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Physical Healing Methods
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~ Physical Healing Methods

All the biomechanical therapies--grouped here as "physical healing methods"--are based on the understanding that dysfunction of any discrete body part often affects secondarily the function of other discrete, not necessarily directly connected, body parts, both in close proximity and at a distance. The various manual medicines have developed theories and processes that treat these secondary dysfunctions through a variety of methods that manipulate the soft tissues or realign the body parts. Overcoming these misalignments and manipulating soft tissues bring the individual parts back to optimal function and return the body to health.

Osteopathic Medicine

One of the earliest systems of health care in the United States to use manual healing methods was osteopathic medicine. To its practitioners and to much of the public, the manual healing methods of osteopathic medicine are mainstream processes, but some people consider them ~alternative.

The principles and philosophy of osteopathy integrate health and illness, emphasizing four major areas:

• Structure and function are interdependent. Furthermore, behavior is an intermingled complex in which psychosocial influences can affect both anatomy (structure) and physiology (function). All these relationships are fundamentally designed to work in harmony.

• The body has the ability to heal itself, and the role of the osteopathic physician is to enhance the healing process as much as possible.

• Diseases, impairments, and disabilities arise from disruptions of the normal interactions of anatomy, physiology, and behavior.

• Appropriate treatment is based on the ability to understand, diagnose, and treat--by ~whatever methods are available--including manually applied procedures. When hands-on procedures are used to identify somatic dysfunction (see the glossary), the practitioner then determines whether the pattern of somatic dysfunction that is observed can be related to any visceral (that is, related to the internal body organs), neuromusculoskeletal, or--occasionally--behavioral dysfunction.

History and context     » top of this page

American osteopathic medicine was begun by Andrew Taylor Still (1828-1917). Still was a physician of his period, trained mainly through apprenticeships. It is said that he attended a medical school in Kansas City, MO, for one semester but found it boring and irrelevant (Gevitz, 1980). As a result of many adverse experiences with then contemporary medical practices, including the death of several family members from untreatable meningitis and pneumonia, Still began a personal search for improved methods to treat diseases and restore health (Gevitz, 1980; Schiotz, 1958). This empirical approach continues to be used by many osteopathic physicians.~Development and use of osteopathically oriented manipulative skills began around the time of Still's search (Carlson, 1975; Gevitz, 1980), but how he developed his system that combined "lightning bone setting" with the magnetic healing concepts of Mesmer is not clear (Hood, 1871).

It seems likely that his knowledge (of manipulation) was derived from simply observing the work of another practitioner in the field. However he learned these methods, Still soon afterwards made an important discovery, namely, that the sudden flexion and extension procedures peculiar to the spinal area were not limited to orthopedic problems; furthermore, they constituted a more reliable means of healing than simply rubbing the spine (Gevitz, 1980).

Whatever the circumstances, Still began his new health profession in 1874, before beginning his use of manipulation, which he was reported to use somewhat later in that decade (Gevitz, 1980). After advertising and working as both a magnetic healer and a lightning bone setter, he began writing about his ideas (Still, 1899). Ultimately, he founded his first school, the ~American School of Osteopathy, in 1892 at Kirksville, MO, to improve on existing surgical and obstetrical practices. The original emphasis was on observing the relationship between structure and function. He incorporated assumptions that manual restoration of normal anatomic relationships leads to physiological improvements. This reasoning included by definition a spectrum not only of health issues but of specific recommendations for disease and obstetrical interventions. Some examples from osteopathic literature include discussions dealing with labor and delivery, postoperative ileus (bowel) paralysis, asthma, otitis media (middle ear infection), hypertension, coronary artery disease, back pain, neck pain, diabetes, trauma of all kinds, migraine headache, and stress-related illnesses (Downing, 1935; Kuchera and Kuchera, 1990; Sleszynski and Kelso, 1993).

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Osteopathy spread to England in the 1920s when John Littlejohn emigrated from Chicago to London, establishing the British School of Osteopathy, the first of several such schools. The expansion continued as continental European practitioners studied at the British schools in the 1930s and 1940s.

~Historically, many currently popular manual medical techniques--with the exceptions of "energy" techniques, massage, and high-velocity maneuvers (Hood, 1871)--originated within American osteopathy and spread elsewhere. Among those techniques are manual methods applied in other medically oriented systems and also activities of alternative health care providers. Examples include muscle energy and postisometric relaxation concepts, which were originally developed and codified by Fred Mitchell, Sr. and Paul Kimberly; fascial-myofascial release and visceral techniques, developed by A.T. Still and others, including Charles Neidner; cranial-craniosacral techniques, William G. Sutherland (Sutherland, 1990); strain and counterstrain, Lawrence Jones; and thoracic pump and lymphatic techniques, A.T. Still, Gordon Zink, and several contemporaries. (Most of these techniques are described briefly in the "Osteopathic Education" section.)

In many instances, contemporary practices of these methods throughout the world are extensions and refinements of original osteopathic concepts. Other systems, such as chiropractic, Swedish massage, Cyriax (Great Britain), Mennell (Great Britain), Lewit (Czech Republic), Dvorak (Switzerland), and several German systems also have influenced ~current practices, both in the United States and elsewhere. Two current osteopathically based examples are advances in myofascial release and fascial unwinding maneuvers and in "energy"-based practices arising from basic cranial concepts, codified by both Sutherland and Harold Magoun, Sr. (Magoun, 1976; Sutherland, 1990).

Demographics. As of 1993, this country had more than 32,000 American-educated and licensed doctors of osteopathy (D.O.s), some in every State. They perform all aspects of medical care, including all specialties and family practice. Sixteen colleges and schools graduate approximately 1,500 D.O.s annually. While graduates make up about 5 percent of the country's physician population, the profession is responsible for approximately 10 percent of total health care delivery in the United States. More than 60 percent of osteopathic physicians are involved in primary care areas--family medicine, pediatrics, internal medicine, and obstetrics-gynecology (Annual Directory, 1993).

Many osteopathic physicians from a variety of disciplines regularly incorporate structural diagnosis of abnormalities of musculoskeletal function and manual medical treatments in their ~day-to-day activities.1 Ironically, because of current attitudes among third-party payers toward physician use of manual medicine, many are not paid for these services. Much of the reluctance to pay is based on a lack of adequately funded research, particularly relating to outcome measures. From an osteopathic perspective, what is considered "alternative" by most of the medical and research establishment is mainstream for the average D.O. (Gevitz, 1980; Grad, 1979; Schiotz, 1958).

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Osteopathic education. Basic American osteopathic education (Gershenow, 1985) includes substantial emphasis on osteopathic philosophy and principles including extensive manually oriented training designed to develop manual medicine diagnosis and treatment skills. The profession generally refers to the latter as structural diagnosis and manipulative treatment. These skills have been used by osteopathic physicians for more than 100 years in a context of total patient care.

The Education Council on Osteopathic Principles, representing the 16 osteopathic colleges, is currently contributing to osteopathic education through three principal projects: the 1982 ~publication of an updated glossary of osteopathic terminology; development of a core curriculum for osteopathic principles; and development of state-of-the-art textbook chapters highlighting the uses of palpatory diagnosis (use of touch) and manipulative treatment in multiple clinical disciplines.

Basic palpation and structural diagnosis and treatment skills are emphasized in preclinical American osteopathic education, and eight major manual medical methods are taught in osteopathic colleges. These eight methods are as follows:

1. Soft-tissue techniques that enhance muscle relaxation and circulation of body fluids.

2. Isometric and isotonic techniques (often referred to as muscle energy or postisometric relaxation) that focus primarily on restoring physiological movements to altered joint mechanics.

3. Articulatory techniques (also called joint play and manipulation without impulse) that ~emphasize restoration of intrinsic joint mobility.

4. High-velocity, low-amplitude techniques (also called manipulation with impulse), designed to restore the symmetry of the movements associated with the vertebral joints.

5. Myofascial release techniques (also called fascial release techniques) that use combinations of so-called direct and indirect methods (see the glossary) to modify problems of individual and interactively related muscle groups and surrounding or covering (myofascial) tissues.

6. Functional techniques that emphasize treatment of restrictive patterns in joint, myofascial, and neural systems, using "ease," "bind," "sensing," and "motor" hands (see the glossary) as proprioceptive (see the glossary) diagnostic concepts.

7. Strain and counterstrain techniques, designed to locate sore places at specific sites on the body, tender points that relate to specific patterns of abnormal joint movement. The ~points are "turned off" by moving the body or limb to a treatment position that quiets painful feedback. The position is held for 90 seconds. Reevaluation typically reveals improvement in movement and a decrease in local pain.

8. Cranial techniques (also called craniosacral techniques) that highlight the manual ability to assess and release tensions associated with subtle, reciprocating cranial (head) and sacral (tailbone) oscillations. These movements are thought to arise from a complex combination of dural (covering) and ligamentous (fibrous connecting tissue) relationships in the spinal network. Adams and Heisey have documented movement of cranial bones in studies using cats. They found cerebrospinal fluid waves having various frequencies and amplitudes (Adams et al., 1992; Heisey and Adams, 1993). Opportunities for research in this area abound.

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A number of continuously evolving diagnostic and treatment systems that are osteopathically oriented and manually based incorporate various of these eight manual techniques. Some systems are meant to stand on their own, while others are integrated to a greater or lesser ~extent with medically (i.e., allopathically) oriented decisionmaking.

Postdoctoral training, certification, and fellowship status in manual medicine are available to American osteopathic graduates, approximately 35 postdoctoral positions are available each year. Programs last 1 to 4 years. One-year fellowships are available for D.O.s and M.D.s who have finished a previously approved residency. Standalone 2-year programs leading to manual medicine certification are available in several colleges. Interdisciplinary 3-and 4-year programs that combine some of the many specialties and subspecialties are also available. The most popular are combinations of manual medicine with either family practice or physical medicine and rehabilitation.

Total patient care. Osteopathic physicians are involved in all aspects of total patient care (Northup, 1966), including structural diagnosis and manipulative treatment. Manipulative treatment is commonly used, especially by osteopathic family physicians, as adjunctive care for systemic illness and for various neuromusculoskeletal problems, such as low back, head, and neck pain. In this context, a wide variety of hands-on and--in some situations--"energy" ~applications are used in a range of disciplines, including family practice, pediatrics, geriatrics, physical medicine, surgery of all kinds, physical medicine and rehabilitation, neurology, rheumatology, pulmonology, and sometimes behavioral medicine and psychiatry. A few disciplines have conducted research using manual methods (Reynolds et al., 1993; Sleszynski and Kelso, 1993), but many questions remain.

Research base. Since its inception, the osteopathic profession has maintained and pursued active research in many areas. This work has usually been published in the Journal of the American Osteopathic Association, which until recently was not listed in Index Medicus. Present activities designing research tend to be directed toward evaluating (1) long-term effects of somatic dysfunctions and facilitated segments in disease states and (2) the outcome resulting from the use of manipulative treatment.

An extensive body of work supports a physiological basis for using osteopathic techniques in both musculoskeletal and nonmusculoskeletal problems. Of particular interest are studies dealing with~ • interactions between internal body organs and neuromuscular structures,

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• alterations in reflex thresholds,

• reliability of physician palpatory skills (inter-rater reliability studies), and

• effects of manipulative treatments on disease processes and a variety of physiological functions.

Early work performed by Louisa Burns demonstrated that spinal strain has adverse effects on both functional and motor neuron levels (Burns, 1917). Later work by Denslow and Korr demonstrated long-lasting, highly individual patterns of spinal hyperexcitability associated with neuromuscular and various visceral dysfunctions. This research led to the concept of the "facilitated segment" (fig. 1; also see "facilitation" in the glossary), which has been associated with a variety of clinical problems (Denslow et al., 1947; Korr, 1947, 1955). The concept of the facilitated segment is that repeated stimulation produces ~hyperactive responses, resulting in improper functioning of some body part.

By considering function along with structure, osteopathic theory has included conjecture on the role of the body's communication systems--nervous, circulatory, and endocrine--in initiating somatic dysfunction and causing additional responses in the body. Some early research (Northup, 1970) supports this supposition with regard to reflexes having a role in mediating both the origin of somatic dysfunctions and the effects of manipulative treatment. Osteopathic medicine needs continuing basic research on the role of the nervous system in establishing and maintaining somatic dysfunctions and effecting interactions with the rest of the body.

Figure 1 demonstrates potential effects of repeated facilitation; that is, inducing a hyperactive response, leading to somatic dysfunction. The term facilitation is usually used to describe enhancement or reinforcement of otherwise subthreshold neuronal activities that stimulate effector units to inappropriately carry out whatever action they are programmed to do. Examples of effector sites are muscle bundles, muscle groups, viscera, and other neural units ~and networks. Osteopathic treatment is designed to raise these stimulus thresholds so that the stimulatory event is less likely to occur.

More recent examples of osteopathic research include a preliminary assessment of the effectiveness of manipulative treatment for paresthesias (abnormal sensations) with peripheral nerve involvement (Larson et al., 1980) and thermographic studies of skin temperature in patients receiving manipulative treatment for peripheral nerve problems (Kappler and Kelso, 1984; Larson, 1984). Thermography was selected as a promising method to study segmental facilitation of sympathetic nerves without invading the body (as would be required if needle electrodes were used). Initial studies have been complicated, however, by the number of variables affecting skin-level circulation, including circulatory patterns, local influences, and local shunting. If methods can be developed to identify the effects of these variables, then thermography may prove useful for detecting changes in the sympathetic nervous system that affect skin-level circulation.

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Other current clinical research projects that examine the effects of manual treatments have ~researched their effects on postoperative pulmonary flow rates (Sleszinski and Kelso, 1993), pain management (Zhu et al., 1993), and electromyographic changes associated with manual treatments. If vibration is applied to muscles near the spine or these paraspinal muscles contract voluntarily, weakened electrical potentials are observed in the cerebrum, the main part of the human brain. This finding suggests that muscle spindle receptors are responsible for providing signals that cause the early components of magnetically evoked brain potentials. The brain's evoked potentials return to normal amplitude (1) when the muscle spasm subsides after a period of time and (2) after spinal manipulative therapy is applied (Zhu et al., 1993).

Additional research on the interaction of visceral and somatic structures (Eble, 1960) has supported clinical findings that palpation of neuromuscular structures can help identify visceral disturbances (Johnston, 1992; Kelso et al., 1980) and that manual procedures can help restore both visceral and neuromuscular (somatic) functions (Buerger and Greenman, 1985; Korr, 1978; Northup, 1970). The latter include situations involving low back pain (Hoehler et al., 1981), neurological development in children (Frymann et al., 1992), carpal ~tunnel syndrome (Sucher, 1993), postoperative collapsed lung (Sleszynski and Kelso, 1993), and burning pain in an extremity (Levine, 1991). Moreover, in some preliminary observations with cadavers, Reynolds and Ward (Ward, 1994) found that palpatory diagnoses tended to correlate with radiographic and autopsy data.

One example of the diagnostic potential of osteopathic palpation is the studies of Johnston and colleagues (Johnston et al., 1980, 1982b), comparing subjects with normal and high blood pressure. A significant number of the hypertensive patients were shown to have a stable pattern of musculoskeletal findings in the cervicothoracic spinal region. This finding suggests that osteopathic diagnoses could contribute to identifying internal difficulties.

Another issue that osteopathic researchers have addressed is the accuracy of their examinations of patients before and after manipulative treatment, including whether such observations are consistent among a group of osteopathic physicians. Several studies (Beal et al., 1980, 1982; Johnston, 1982a; Johnston et al., 1982a, 1982c, 1983; McConnell et al., 1980) have been conducted in which osteopathic physicians working independently have ~used a mutually agreed-upon test procedure. These studies of inter-rater reliability look for correlations in the observations of two or more independent raters. Results suggest that when there is prior training or agreement on which tests to use and what is clinically significant with respect to findings, inter-rater agreement can be achieved consistently. This ability to reach agreement becomes particularly important as the basis for establishing a method of setting up controlled clinical trials to determine the success of manipulative treatments.

Virtually all osteopathically oriented research has been funded from the private sector, mainly through the bureau of research of the American Osteopathic Association. The largest grant to date, $400,000, is for evaluating outcomes associated with the use of manipulation for back pain in a Chicago health maintenance organization population. This is a 3-year prospective study conducted by two osteopathic physicians specializing in musculoskeletal medicine. Patients having acute back pain with and without sciatica (pain radiating downward into the leg) are randomized into the project so that some receive manipulative care while others receive "standard" medical care. Clinical outcomes are evaluated by ~uninvolved clinicians. Preliminary data are expected in late 1994.

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Barriers and key issues. Historically, Federal research initiatives relevant to osteopathic medicine (for example, from the National Institute of Neurological Disorders and Stroke at the National Institutes of Health (NIH) or from the Centers for Disease Control and Prevention) have been controlled by traditionally defined disciplines and their expert panels. Manual-methods research panels are not among them, and the result is a lack of genuine peer review capability. This sociological fact of life has inhibited development and understanding of the manual medicine field, even though public acceptance has been and continues to be high throughout the world.

Some major issues to be considered in trying to improve osteopathic research opportunities are the following:

• Selecting appropriate patient populations in which to study the effects of manual manipulation.~ • Arranging for knowledgeable peer review and research guidance, including (1) ensuring that persons with osteopathic experience serve on peer review panels (see also the "Peer Review" chapter) and (2) determining appropriate procedures for measuring success of osteopathic treatments.

• Establishing whether previous inter-rater agreement studies support the use of the inter-rater agreement method in osteopathic and other kinds of research.

• Making previous osteopathic research more accessible (for example, the recent inclusion of the Journal of the American Osteopathic Association in Index Medicus), which could educate other investigators about osteopathic issues and possibly lead to collaborative research. (See also the "Research Databases" chapter.)

• Ensuring that osteopathic clinician-researchers are part of any research team so that persons inexperienced with osteopathic diagnosis and treatment do not conduct the work improperly. Additional training in planning, conducting, evaluating, and reporting clinical ~research should be made available to the osteopathic clinicians.

• Setting up a review process to integrate available information from outside the osteopathic profession with osteopathically based research on the structure-function relationship. Included would be research, for example, on homeostasis; short-, intermediate-, and long-term responses to different stressors; and adaptation to changes in internal and external environment. Useful new research questions are likely to result.

• Documenting anecdotal observations of patients and osteopathic clinicians who treat the somatic component of medical and health-related problems to tabulate patient benefits that include relief from stress and improvement in function and well-being. Attention should be paid to all patient health outcomes, not just short-term benefits from manipulation; for example, reducing health risks, improving health maintenance, and modifying adaptive responses would be included.

• Designing and conducting research to support or refute the use of palpatory ~examination and manipulative treatment for the somatic component of dysfunction and illness. Also researching the role of the somatic system; identifying the nature and effects of somatic dysfunctions and their incidence, prevalence, and effects on acute illness and long-term health; and any changes in those effects resulting from treatment.

• Developing alternative research designs for safety and efficacy studies that do not require blind controls for manual procedures. (See also the "Research Methodologies" chapter.) There are both practical and ethical reasons not to use blind controls for a hands-on procedure. One alternative is to use naive patients who lack any expectation that the treatment will be beneficial.

• Developing and integrating cost-benefit research that compares the use of palpatory examination and manipulative treatment with mainstream health care and disease management procedures. Common examples include headaches of all kinds, back pain, allergy, asthma, many orthopedic problems, postoperative and posttraumatic effects of all kinds, and various rheumatologic diseases.~Chiropractic

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Chiropractic science is concerned with investigating the relationship between structure (primarily of the spine) and function (primarily of the nervous system) of the human body in order to restore and preserve health. Chiropractic medicine addresses how to apply this knowledge to diagnose and treat structural dysfunctions that affect the nervous system.

Chiropractic philosophy and practice emphasize four major points:

• The human body has an innate self-healing ability and seeks to maintain homeostasis (see the glossary), or balance.

• The nervous system is highly developed in humans and influences all other systems in the body, thereby playing a significant role in health and disease.

• The presence of joint dysfunction and subluxation (see the glossary) may interfere with ~the ability of the neuromusculoskeletal system to act efficiently and may lead to or be a concomitant of disease.

• Treatment is based on the chiropractic physician's ability to diagnose and treat existing pathologies and dysfunctions by appropriate manual and physiological procedures.

The chiropractic physician relies heavily on hands-on procedures using touch (palpation) to determine both structural and functional joint "dysrelationships." These hands-on procedures are carried out alongside more traditional forms of diagnostic assessment. By training and by law, chiropractic physicians use manual procedures and interventions, not surgical or chemotherapeutic ones.

History and context. While manipulative medicine has been practiced for millennia, the chiropractic profession is only now preparing for its centennial. The profession was founded in the 1890s when Daniel David (D.D.) Palmer, a grocer and magnetic healer, applied his knowledge of the nervous system and manual therapies, thrusting on a thoracic vertebra to ~restore the hearing of Harvey Lillard, a local janitor. While Palmer was not the first to practice manual thrusting, he was the first to use the bony projections, or processes, of the vertebrae (specifically, the spinous and transverse processes) as levers for the manual contact.

Within 2 years of this initial discovery, Palmer had founded his Chiropractic School and Cure, while at the same time developing the concept of subluxation, a type of partial joint dislocation, as a causal factor in disease. For these reasons, D.D. Palmer is known as the Founder.

By 1902, Palmer's son Bartlett Joshua (B.J.) had enrolled in his father's school; he gained operational control by late 1904, and by 1906, D.D. Palmer was no longer associated with the college he had founded. The year 1906 also saw the development of the schism that still exists in the profession today; several faculty members, including John Howard, left Palmer College because of deep differences with B.J. Palmer (who came to be known as the Developer) over the role of subluxation in disease. By that time, B.J. was espousing subluxation as the cause of all disease; John Howard, however, saw a need for what he considered to be a more rational alternative to such thinking and focused his new National School of Chiropractic around a broad-based educational program incorporating basic and clinical sciences, laboratory work, dissection, and clinical care (Beideman, 1983).

From 1910 to 1920, many other chiropractic colleges came into existence; some followed the lead of B.J. Palmer in a "straight" form of chiropractic, while others followed the lead of Howard in developing "mixer" programs. The development of the profession could not have occurred without the missionary zeal of B.J. Palmer, who led his namesake college for 54 years. But others helped to advance the profession as well, including Carl Cleveland, Earl Homewood, Fred Illi, Joseph Janse, Herbert Lee, and Claude Watkins.

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What these innovators did--in addition to all their educational and scientific advancements--was to place disease in a different context involving the concept of subluxation (Bergmann et al., 1993). Some factors are common to chiropractic and allopathic medicine. Both recognize the existence of bacteria and other "germs" and their role ~in creating disease; both mandate that a susceptible host be present along with the germ. Both also accept that the host's susceptibility depends on many factors. But only in the chiropractic model is the presence of subluxation stressed as an important factor; the contention of chiropractic is that since the subluxation can serve as a noxious irritant to the body, its removal becomes critical for restoring optimal health.

Chiropractors are responsible for the development and refinement of manual therapies, particularly those known as high velocity, short amplitude. Within the purview of these therapies, many systems have been developed concerning how to apply the various procedures. Examples include:

• sacrooccipital technique, originally developed by Major B. De Jarnette;

• activator technique, developed and advanced by Arlan Fuhr;

• diversified technique, which comes from many sources--including manual medicine ~(physician John Mennell), and various chiropractors, including Arnold Hauser and Joseph Janse--and which was developed largely in the National College of Chiropractic;

• Thompson terminal point technique, developed by J. Clay Thompson;

• flexion-distraction technique, developed from original osteopathic concepts by James Cox (this is not a traditional thrusting procedure);

• Gonstead technique, developed by Clarence Gonstead; and

• applied kinesiology, developed by George Goodheart.

This list is by no means exhaustive; other innovators include L. John Fay, Henri Gillet, and John Grostic.

Today's common chiropractic procedures are refinements of systems developed during the ~past half-century, both in diagnosis (the motion palpation of Fay and Gillet, for example [Gillet and Liekens, 1984; Schaefer and Fay, 1989]) and in therapy.

Today chiropractic procedures are being examined by researchers from most of the chiropractic colleges, who also are receiving input from field-based chiropractors. Standards of care are being determined by coalitions of chiropractors, including practitioners, academics, researchers, and administrators. One group has already produced a set of guidelines called the Mercy Conference guidelines (Haldeman et al., 1992).

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In reaching their decisions concerning practice parameters and standards of care, the various groups of chiropractors have been participating in consensus-development procedures (Hansen et al., 1992).

Demographics. In 1993 more than 45,000 licensed chiropractors were practicing in the United States alone. Licensing occurs in every State in the Union as well as in many foreign countries. Chiropractors provide various aspects of health care but cannot use surgery or ~drugs; they have several specialty areas, such as radiology, orthopedics, neurology, and sports medicine. Seventeen American chiropractic colleges graduate more than 2,000 chiropractors annually; colleges also exist in Canada, Australia, England, France, and Japan. Some other foreign countries are considering them (e.g., South Africa, Italy, and Germany). Chiropractors currently see 12 percent to 15 percent of the U.S. population, and most professionals practice in private office settings, usually solo.

Most chiropractic physicians incorporate structural diagnosis into their practice and use manual adjusting therapies as their main treatment mode. Today, most third-party payers accept chiropractic services, though they did not always. Increased chiropractic research has helped to allay the reluctance of insurance companies toward chiropractic, and the recent development of professional standards of care has opened new avenues for chiropractic coverage.

Chiropractic education. Today's chiropractic educational program is a 5-year curriculum that emphasizes chiropractic philosophy, basic and clinical science, and clinical care in outpatient ~settings. Standard forms of medical diagnosis are heavily detailed, with additional workloads in structural and functional diagnosis and chiropractic technique. All chiropractic colleges require at least 2 years of college education prior to matriculation, as well as a series of courses (e.g., chemistry, physics) meeting criteria set by the Council of Chiropractic Education (CCE).

Manual therapies include any procedure during which the hands are used to palpate, diagnose, mobilize, adjust, or manipulate the somatic or visceral structures of the body. There are two broad groups--joint manipulation procedures and soft-tissue manipulation procedures. Adjustments are the most commonly applied chiropractic therapy within either group. The most common forms of adjustment taught in chiropractic colleges are the diversified, Gonstead, activator, and sacrooccipital techniques.

Today CCE accredits chiropractic colleges on the professional level, while regional accreditation also occurs. All CCE-accredited colleges teach a comprehensive program that incorporates elements of basic science (physiology, anatomy, and biochemistry); clinical ~science (such as laboratory diagnosis, radiology, orthopedics, and nutrition); and clinical experience (e.g., patient management in the clinical setting). In addition, the profession offers postdoctoral training in a wide range of disciplines, with orthopedics and radiology the most popular. In this country, some hospital training has recently become available to chiropractic students and residents; such training has been available in Canada since 1975.

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Research base. The chiropractic profession has performed rigorous research since its early days. However, at least in one sense, the research within the profession is still very much in its infancy, because the profession "lost" much of its early work for lack of an appropriate forum in which to publish it. Today the Journal of Manipulative and Physiological Therapeutics is the sole chiropractic research publication indexed in Index Medicus, Current Contents, BIOSIS, and Excerpta Medica. However, other journals such as Spine, which is indexed in the major medical data bases, do public chiropractic-related research.

Current chiropractic research interests include back and other pain, somatovisceral disorders, and reliability studies.~Back and other pain. Recent emphasis in research trials has been on manipulation and back pain, manipulation and various organic disturbances, and reliability and validity. In 1984, Brunarski identified 50 trials of spinal manipulation (Brunarski, 1985); the number has increased since then. Studies by Bergquist-Ullman and Larsson (1977), Godfrey et al. (1984), Hadler et al. (1987), Mathews et al. (1987), and Waagen et al. (1986) were all important in establishing a definitive role for manipulation in the management of low back pain. The argument for including chiropractic in British National Health Service coverage was based on recent work by Meade et al. (1990), comparing chiropractic care to hospital outpatient care. The research of Koes (1992) served a similar role in the Netherlands. Further, the RAND report (cited in Haldeman et al., 1992), a recent and large undertaking examining all published literature on the use of manipulation for low back pain, made definitive comments regarding its use in specific situations.

The RAND report found that manipulation was effective in the following five situations: (1) acute low back pain without evidence of neurological involvement or sciatic nerve irritation; (2) acute low back pain with sciatic nerve irritation; (3) acute low back pain with minor ~neurological findings and sciatic nerve root irritation (although there was some conflicting evidence); (4) subacute low back pain with no evidence of neurological involvement or sciatic irritation; and (5) subacute low back pain with minor neurological findings and major neurological findings. In other situations, the literature was found to present too many conflicts to determine effectiveness of manipulation.

Besides these trials, research has examined patient perceptual issues in the use of chiropractic care. Notable here is the research of Cherkin and MacCornack (1989), who reported that patients seeing chiropractors for low back pain were happier with the treatment they received than were similar patients seeing medical doctors for similar problems.

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Studies examining manipulation for pain other than low back pain include work of Barker (1983) on thoracic pain; Molea et al. (1987) on postexercise muscle soreness; Terrett and Vernon (1984) on paraspinal cutaneous pain tolerance; Vernon (1982) on headache; Jirout (1985) on C2-C3 vertebral dysfunction; and Parker et al. (1978) on migraine.~Somatovisceral disorders. One area that is gaining in research interest is the type O disorder (O for organic, as opposed to M for musculoskeletal). Much of the early impetus for studies of type O disorders came from osteopathic research examining somatic dysfunction. Examples of this work include studies by Johnston et al. (1985) and Vorro and Johnston (1987) using kinematic and electromyographic instrumentation to investigate clinical signs of somatic dysfunction. Johnston developed a way to detect "mirror image asymmetries," a presumed indicator of the presence of somatic dysfunction (the osteopathic spinal lesion). He laid out palpatory procedures to look for these asymmetries and later refined his concepts in a series of three papers (Johnston, 1988a, 1988b, 1988c) discussing palpatory diagnosis.

Studies that have examined manipulation in treating hypertension include work of Fichera and Celander (1969), Morgan et al. (1985), and Plaugher and Bachman (1994). All of these studies demonstrated changes in blood pressure following spinal manipulation, but the changes were relatively transient. Kokjohn et al. (1992) examined manipulation to treat dysmenorrhea.~Reliability studies. Clinical trials are simply not possible unless their assessment procedures have themselves been tested and found reliable. A procedure is said to be reliable if it gives similar results when applied more than once to the same object it is measuring or when it gives similar results when applied to a series of objects with similar qualities. (See also the "Research Methodologies" chapter.) Reliability tests within chiropractic are commonly used to evaluate specific diagnostic procedures, such as motion palpation.

Motion palpation (examination for presence or absence of joint play) was first advanced by Gillet and Fay as a diagnostic procedure; it has since become a well-studied, common diagnostic procedure. Gonnella et al. (1982) used a seven-point scale to evaluate interexaminer and intraexaminer reliability, while Boline et al. (1988), Love and Brodeur (1987), Mior et al. (1985), Mootz et al. (1989), Nansel et al. (1989), and Wiles (1980) examined simple reproducibility. Beattie et al. (1987) studied the attraction method of measuring motion, and Lovell et al. (1989) used a flexible ruler to assess lumbar lordosis (spinal curvature, such as swayback).

~Besides doing clinical studies of various chiropractic procedures, Haas (Haas, 1991; Haas et al., 1993) has made several important additions to reliability literature, even going so far as to study the reliability of reliability. Lawrence (1985) published a critique of reliability studies for measuring leg length, and Frymoyer et al. (1986) have looked at radiographic interpretation. (This list is by no means all-inclusive.)

The research described above has been accomplished largely without any Federal funding. The largest funding agency in the chiropractic profession is the Foundation for Chiropractic Education and Research, which generally has an annual research budget well below $1 million. Chiropractors have made an impressive addition to scientific knowledge despite the lack of encouragement and support by government agencies and medical personnel outside the chiropractic profession.

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Barriers and key issues. Several barriers and key issues need to be addressed so that chiropractic research can progress:

~ • Lack of access to Federal funds has negatively affected the chiropractic research enterprise. Ways must be found to make funds available for chiropractic research through the various agencies. To date, no chiropractic research has been funded by NIH, although several approved studies later failed to meet funding cutoff guidelines. A Small Business Administration innovative research grant funded one study. One approach to alleviating this situation is through the workshops the Office of Alternative Medicine (OAM) is conducting on grant writing and research design. OAM's ability to fund small-scale projects is also a help. If research resources could be increased, much more could be accomplished.

• Lack of access to previous chiropractic research through indexing and databases also hampers research. As mentioned earlier, only a single solely chiropractic research publication is internationally indexed. (The Journal of Manipulative and Physiological Therapeutics is indexed in the former Soviet Union as well as in the Western publications previously cited.) Because other chiropractic research journals are unlikely to gain the status of indexing in a conventional database, it is necessary to consider including chiropractic research in an alternative medicine database. Meanwhile, the inclusion of CHIROLARS ~(Chiropractic Literature and Retrieval System) in BRS Colleague as a sub-database may help to make chiropractic literature more accessible. (For information about research databases see the "Research Databases" chapter.)

• Philosophical differences (the straight-vs.-mixer controversy) continue to split the profession without any obvious solution. Unification is a goal that may still be years away.

• Inclusion of chiropractic in any of the proposed reforms of the health care system, such as those proposed by the Clinton administration, is not assured. It may be that the decision whether to include chiropractic in a national health care plan will be driven by congressional action. Major efforts are already under way to make contact with politicians regarding this issue, and chiropractic input was provided to the President's Health Care Task Force.

New avenues for the chiropractic profession have become available as a result of the decision against "biomedicine's" restraint of trade in the 1991 judgment rendered in Wilk et al. v. the American Medical Association (AMA) (see the "Introduction"). While it is likely to ~take many years to overcome the AMA's history of opposition to chiropractic, continuing quality research and patient care will negate this opposition. The current processes by which chiropractors are reviewing standards of care and chiropractic procedures should help solidify the public standing of this field.

Massage Therapy    » top of this page

Massage therapy is one of the oldest methods in the gallery of health care practices. References to massage are found in Chinese medical texts 4,000 years old. Massage has been advocated in Western health care practices in an almost unbroken line since the time of Hippocrates, the "father of medicine." In the 4th century B.C., Hippocrates wrote, "The physician must be acquainted with many things and assuredly with rubbing" (the ancient Greek and Roman term for massage).

Some of the greatest physicians in history advocated massage, including Celsus (25 B.C.-50 A.D.), who wrote De Medicinia, an encyclopedia of Roman medical knowledge that dealt ~extensively with prevention and therapeutics using massage; Galen (131-200), the most influential physician in the ancient, medieval, and Renaissance worlds, who addressed techniques and indications for massage in his book De Sanitate Tuenda (which is translated as The Hygiene, meaning prevention); and Avicenna (980-1037), a Persian physician who wrote extensively about massage in his Canon of Medicine, which was considered the authoritative medical text in Europe for several centuries. A sampling of other noted advocates includes Ambrose Parι, who wrote the first modern textbook of surgery; William Harvey, who demonstrated the circulation of the blood; and Herman Boerhaave, who introduced the clinical method of teaching medicine.

Modern, scientific massage therapy was introduced in the United States in the 1850s by two New York physicians, brothers George and Charles Taylor, who had studied in Sweden. The first massage therapy clinics in this country were opened by two Swedes after the Civil War: Baron Nils Posse ran the Posse Institute in Boston, and Hartwig Nissen opened the Swedish Health Institute near the U.S. Capitol in Washington, DC. Several members of Congress and U.S. Presidents, including Benjamin Harrison and Ulysses S. Grant, were ~among the massage therapy clientele.

As the health care system in the United States became more influenced by biomedicine and technology in the early 1900s, physicians began assigning massage duties (which were also labor-intensive, requiring more time to be spent with patients) to assistants, nurses, and physical therapists. In turn, in the 1930s and 1940s, nurses and physical therapists lost interest in massage therapy, virtually abandoning it. However, a small number of massage therapists carried on until the 1970s, when a new surge of interest in massage therapy revitalized the field, albeit in the realm of alternative health care. That interest has continued to the present.

Basic approach. Massage therapy is the scientific manipulation of the soft tissues of the body to normalize those tissues. It consists of a group of manual techniques that include applying fixed or movable pressure, holding, and/or causing movement of or to the body, using primarily the hands but sometimes other areas such as forearms, elbows, or feet. These techniques affect the musculoskeletal, circulatory-lymphatic, nervous, and other systems of ~the body. The basic philosophy of massage therapy encompasses the concept of vis medicatrix naturae--that is, aiding the ability of the body to heal itself--and is aimed at achieving or increasing health and well-being.

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Touch is the fundamental medium of massage therapy. While massage methods can be described in terms of a series of techniques to be performed, it is important to understand that touch is not used solely in a mechanistic way in massage therapy; there is also an artistic component. Because massage usually involves applying touch with some degree of pressure, the massage therapist must use touch with sensitivity to determine the optimal amount of pressure appropriate for each person. Touch used with sensitivity also allows the massage therapist to receive useful information about the body, such as locating areas of muscle tension and other soft-tissue problems. Because touch is also a form of communication, sensitive touch can convey a sense of caring--which is an essential element in the therapeutic relationship--to the person receiving massage. Using the wrong kind of touch--sometimes thought of as "toxic touch"--is counterproductive, tending to render a technique ineffective and to cause the body to defend or guard itself, which in turn introduces greater tension.~Demographics. The advancement of higher standards and the development of a system of professional credentials have paralleled the dynamic growth of the massage therapy profession. Massage therapists are currently licensed by 19 States and a number of localities; additional States are expected to adopt licensing acts in the near future. Most States require 500 or more hours of education from a recognized school program and a licensing examination. While some States require continuing education, most massage therapists voluntarily take additional courses and workshops on a regular basis during their careers.

The National Certification Exam, a professional certification program accredited by the National Commission for Certifying Agencies in December 1993 and currently administered by the Psychological Corporation, was inaugurated in June 1992. More than 9,000 people nationwide were certified as of July 1994. Six States have already adopted the exam as their licensing exam, and more States are expected to follow suit.

The Commission on Massage Training Accreditation/Approval, a national accreditation ~agency that was set up in accord with the guidelines of the U.S. Department of Education, currently recognizes 60 school programs. Curriculums must consist of 500 or more hours and include specified hours of anatomy, physiology, massage theory and practice, and ethics.

The primary sponsor of the national certification and accreditation programs is the American Massage Therapy Association (AMTA), the largest and oldest national professional membership association for massage professionals. AMTA currently has more than 20,000 members and publishes the Massage Therapy Journal. The association recently founded the public, charitable AMTA Foundation to fund projects for research, education, and outreach; the foundation awarded its first grants in June 1993.

Each of a number of other national nonprofit membership associations for massage professionals has between 200 and 1,500 members. These groups usually are formed for practitioners of specific methods. To alleviate the competition and infighting that are sometimes found among various professional groups, an innovative coalition known as the ~Federation of Therapeutic Massage and Bodywork Organizations was formed in 1991 by the AMTA, the American Oriental Bodywork Therapy Association, the American Polarity Therapy Association, the Rolf Institute, and the Trager Institute. The federation fosters greater communication and cooperation among its members.

The number of massage therapists in the United States can only be estimated, because no formal census has been taken. Furthermore, a census or estimate would be affected by the criteria for inclusion, which would involve such variables as extent of training, number of hours worked, and whether methods used by an individual are considered forms of massage. It is estimated that there are approximately 50,000 qualified massage therapists in the United States, providing some 45 million 1-hour massage sessions per year. The number of massage therapists appears to be increasing rapidly along with a corresponding increase in use by the American public. An estimated 20 million Americans have received massage therapy. Indeed, in the study by Eisenberg and colleagues (1993)--which found that 34 percent of the American public used alternative health care--relaxation techniques, chiropractic, and massage were the most frequently used forms of alternative health care.~Methods. Some 80 different methods may be classified as massage therapy, and approximately 60 of them are less than 20 years old. There are several reasons why this is the case.

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The period of the 1940s to the mid-1970s was relatively dormant for the massage therapy profession. Little standardization was established in the field. Then in the 1970s, stimulated by changes in society such as greater interest in fitness, healthier lifestyles, personal improvement, and alternative methods of health care to complement conventional medicine, interest in massage therapy increased. An influx of new practitioners brought with them a wave of new ideas and creativity regarding ways to use hands-on techniques. Since there was little standardization, these techniques sometimes developed into freestanding methods rather than being incorporated into an existing system of classification.

Another source of new techniques was the various forms of massage native to most cultures around the world but not previously described outside each culture. For example, many of the forms of massage that come from Asia are based on concepts of anatomy, physiology, ~and diagnosis that differ from Western concepts.

The proliferation of methods has slowed. It is expected--as has happened in the development of other professions--that as the development of standards and credentials continues, there will be some consolidation and integration of methods.

The forms of massage therapy described in this section are either among the most widely used or representative of a group of similar practices. Several forms that include additional techniques besides massage are listed briefly here and discussed in more detail in the following sections. In actual practice, many massage therapists use more than one method in their work and sometimes combine several.

Swedish massage uses a system of long gliding strokes, kneading, and friction techniques on the more superficial layers of muscles, generally in the direction of blood flow toward the heart, sometimes combined with active and passive movements of the joints. This system is used to promote general relaxation, improve circulation and range of motion, and relieve ~muscle tension. Swedish massage is the most common form of massage.

Deep-tissue massage is used to release chronic patterns of muscular tension using slow strokes, direct pressure, or friction directed across the grain of the muscles with the fingers, thumbs, or elbows. It is applied with greater pressure and to deeper layers of muscle than Swedish massage.

Sports massage uses techniques that are similar to Swedish and deep-tissue massage but are specially adapted to deal with the needs of athletes and the effects of athletic performance on the body.

Neuromuscular massage is a form of deep massage that is applied specifically to individual muscles. It is used to increase blood flow, release trigger points (intense knots of muscle tension that refer pain to other parts of the body), and release pressure on nerves caused by soft tissues. It is often used to reduce pain. Trigger point massage and myotherapy are similar forms.~Manual lymph drainage improves the flow of lymph by using light, rhythmic strokes. It is primarily used for conditions related to poor lymph flow, such as edema, inflammation, and neuropathies.

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The reflexology, zone therapy, tuina, acupressure, rolfing (structural integration), Trager, Feldenkrais, and Alexander methods are addressed in the following sections.

The various methods of massage therapy can be divided into two major groupings:2

1. Traditional European methods based on traditional Western concepts of anatomy and physiology, using five basic categories of soft-tissue manipulation: effleurage (gliding strokes), petrissage (kneading), friction (rubbing), tapotement (percussion), and vibration. Swedish massage is the main example.

2. Contemporary Western methods based on modern Western concepts of human functioning, using a wide variety of manipulative techniques. These may include broad applications for personal growth; emotional release; and balance of the mind, body, and spirit in addition to traditional applications. These methods go beyond the original framework of Swedish massage and include neuromuscular, sports, and deep-tissue massage; and myofascial release, myotherapy, Bindegewebsmassage, Esalen, and manual Lymph Drainage.

In addition, there are structural, functional, and movement integration methods that organize and integrate the body in relationship to gravity through manipulating the soft tissues or through correcting inappropriate patterns of movement; methods that bring about a more balanced use of the nervous system through creating new, integrated possibilities of movement. Examples are Rolfing, Hellerwork, Aston patterning, Trager, Feldenkrais, and Alexander.

Current research. From 1873, when the term massage first entered the Anglo-American medical lexicon, through 1939, more than 600 journal articles appeared in mainline English language journals of medicine, including the Journal of the American Medical Association, ~Archives of Surgery, and the British Medical Journal. During the past 50 years, reports on nearly 100 clinical trials have been published in the medical and allied health literature. Many well-designed studies have documented the benefits of several methods of massage therapy for the treatment of acute and chronic pain; acute and chronic inflammation; chronic lymphedema; nausea; muscle spasm; various soft-tissue dysfunctions; grand mal epileptic seizures; anxiety; and depression, insomnia, and psychoemotional stress, which may aggravate significant mental illness. A larger number of studies also have been carried out in Europe, particularly in the former Soviet Union and East Germany. Unfortunately, the published reports on most of these have not been translated into English.

Research base. The following studies reflect the versatility of massage therapy and its broad and diverse range of applications.

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Premature infants treated with daily massage therapy gain more weight and have shorter hospital stays than infants who are not massaged. A study of 40 babies with low birth weight found that the 20 massaged babies had 47-percent greater weight gain per day and stayed in ~the hospital an average of 6 fewer days than 20 similar infants who did not receive massage; the cost saving was approximately $3,000 per infant (Field et al., 1986). Cocaine-exposed preterm infants given massages three times daily for a 10-day period showed significant improvement. Results indicated that massaged infants had fewer postnatal complications and exhibited fewer stress behaviors during the 10-day period, had 28-percent greater daily weight gain, and demonstrated more mature motor behaviors at the end of the 10-day course of massage therapy (Field, 1993).

A study comparing 52 hospitalized depressed and adjustment-disorder children and adolescents with a control group that viewed relaxation videotapes found that the massage therapy subjects were less depressed and anxious and had lower saliva cortisol levels (an indicator of less depression) (Field et al., 1992).

Another study showed that massage therapy produced relaxation in 18 elderly subjects. This study demonstrated physiological signs of relaxation in measures such as decreased blood pressure and heart rate and increased skin temperature (Fakouri and Jones, 1987).~A combination of Swedish massage, shiatsu, and trigger point suppression in 52 subjects with traumatically induced spinal pain led to significant alleviations of acute and chronic pain and increased muscle flexibility and tone. This study also found massage therapy to be extremely cost-effective in comparison with other therapies, with savings ranging from 15 percent to 50 percent (Weintraub, 1992a, 1992b). Massage has also been shown to stimulate the body's ability to control pain naturally; in one study, massage stimulated the brain to produce endorphins, the neurochemicals that control pain (Kaarda and Tosteinbo, 1989). Fibromyalgia, a painful type of inflammation, is an example of a condition that may be favorably affected by this mechanism.

A pilot study of five subjects with symptoms of tension and anxiety found a significant response to massage therapy based on one or more psychophysiological parameters, including heart rate, frontalis and forearm extensor electromyograms, and skin resistance; these changes denote relaxation of muscle tension and reduced anxiety (McKechnie et al., 1983).

~Another study found that massage therapy can have a powerful effect on psychoemotional distress in persons suffering from chronic inflammatory bowel disease. Stress can worsen the symptoms of ulcerative colitis and Crohn's disease (ileitis), which can cause great pain and bleeding and even lead to hospitalization or death. Massage therapy was effective in reducing the frequency of episodes of pain and disability in these patients (Joachim, 1983).

Lymph drainage massage has been shown to be more effective than mechanized methods or diuretic drugs to control lymphedema (a form of swelling) secondary to radical mastectomy (removal of breast tissues). It is expected that using massage to control lymphedema will significantly lower treatment costs (Zanolla et al., 1984).

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Research opportunities. The pace of research in the United States involving massage therapy appears to be increasing, and the activities of OAM may play a supportive role. A list of studies (directed by Tiffany Field) under way at the Touch Research Institute of the University of Miami Medical School illustrates the range of possibilities for research:

~ • Infant studies--infants exposed to human immunodeficiency virus (HIV), depressed infants, infant colic, sleep disorders, and pediatric oncology.

• Child studies--asthma, autism, posttraumatic stress disorder following natural disasters, neglected and abused children in shelters, preschool behavior, pediatric skin disorders, diabetes, and juvenile rheumatoid arthritis.

• Adolescent studies--depressed adolescent mothers, adolescent mothers after childbirth, and eating disorders.

• Adult studies--job performance and stress, eating disorders, pregnancy and neonatal outcome, hypertension, HIV-positive adults, spinal cord injuries, fibromyalgia syndrome, rape and spouse abuse victims, and couples therapy.

• Elderly studies--volunteer foster grandparents giving and receiving massage, and arthritis.~Research recommendations. The preceding section indicates the diversity and breadth of applications of massage therapy and suggests the range of possibilities for future research.

General studies of the efficacy and effectiveness of massage therapy are still needed. Outcome studies are recommended that would allow massage therapists to work in a manner and setting that approximate actual working conditions as much as is possible. Cost-effectiveness studies also are needed. Several of the studies cited in this report have indicated that massage therapy provides substantial cost savings; this is a critical issue related to health care reform. To verify the savings, some of the more recent studies should be replicated as part of this approach.

There are numerous possibilities for studying effects of massage on many health conditions:

• Since massage therapy is especially effective with soft-tissue problems, studies involving muscle strains, sprains, tendinitis, problems related to acute and chronic muscle tension, and other such conditions would be useful, as would studies of the effect of massage on the ~tissue healing process.

• Because research offers mounting evidence that a significant percentage of health problems can be attributed to stress and that stress reduction can be a powerful means of preventing or treating such problems, studies of the stress-reduction effects of massage therapy would be valuable.

• Another question that needs to be addressed is whether massage can cause cancerous tumors to metastasize.

• The various subject areas under investigation at the Touch Research Institute are also examples of areas that merit further study.

Barriers and key issues. Several barriers and key issues need to be addressed to make research on massage therapy more productive:

~ • Study design. A key issue related to research is the need for researchers to collaborate with massage therapists during the design stage of a study. Some previous studies used massage in an inappropriate or ineffective manner. For example, the duration of massage is an important factor; a common error is use of massage sessions that are too brief to be effective. Another error is the choice of techniques that are not effective.

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• Appropriate use of therapists. Properly qualified and skilled massage therapists should be used in each study. Some studies have been carried out in which individuals who were untrained or undertrained applied massage; it then became impossible to discern whether any negative results meant that massage was ineffective or that it was not applied properly.

• Collaborations. Since few individuals are both doctorate-level researchers and massage therapists, it is recommended that NIH facilitate collaboration between researchers and massage therapists. Researchers would benefit by knowing more about interesting and promising possibilities for research, resources available from the massage therapy profession, and massage therapy itself. Massage therapists would benefit by being able to ~locate researchers with whom to collaborate (1) to pursue study ideas and (2) to have a better understanding of the needs of researchers and the research process itself.

• Translations. Because many studies are in foreign languages, translations of such studies are needed.

• Regulatory barriers. Another key issue is the existence of barriers to practice that hinder massage therapists; these must be removed. In some States, regulatory boards use powers granted through licensing laws to limit the practice of legitimate massage therapy by qualified massage therapists. These barriers also restrict the ability to conduct research on massage therapy in traditional settings, such as clinics and hospitals, thereby hampering research efforts.

If regulatory, insurance payment, and research barriers are not removed, they will inhibit progress regarding massage therapy, along with other forms of alternative health care.

~Pressure Point Therapies     » top of this page

Pressure point therapies use finger pressure on specific points--usually related to the oriental meridian points (see the glossary), but also other neurological release points--to reduce pain and treat various disease states. There are antecedents in Europe, Asia, and the United States. Adamus and A'tatis described a pressure system in 1582, and the sculptor Cellini (1500-71) wrote of using pressure points to relieve pain. In 1770 the Jesuit Amiat contributed to European understanding with an article on Chinese pressure point "massage." This article influenced the Swedish therapeutic massage pioneer Ling. In turn, Swedish therapeutic massage influenced traditional Japanese folk massage in the early 20th century, and this cross-fertilization became known as shiatsu. About 1913, Fitzgerald, an American, developed what came to be known as zone therapy. Fitzgerald had been influenced by Bressler in Europe. The use of pressure points has evolved under several systems, some of which are discussed below.

Reflexology. Fitzgerald's work with hand reflex points was developed and promoted by ~Ingram in the United States and Marquardt in Europe. Because in this system specific "zones" on the feet are related to specific organs, the system is often called zone therapy. There is a related system of hand zone therapy as well. The results reported for the process include relief of pain; release of kidney stones; and recovery from the effects of stroke, sinusitis, sciatica, and menstrual and other disorders (Marquardt, 1983).

Traditional Chinese massage. Traditional Chinese remedial massage methods were described in the texts of the Han period (202 B.C. to circa 220 A.D.). By the Tang Dynasty (618-907 A.D.), these systems were taught in special institutes. Both "tonification" (energizing) and "sedation" techniques are used to treat and relieve many medical conditions. Major techniques in use are

• ma, rubbing with palm or finger tips;

• pai, tapping with palm or finger tips;

~ • tao, strong pinching with thumb and fingertip;

• an, rapid and rhythmical pressing with thumb, palm, or back of the clenched hand;

• nie, twisting, with both thumbs and tips of the index fingers grasping and twisting the area being treated;

• ning, pinching and lifting in a stationary position;

• na, moving while performing ning; and

• tui, pushing, often with slight vibratory effect.

These techniques are usually used in combinations. Two prominent groupings of techniques are known as an-mo and tui-na.

~Widely varying illnesses and conditions are treated with traditional Chinese massage, including the common cold, sleeplessness, leg cramps, painful menses, whooping cough, diarrhea, abdominal pains, headache, asthma, rheumatic pains, stiff neck, colic, bed-wetting, nasal bleeding, lumbago, and throat pains.

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Acupressure systems. Currently, four systems in which the fingers manipulate the oriental meridian system are in widespread use in the United States. In all these systems, pressure is applied to meridian points (acupuncture points on the meridians; also called acupoints) to stimulate or sedate them. Amounts of pressure and length of application vary according to the system, the ailment, and the intent. All of these systems--shiatsu, tsubo, jin shin jyutsu, and jin shin do--rely on traditional oriental medical theory (see the "Alternative Systems of Medical Practice" chapter), although their treatment methods vary considerably.

Shiatsu and tsubo rely largely on sequenced applications of pressure applied from one end of each meridian to the other. The patient reclines, usually lying on the back and then the front for approximately equal periods as the practitioner uses thumb pressure to stimulate the ~point through a combination of direct pressure and transference of qi (see the glossary) to the point from the practitioner's thumb. "Barefoot shiatsu" is a form that uses foot pressure to stimulate the meridian points. Sessions typically treat the meridians of the entire body in an attempt to bring relaxation, harmony, and balance to the patient. Shiatsu, which is traditional in Japan, has been used in the United States quite extensively for about 20 years. Therapy sessions have a strong focus on long-term health improvement. Procedures include specific treatments for a variety of functional disorders as well as postural, stress-related, and emotional problems. Conditions that have been improved include headache, asthma, bronchitis, diarrhea, depression, and circulatory problems (Namikoshi, 1969).

Jin shin jyutsu and jin shin do have developed sequences of meridian point pressure applications that are specific to the ailment being addressed. These systems are used more often than shiatsu and tsubo as alternative treatment approaches. Jin shin jyutsu, the "art of circulation awakening," was developed in Japan by Jiro Murai in the early 1900s and brought to the United States in the 1960s by Mary Iino Burmeister. It is the antecedent of jin shin do, which was developed in the United States by Iona Teeguarden in the 1980s. ~Sessions are primarily for treatment of specific problems. The approach is similar to that of acupuncture, as the meridian connections to the organs are understood and applied, but from somewhat different application perspectives. Pressure is applied to the meridian points, which are then held in specific patterns, to tonify or detonify (energize or enervate) the meridian qi. Conditions addressed include a wide range of organic dysfunctions (Teeguarden, 1987).

Postural Reeducation Therapies     » top of this page

Three prominent therapies in the United States use as their approach the reeducation of the body through movement and physical touch. In all three systems--Alexander, Feldenkrais, and Trager--patients are taught how to retrain their bodies to come into alignment to release and change postural faults, to improve coordination and balance, and to relieve structural and functional stress. A major principle underlying the three methods is that awareness has to be experienced rather than taught verbally. The awareness may then lead to more effective use of one's whole self.~Alexander technique. The Alexander method is a system of body dynamics, especially in respect to the head, neck, and shoulders. The technique was developed by the actor F.M. Alexander, who created the method after concluding that bad posture was responsible for his chronic periods of voice loss (Maisel, 1989). The technique includes simple movements that improve balance, posture, and coordination and relieve pain. During a session the client typically goes through a series of standing and seated exercises while the practitioner applies light pressure to points of contraction in the body. These pressures are intended to awaken kinesthetic response (sensitivity to motion by the muscles) and retrain the kinesthetic organs in the joints to their proper spatial relationship. The process is taught in many drama schools and is popular with performers. The techniques help clients learn how to use their bodies with less tension and more awareness and efficiency.

Alexander practitioners report success with neck and back pain, postural disorders, whiplash injury, breathing problems, myalgia, rheumatica, repetitive strain injury, hypertension, anxiety, stress, and other chronic conditions.

~Feldenkrais method. The Feldenkrais method was developed by Moshe Feldenkrais, a Russian-born Israeli physicist, who turned his attention to the study of human functioning. His work integrated an understanding of the physics of the body's movement patterns with an awareness of the way people learn to move, behave, and interact (Feldenkrais, 1949, 1972, 1981, 1985). He began teaching his method in North America in the early 1970s. The Feldenkrais method consists of two branches--"awareness through movement" and "functional integration."

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• Awareness through movement. This verbally directed form of the Feldenkrais method consists of gentle exploratory movement sequences organized around a specific human function (such as reaching, bending, or walking) with the intention of increasing awareness of multiple possibilities of action. A group of students may be standing, sitting, or lying on the floor. Thinking, sensory perception, and imagery are also involved in examining each function.

• Functional integration. This method involves the practitioner's use of words and gentle, ~noninvasive touch to guide an individual student to an awareness of existing and alternative movement patterns. The teacher communicates to the student--who may be lying, sitting, standing, kneeling, or in motion--how she or he organizes herself or himself and suggests additional choices for functional movement patterns. The use of touch is for communication, not correction, and there are no special techniques of pressing or stroking. Any changes in functioning result from the student's actions.

Practitioners report success with a variety of postural and functional disorders in such diverse applications as sports performance, equine training, physiotherapeutics, zoo animal rehabilitation, the performing arts, neurological and orthopedic physical therapy practice, pain management, and habilitation of developmentally impaired children.

Currently, the North American Feldenkrais Guild has approximately 1,000 members. As of January 1994, 31 training programs lasting 3 to 4 years were available around the world for Feldenkrais practitioners.

~The method is a synthesis of modern ideas and basic research findings in perception, motor learning, neural plasticity, and sensory integration (Edelman, 1987; Georgopolus, 1986; Jacobson, 1964; Jenkins and Merzenic, 1987; Jenkins et al., 1990; Kaas, 1991; Kandel and Hawkins, 1992; Seitz and Wilson, 1987; and Sweigard, 1974). Only limited clinical research studies have been conducted to document the Feldenkrais method. Clinical successes have been cited in several review articles and clinical guidelines for physical therapy and pain management (DeRosa and Porterfield, 1992; Jackson, 1991; Lake, 1985; and Shenkman and Butler, 1989) and have included reports on exercise for the elderly and for persons recovering from spinal injury (Ginsberg, 1986; Gutman, 1977).

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In one research study, Jackson-Wyatt and colleagues (1992) used video analysis to measure the kinetics of the change in motor ability in a vertical jump test in a subject who completed eight 5-day weeks of 6-hour training days in a Feldenkrais practitioner training program. Dramatic improvement in power, velocity, and movement efficiency were demonstrated.

~Narula (1993) similarly examined the sit-to-stand movement, walking speed, and grip strength of four subjects with class 2 rheumatoid arthritis. After attending a twice-weekly 75-minute class for 6 weeks, all subjects showed decreased pain, improved walking performance, and improved kinetics of the sit-to-stand movement, but no improvement in grip strength. The results suggest that lessons in awareness through movement could be used by individuals to improve their functions despite long-term disabling medical conditions.

Ruth and Kegerries (1992) used a 25-minute, four-step process to test the flexion range of neck motion in college students before and after half the group received a 15-minute sequence from the awareness through movement methods. Compared with the control group, students experiencing this sequence showed measurably improved neck flexion motion and a decrease in the perceived effort to accomplish this motion.

Since Feldenkrais's functional integration method involves a highly individual interaction between practitioner and client, outcomes research should be long-term, using both subjective and objective measures. Such studies could establish whether various applications ~of the Feldenkrais method are useful both for medical care and in educational systems.

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Trager psychophysical integration. The Trager method uses light, rhythmic rocking and shaking movements that loosen joints, ease movement, and release chronic patterns of tension. This method was developed by a Hawaiian physician, Milton Trager, on the basis of his experience as a trainer for the sport of boxing. The Trager practitioner uses his or her hands with the aim of influencing deep-seated psychophysiological patterns in the client's mind and interrupting the projection of those patterns into body tissues.

This method of movement reeducation is distinguished by compressions, elongations, and light bounces as well as rocking motions. These actions cause patients or clients to begin to experience freedom of movement of their body parts. Since practitioners believe they are affecting the inhibiting patterns at their source, it is expected that clients can experience long-lasting gains.

The goal of Trager work is general functional improvement, partly by creating a feeling of ~pleasure in being able to move body parts more freely. The process incorporates a meditative state called "hookup," which is intended to enhance sensory, kinesthetic, and other pleasurable experiences for the client.

Several case histories describe long-term improvement in movement function for persons with multiple sclerosis; in chest mobility with lung disease (Witt and MacKinnon, 1986); and in trunk mobility with childhood cerebral palsy (Witt and Parr, 1986). Other reports suggest success in treating chronic pain of various sorts, headaches, muscular dystrophy, muscle spasms, temporomandibular joint pain, recovery from stroke, spinal cord injuries, and polio.

The Trager method also includes Trager "mentastics," a system of mentally directed physical movements developed to maintain and enhance a sense of lightness, freedom, and flexibility. Mentastics is used by Trager practitioners and is taught to clients to enhance results.

There are now more than 800 certified Trager practitioners around the world. Training is available in the United States and several other countries.~Structural Integration (Rolfing)

Unlike most systems of body manipulation, which are concerned with the muscular system or the skeletal systems or both, structural integration focuses on the fascias, which are sheets of connective tissue. Ida Rolf, whose work was the foundation of the various systems of structural integration, noted that while bones support the body and muscles connect the bones. It is the enwrapping fascias that support and hold the muscle-bone combinations in place. Rolf's second precept was that the fascias would maintain not only the normal relationship of bone and muscle but also whatever postural misalignment the body might adopt. This misalignment could incorporate effects of trauma as well as poor posture.

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Later theorists have used renowned architect and designer Buckminster Fuller's "tensegrity mast" as an explanatory model for the relationship of the bones and fascias. In this structure, none of the solid elements are connected directly together but are held by tensioned wires. The structure becomes a model for the body if the solid segments are called the bones and the flexible wires are called the fascias (Robie, 1977).~When the body attempts to distribute the stress of an injury, the result is likely to be shortened and thickened fascias, which may in turn lead to symptoms somewhere other than the site of the original trauma. Structural integration is a system to "unwind" and stretch the distorted fascias back to their normal condition, thereby allowing the bones and muscles to come back to normal alignment and the body to return to normal functioning. Structural integration, or "Rolfing," involves stretching the fascia sheaths by applying sliding pressure to the affected area with fingers, thumbs, and occasionally elbows. In its early days, the process was known to be quite painful, but later refinements in technique have made Rolfing considerably more comfortable.

Rolf postulated that the plasticity of the fascias in the body could offset the aging process (Rolf, 1973). Research in Rolfing has suggested beneficial results with cerebral palsy in children (Perry et al., 1981), state-trait anxiety (i.e., a person's current anxiety state or level is measured against his or her anxiety traits) (Weinberg and Hunt, 1979), the stress and symptoms of lower back pain and whiplash (Rolf, 1977), and changes in parasympathetic tone (degree of vigor and tension of muscles innervated by parasympathetic nerves) ~(Cottingham et al., 1988a, 1988b). Changes in psychological and physiological function have also been measured (Silverman et al., 1973).

The Rolf Institute, the first school to teach the principles of structural integration, offers a post-bachelor's degree training program requiring 28 weeks of classroom work. Today there are also three other schools based on Rolf's work and 1,500 practitioners who treat an estimated 150,000 individuals per year. Licensing requirements differ in various States.

Aston patterning, developed by Judith Aston, and Hellerwork, developed by Joseph Heller, are major offshoots of structural integration. Both incorporate movement reeducation training to bring the body into fuller activity and expression.

Bioenergetical Systems    » top of this page

Several therapeutic systems using manual healing are designed to release bodily held emotions through various combinations of activity on the part of the client and applied ~pressure or holding on the part of the practitioner. These systems derive from Wilhelm Reich's original observations about bodily held emotions and his work with patients and clients to release emotion (Reich, 1973). In this work, the client assumes and holds one of several different postures, either seated or reclining. Simultaneously, the practitioner applies pressure to areas of abnormal stress that are revealed by the posture. The client may then be invited to breathe deeply into the stressed area. The combination of external, inwardly directed pressure and outwardly directed breath exaggerates holding patterns that have become so deeply imbedded that the client is no longer aware of them. Release of the emotion can be quite pronounced, resulting in spontaneously revealed insight, increased freedom of movement, and new social postures. Individual releases during the process may be accompanied by pronounced but brief periods characterized by increased body heat, tingles, and reported rushes of "energy."

Bioenergetics, core energetics, Lowenwork, neo-Reichian therapy, radix, and some other methods derive from Reich's basic approach.

~Although some psychotherapists incorporate various forms of this work into their practices, there are constraints in some States because of ethical questions about touching the client. Discussions with various psychotherapists indicate that some would like to include these therapies but fear to do so at this time, when the legal and ethical considerations have not been resolved. Those who do the work operate in a dual capacity--as psychotherapist and bioenergetic body worker. However, they do not apply touch during straight psychotherapy sessions, and the straightforward touch used during the body work is clinically applied pressure and not sensually evocative.

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