy.
Because stationary and perhaps deeper application of pressure is a major part of shiatsu technique, caution should be exercised when treating people who bruise easily, have low platelet counts, or have leukemia, lymphoma, or extensive skin or other cancers. Clients who have an acute or chronic cystic condition must clearly communicate their complete history to reduce any potential risk. Although burn victims have benefited from massage therapy, the application of shiatsu at or near a burn site is not appropriate. In theory or in practice, however, shiatsu should not be considered a painful massage therapy; quite the opposite is the norm.
The previous description of a shiatsu session should be considered generic. There are many variations to the basic techniques, and numerous schools that teach specific shiatsu practices offer a more distinct focus to the underlying themes presented. For a more thorough description and expansion on the practice of Shiatsu, readers are directed to Shiatsu: Theory and Practice (Beresford-Cooke, 2001).
The American Organization of Body Therapies of Asia (AOBTA) notes 12 specific areas of Asian technique. Six major schools of Asian practice often described by shiatsu practitioners are discussed in the following sections, as noted on the AOBTA website.
Acupressure
Acupressure is a system of balancing the body’s energy by applying pressure to specific acupoints to release tension and increase circulation. The many hands-on methods of stimulating the acupressure points can strengthen weaknesses, relieve common ailments, prevent health disorders, and restore the body’s vital life force.
Five-Element Shiatsu
The primary emphasis of five-element shiatsu is to identify a pattern of disharmony through use of the four examinations and to harmonize that pattern with an appropriate treatment plan. Hands-on techniques and preferences for assessment vary with the practitioner, depending on individual background and training. The radial pulse usually provides the most critical and detailed information. Palpation of the back and/or abdomen and a detailed verbal history serve to confirm the assessment. The client’s lifestyle and emotional and psychological factors are all considered important. Although this approach uses the paradigm of the five elements to tonify, sedate, or control patterns of disharmony, practitioners of this style also consider hot or cold and internal or external symptoms and signs.
Japanese Shiatsu
Shiatsu literally means finger (shi) pressure (atsu), and although shiatsu is primarily pressure, usually applied with the thumbs along the meridian lines, extensive soft tissue manipulation and both active and passive exercise and stretching may be part of the treatments. Extensive use of cutaneovisceral reflexes in the abdomen and on the back is also characteristic of shiatsu. The emphasis of shiatsu is the treatment of the whole meridian; however, effective points are also used. The therapist assesses the condition of the patient’s body as treatment progresses. Therapy and diagnosis are one.
Macrobiotic Shiatsu
Founded by Shizuko Yamamoto and based on George Ohsawa’s philosophy that each individual is an integral part of nature, macrobiotic shiatsu supports a natural lifestyle and heightened instincts for improving health. Assessments are through visual, verbal, and touch techniques (including pulses) and the five transformations.
Treatment involves noninvasive touch and pressure using hand and barefoot techniques and stretches to facilitate the flow of qi and to strengthen the body-mind. Dietary guidance, medicinal plant foods, breathing techniques, and home remedies are emphasized. Corrective exercises, postural rebalancing, palm healing, self-shiatsu, and qigong are included in macrobiotic shiatsu.
Shiatsu Anma Therapy
Shiatsu anma therapy uses a unique blending of two of the most popular Asian bodywork forms practiced in Japan. Dr. Kaneko introduced traditional anma massage therapy based on the energetic system of traditional Chinese medicine in long form and contemporary pressure therapy, which is based on the neuromusculoskeletal system, in short form. Ampuku, abdominal massage therapy, is another foundation of anma massage therapy in Kaneko’s school.
Zen Shiatsu
Zen shiatsu is characterized by the theory of kyo-jitsu, its physical and psychological manifestations, and its application to abdominal diagnosis. Zen shiatsu theory is based on an extended meridian system that includes as well as expands the location of the traditional acupuncture meridians. The focus of a Zen shiatsu session is on the use of meridian lines rather than on specific points. In addition, Zen shiatsu does not adhere to a fixed sequence or set of methods that are applied to all. It uses appropriate methods for the unique pattern of each individual. Zen shiatsu was developed by Shizuto Masunaga.
The extended meridian network described and taught by Masunaga is a highly regarded part of shiatsu education. It is taught in quality schools as an integral part of shiatsu theory, diagnosis, and style. A practitioner often learns the extended meridian network toward the end of shiatsu education as an extension to the classic meridian network, in the same manner that Master Masunaga explored this expansion in shiatsu thinking, theory, and practice (AOBTA, n.d.).
TRAINING AND CERTIFICATION
There are currently no federal regulatory standards in the United States for shiatsu practitioners or any massage therapists. As of December 2008, Massage Magazine indicated that 40 states, plus the District of Columbia and four Canadian provinces, will soon have regulations governing massage therapy, and the American Bodywork and Massage Professionals states that there are over 278,000 credentialed practitioners.
Numerous schools of massage offer certificate programs in shiatsu or more broad-based programs that include shiatsu massage. These programs may be weekend seminars of 1 or 2 days or may provide 600 or more hours of training particular to shiatsu. Schools may offer 350 to 500 hours of training in classic shiatsu with an additional 150 hours in anatomy and physiology. There appears to be a growing trend toward internships in all schools of massage.
The American Organization for Bodywork Therapies of Asia (AOBTA; formerly the American Asian Body Therapy Association) is the largest and most widespread organization specific to the practice of shiatsu. Applicants who wish to earn the title of Certified Practitioner must complete a 500-hour program, preferably at a school or institution recognized by the AOBTA.
The American Massage Therapy Association (AMTA) is a general association of massage practitioners; it does not actively focus on shiatsu therapy. This association meets regularly with the AOBTA as a federated massage-supporting organization. The AMTA’s mission is to develop and advance the art, science, and practice of massage therapy in a caring, professional, and ethical manner to promote the health and welfare of humanity.
The American Bodywork and Massage Professionals (ABMP) is another highly respected association of massage professionals. Unlike the AOBTA and the AMTA, the ABMP is a for-profit organization.
The National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) is a nationally recognized credentialing body formed to set high standards for those who practice therapeutic massage and bodywork. It accomplishes this through a nationally recognized certification program that evaluates the competency of its practitioners. Since 1992, more than 40,000 massage therapists and bodyworkers have received their certification. The NCBTMB examination is now legally recognized in more than 20 states and in many municipalities. The NCBTMB represents a diverse group of massage therapists, not just shiatsu practitioners. A minimum of 500 hours of formal massage education and successful completion of a written examination are the basic requirements for certification. Practitioners must be recertified every 4 years.
A person considering the use of any massage therapy as an adjunct to health maintenance should carefully select the provider of that therapy. In addition to obtaining personal references, it is important to evaluate the practitioner’s training, experience, professional affiliations, and certification. Due to the diversity of massage practices available, a seeker of shiatsu therapy should not evaluate a potential therapist based on certification standards applicable to those who practice nonshiatsu techniques.
RESEARCH
The results of a number of randomized controlled trials of shiatsu therapy have recently been published. The following sections provide a brief listing of these shiatsu studies, grouped by category.
Cancer and Sleep Disturbances
A study was recently completed at the Joan Karnell Cancer Center at Pennsylvania Hospital to evaluate the effectiveness of shiatsu therapy for treating sleep disturbances in cancer patients. Results are forthcoming. Preliminary data suggest that Shiatsu therapy effectively increased both the quality and the hours of sleep in patients with cancer.
Cardiovascular System
A blind randomized controlled trial at a university-affiliated hospital documented a decrease in systolic, diastolic, and mean arterial pressure, as well as heart rate and skin blood flow, when acupoints were stimulated by pressure. Researchers concluded that acupressure can significantly and positively influence the cardiovascular system (AOBTA, n.d.).
A single-blind pretest-posttest crossover study in which patients were taught how to self-administer acupressure concluded that real acupressure was more effective than sham acupressure in reducing dyspnea (Felhendler et al, 1999).
Sixty-nine patients with severe angina pectoris were treated with acupuncture, shiatsu, and lifestyle adjustments. Invasive treatment was postponed in 61% of patients because of clinical improvement, and the annual number of in-hospital days was reduced 90%, which was calculated to be an annual savings of $12,000 for each patient in the study. The researchers concluded that this combined treatment may be highly effective for patients with advanced angina (Ballegaards et al, 1996).
Maternity
In a Boston study, postterm women who used shiatsu were more likely to undergo labor spontaneously than those who did not. The shiatsu group had a significantly lower rate of inductions and slightly fewer cesarean births and instrumental deliveries (Yates, 2004).
Nausea with Breast Cancer Chemotherapy
Finger pressure applied bilaterally to two “major” acupressure points during the first 10 days of a chemotherapy cycle reduced the intensity and experience of nausea among women undergoing therapy (Maa et al, 1997).
Nausea and Vomiting
The use of acupressure at the P6 acupoint was shown to reduce the incidence of nausea and vomiting within 24 hours of anesthesia from 42% to 19% compared with placebo (Dibble et al, 2000).
The use of acupressure at the P6 point was shown to reduce the incidence of nausea and vomiting after cesarean birth compared with placebo (Harmon et al, 1999, 2000).
Placement of acupressure bands at the P6 points on patients receiving general anesthesia for ambulatory surgery led to reduced nausea (23%) compared with the control group (41%), which suggests that this method can be used as an alternative to conventional antiemetic treatment (Harmon et al, 1999, 2000).
Children who received stationary acupressure applied to the Korean K-K9 point for 30 minutes before and 24 hours after strabismus surgery showed a significantly lower incidence of postoperative vomiting (20%) than children in the placebo group (68%) (Fan et al, 1997).
As compared to stimulation of the K-K9 point, stimulation of the P6 (neiguan) acupoint was determined to prevent nausea and vomiting in adults, although no antiemetic effects were noted in children undergoing strabismus surgery. However, it was determined that prophylactic use of bilateral acuplaster in children reduced the incidence of vomiting from 35.5% to 14.7% in the early emesis phase, 58.1% to 23.5% in the late emesis phase, and 64.5% to 29.4% overall. Researchers concluded that the use of acuplaster reduced vomiting in children undergoing strabismus correction (Schlager et al, 2000).
Shiatsu as developed in Korea and Japan is increasingly popular in the United States and stands at the intersection of hands-on therapy, massage and manipulative therapy, and energy healing as representing an ancient Asian healing tradition—thus appropriately placed at a crossroads in this book.
Chapter References, Suggested Readings, and Resources can be found on the Evolve website at http://evolve.elsevier.com/Micozzi/complementary/