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Shiatsu, similar to acupressure, uses finger pressure, manipulations and stretches, along Traditional Chinese Medicine meridians. Shiatsu is popular in Europe, but lacks reviews on its evidence-base. Acupressure and Shiatsu clinical trials were identified using the MeSH term 'acupressure' in: EBM reviews; AMED; BNI; CINAHL; EMBASE; MEDLINE; PsycARTICLES; Science Direct; Blackwell Synergy; Ingenta Select; Wiley Interscience; Index to Theses and ZETOC. References of articles were checked. Inclusion criteria were Shiatsu or acupressure administered manually/bodily, published after January 1990. Two reviewers performed independent study selection and evaluation of study design and reporting, using standardised checklists (CONSORT, TREND, CASP and STRICTA). Searches identified 1714 publications. Final inclusions were 9 Shiatsu and 71 acupressure studies. A quarter were graded A (highest quality). Shiatsu studies comprised 1 RCT, three controlled non-randomised, one within-subjects, one observational and 3 uncontrolled studies investigating mental and physical health issues. Evidence was of insufficient quantity and quality. Acupressure studies included 2 meta-analyses, 6 systematic reviews and 39 RCTs. Strongest evidence was for pain (particularly dysmenorrhoea, lower back and labour), post-operative nausea and vomiting. Additionally quality evidence found improvements in sleep in institutionalised elderly. Variable/poor quality evidence existed for renal disease symptoms, dementia, stress, anxiety and respiratory conditions. Appraisal tools may be inappropriate for some study designs. Potential biases included focus on UK/USA databases, limited grey literature, and exclusion of qualitative and pre-1989 studies. Evidence is improving in quantity, quality and reporting, but more research is needed, particularly for Shiatsu, where evidence is poor. Acupressure may be beneficial for pain, nausea and vomiting and sleep.
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RESEARC H ARTIC L E Open Access
The evidence for Shiatsu: a systematic review of
Shiatsu and acupressure
Nicola Robinson
1
, Ava Lorenc
1*
and Xing Liao
2
Abstract
Background: Shiatsu, similar to acupressure, uses finger pressure, manipulations and stretches, along Traditional
Chinese Medicine meridians. Shiatsu is popular in Europe, but lacks reviews on its evidence-base.
Methods: Acupressure and Shiatsu clinical trials were identified using the MeSH term acupressurein: EBM reviews;
AMED; BNI; CINAHL; EMBASE; MEDLINE; PsycARTICLES; Science Direct; Blackwell Synergy; Ingenta Select; Wiley
Interscience; Index to Theses and ZETOC. References of articles were checked. Inclusion criteria were Shiatsu or
acupressure administered manually/bodily, published after January 1990. Two reviewers performed independent
study selection and evaluation of study design and reporting, using standardised checklists (CONSORT, TREND,
CASP and STRICTA).
Results: Searches identified 1714 publications. Final inclusions were 9 Shiatsu and 71 acupressure studies. A quarter
were graded A (highest quality). Shiatsu studies comprised 1 RCT, three controlled non-randomised, one within-
subjects, one observational and 3 uncontrolled studies investigating mental and physical health issues. Evidence
was of insufficient quantity and quality. Acupressure studies included 2 meta-analyses, 6 systematic reviews and 39
RCTs. Strongest evidence was for pain (particularly dysmenorrhoea, lower back and labour), post-operative nausea
and vomiting. Additionally quality evidence found improvements in sleep in institutionalised elderly. Variable/poor
quality evidence existed for renal disease symptoms, dementia, stress, anxiety and respiratory conditions. Appraisal
tools may be inappropriate for some study designs. Potential biases included focus on UK/USA databases, limited
grey literature, and exclusion of qualitative and pre-1989 studies.
Conclusions: Evidence is improving in quantity, quality and reporting, but more research is needed, particularly for
Shiatsu, where evidence is poor. Acupressure may be beneficial for pain, nausea and vomiting and sleep.
Background
Shiatsu is a form of complementary and alternative
medicine (CAM) which primarily developed in Japan
[1]. Both Shiatsu and acupressure have roots in Chinese
medicine and embrace the philosophy of Yin and Yang,
the energy meridians, the five elements and the concept
of Ki, or energy. This concept of affecting the balance of
energy through acupoints on the meridians is similar to
acupuncture where needles or heat is applied to acu-
points [2]. Shiatsuliterally means finger pressure,but
uses gentle manipulations, stretches and pressure using
fingers, thumbs, elbows, knees and feet. Shiatsu
incorporates acupressure, which is similar but applies
pressure for longer on specific pressure points on meri-
dians, following Traditional Chinese Medicine (TCM)
theory. Shiatsu tends to cover the whole body[3].
Shiatsu diagnosis is primarily through touch, rather than
TCM which primarily uses the pulse diagnosis and
inspection of the tongue. Shiatsu practitioners are
trained in the anatomical location, functions and uses
over 150 pressure points on the body. Evidence for the
efficacy of acupressure may therefore potentially support
claims about the efficacy of Shiatsu [4].
Shiatsu is practiced in many European countries but
varies in styles, philosophical approaches and theoretical
bases. The approaches most commonly found in Britain
are Zen Shiatsu, Macrobiotic Shiatsu, Healing Shiatsu,
Tao Shiatsu, Seiki, Namikoshi Shiatsu and Hara Shiatsu)
[3,5].
* Correspondence: lorenca@lsbu.ac.uk
Contributed equally
1
Allied Health Sciences Department, Faculty of Health and Social Care,
London South Bank University, 103 Borough Road, London SE1 0AA, UK
Full list of author information is available at the end of the article
Robinson et al.BMC Complementary and Alternative Medicine 2011, 11:88
http://www.biomedcentral.com/1472-6882/11/88
© 2011 Robinson et al; licensee BioMed Central Ltd. This is an Open Access article distr ibuted under the terms of the Creative
Commons Attri bution License (http://creativecommons.org /licenses/by/2.0), which permits unrestricte d use, distribution, and
reproductio n in any medium, provided the original work is properly cited.
Shiatsu aims to balance, restore and maintain the
bodys energy balance and prevent the build up of stress
in the UK. The most common conditions presenting for
treatment are musculo-skeletal and psychological pro-
blems[6]. Health problems which may be amenable to
treatment by Shiatsu include: headaches, migraine, stiff
necks and shoulders, backaches, coughs, colds, men-
strual problems, respiratory illnesses including asthma
and bronchitis, sinus trouble and catarrh, insomnia, ten-
sion, anxiety and depression, fatigue and weakness,
digestive disorders and bowel trouble, circulatory pro-
blems, rheumatic and arthritic complaints, sciatica and
conditions following sprains and injuries [3]. Shiatsu is,
however, a holistic therapy and often also impacts a
patients well-being, lifestyle, diet, body/mind awareness
[7]. Shiatsu is commonly used by older (median age of
50 in the UK) females [7].
This review aimed to identify the evidence base
informing the practice of Shiatsu. Due to the lack of
Shiatsu specific literature and overlap in practice and
theory, acupressure studies were also included. Although
there are a number of systematic reviews for acupres-
sure,theyweremostlyconfinedtoasingle(Western)
condition such as nausea and vomiting [8] or dysmenor-
rhoea [9].
Objectives
To systematically review all papers using Shiatsu or acu-
pressure for any health condition for any population,
using either a systematic review/meta-analysis, RCT,
quasi-experimental, or uncontrolled design.
Methods
Eligibility criteria
Inclusion criteria were:
Shiatsu or acupressure administered manually/
bodily
Meta-analysis, systematic review or clinical trial
Published after January 1990
Exclusions were:
Guidelines for treatment, reports of possible
adverse events, surveys, case reports/series, non sys-
tematic reviews, qualitative studies, conference
abstracts/posters
Newspaper articles, book reviews, popularhealth
publications, general comments or letters.
Papers included in systematic reviews included in
this review
Papers in a language other than English
Use of plasters, devices, or wristbands
Acupressure on auricular or Korean points/
meridians
Information sources
Databases searched were: EBM reviews (includes all
Cochrane Library resources); Allied and Complementary
Medicine (AMED);British Nursing Index (BNI);Cumula-
tive Index to Nursing & Allied Health Literature
(CINAHL); EMBASE; MEDLINE; PsycINFO/PsycARTI-
CLES; Science Direct; Blackwell Synergy; Ingenta Select;
Wiley Interscience; Index to Theses and ZETOC (British
Library electronic table of contents). In addition the
references of retrieved articles were checked to identify
any further studies.
Search
The MeSH term tree acupressurewas used which
incorporates Shiatsu. For databases not using MeSH
terms, shiatsuor acupressurewere used.
Study selection
Study selection was independently performed by two
reviewers using the inclusion/exclusion criteria given
above, followed by discussion and consensus within the
research team. The first stage of selection used the
abstracts, the second stage the full text of the papers.
Data collection process
For each study the following data was extracted inde-
pendently by two reviewers using a standardised extrac-
tion form. Any disagreements were moderated by a
third reviewer.
Authors
Date
Study design (meta analysis, systematic review, ran-
domized controlled trial, case control trial or uncon-
trolled study)
Health condition
Setting
Sample
Intervention
Outcome measures
Results
Conclusion
Quality assessment
The contribution made to the evidence base by each
study, based on the study design, rigour of methods and
reporting, was evaluated independently by two
reviewers, with an independent adjudicator. Studies
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were evaluated on the following quality indicators to
determine its contribution to the evidence base:
The rigour of the study conducted was determined
using a critical appraisal checklist [10]
Adapted STRICTA score for quality of reporting of
the intervention (acupressure only, not Shiatsu) for
each study [11] (reported as a score out of 16 rele-
vant items - item 2 g on STRICTA, needle type was
not relevant)
Quality of reporting, assessed using established
checklists: CONSORT guidelines for RCTs[12];
CASP guidelines for systematic reviews [13]; and
TREND statement for non-randomised studies [14].
Study design (according to the hierarchy meta-ana-
lysis > systematic review > RCT > controlled trial >
uncontrolled trial), as discussed in the NICE guide-
lines manual, section 6 [15].
Studies were graded A (good), B (fair/moderate) or C
(poor) depending on these indicators. Results of this
evaluation are given for each study in Additional file 1.
Synthesis of results
Studies were grouped into either Shiatsu or acupressure
and within these categories according to health condi-
tion treated. For each health condition evidence was
categorised according to criteria from Waddell [16].
Category 1: Generally consistent finding in a range of
evidence from well-designed experimental studies
Category 2: Either based on a single acceptable study,
or a weak or inconsistent finding in some multiple
acceptable studies.
Category 3: Limited scientific evidence, which does
not meet all the criteria of acceptable studies, or an
absence of directly applicable studies of good quality.
This includes published and unpublished expert opinion.
This review has been reported according to the princi-
ples in the PRISMA statement [17] and acupoints are
reported using the WHO system [18]
Results
Study selection
After carrying out the database searches, a total of 1714
publications were identified (Figure 1). After duplicate
items, newspaper articles and commentaries were
removed 1285 items remained. From screening the
abstracts 933 articles were excluded. Two reviewers
screened the full texts of the remaining 351 articles
using exclusion criteria and quality assessment and
excluded 206. Of those remaining, 56 were used for
background information only, leaving 89 studies. A
further 9 were excluded as they were already included
in systematic reviews included in this review. The total
included studies were 9 Shiatsu and 71 acupressure
publications.
Details of included studies are presented in Additional
file 1, grouped by health condition. Just under one third
(27.5%) were graded A (highest quality), 42.5% graded B
and 26.3% C (lowest quality) (3 studies were ungraded);
this grading refers to the contribution the study made
to the evidence, which took into account study design,
rigour and reporting.
Shiatsu
Only 9 Shiatsu studies were of sufficient quality to be
included in the review. These comprised 1 randomised
controlled trial (RCT), three controlled non-randomised,
one within-subjects trial, one observational study and 3
uncontrolled studies. These studies investigated quite
separate health issues, did not use comparable metho-
dology and data could not be pooled due to their het-
erogeneity. Subjects were chronic stress, schizophrenia,
promoting well-being and critical health literacy, angina,
low back and shoulder pain, fibromyalgia, chemotherapy
side effects/anxiety and inducing labour. They are
grouped by methodology and discussed below.
One RCT was identified (integrated care, which
included Shiatsu), for back and neck pain [19]. No sig-
nificant effects, compared to standard care were identi-
fied. The study used a fairly large sample (n = 80) but
was underpowered to detect any statistically significant
effects.
Three studies compared two or more treatments with
non-random group allocation, rather by preference [20],
participants in another study [21] or staff on duty [22].
Figure 1 Flowchart of study selection.
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Lucini et al [20] evaluated Shiatsu for chronic stress; 70
volunteer patients chose either active (relaxation and
breathing training), passive (Shiatsu) or sham treatment
(stress management information). Small sample, limited
the validity of results. Although the design accounted
for patient preference, results were confounded by more
stressed patients choosing sham. Ingram [22] compared
Shiatsu to no intervention for post-term pregnancy in
142 women. The Shiatsu group was significantly more
likely to labour spontaneously than the control (p =
0.038) and had a longer labour (p = 0.03), but groups
were allocated according to which midwife was on duty
(although groups were homogenous for maternal age,
parity and delivery details). Ballegaard et al [21] con-
ducted a study of cost-effectiveness and efficacy of
Shiatsu for angina pectoris. Sixty-nine consecutive
patients were treated and compared with those from a
separate trial of two invasive treatments for angina[23].
Incidence of death/myocardial infarction (MI) was 7% in
this sample, compared to 21% and 15% in the compari-
son group with no significant difference in pain relief.
Additionally a cost-saving of $12000 per patient was
estimated. The groups were from different countries
(USA and Denmark), additionally 56% of the partici-
pants would have been excluded from the one of the
comparison groups. It also used a convenience and
unpowered sample and no blinding.
One study used a within-subjects repeated measures
design, comparing Watsu (water Shiatsu) with Aix mas-
sage for fibromyalgia syndrome [24]. A significant
improvement was seen after treatment with Watsu (p =
0.01) for SF-36 subscales of physical function, bodily
pain, vitality and social function, but not for Aix. The
repeated measures design with counterbalancing should
reduce carryover effects although order effects may have
occurred due to high dropout. In addition it used a
volunteer sample.
Three studies had no separate control group, using a
single group pretest-posttest design[25-27], limiting the
validity of results. Lichtenberg et als [27] pilot study of
Shiatsu for schizophrenia showed significant improve-
ments on scales relating to illness, psychopathy, anxiety,
depression and others (p values ranged from 0.0015 to
0.0192). Brady et al [26] tested Shiatsu for lower back
pain in 66 volunteers. Pain and anxiety significantly
decreased after treatment (p < 0.001), which did not
change when demographic variables were controlled for.
Iida et al [25] investigated the relaxation effects of
Shiatsu on anxiety and other side effects in 9 patients
receiving cancer chemotherapy. The small and self-
selected samples and lack of control group in these stu-
dies limits the quality and generalisablity of the results.
In addition 13 of Brady et als [26] participants had pre-
viously received Shiatsu
Long (2008) conducted a prospective observational
study of 948 patients of Shiatsu practitioners in 3 differ-
ent countries[7]. Significant improvement in symptoms,
especially for tension or stress and structural problems
(effect size 0.66 to 0.77) were demonstrated. This study
is of greater quality than other Shiatsu studies as the
sample size was powered and it used a longitudinal and
pragmatic study design. For a longitudinal observational
design, this study had a good response rate (67% of
patients on average returned all questionnaires). Recruit-
ment of patients was through practitioners, who
received a rigorous training and kept a recruitment log.
Confounding factors are reported and outcomes were
accurately measured. However, data on non-respondents
or those who refused to participate were not reported
so evaluation of response bias is problematic.
Sundberg et al [19] and Ballegaard [21] used a prag-
matic design - Shiatsu as part of an integrated model of
healthcare or with other interventions (acupuncture and
lifestyle adjustment). This reflects normal practice but
specific effects of Shiatsu cannot be isolated.
There was insufficient evidence both in quantity and
quality on Shiatsu in order to provide consensus for any
specific health condition or symptom.
Acupressure
Of a total of 71 included studies described as giving
acupressure as an intervention, 2 were meta-analyses, 6
systematic reviews, 39 RCTs, five crossover trials, 5
within-subjects trials, 5 controlled non-randomised, 7
uncontrolled trials and 1 prospective study. These are
summarised by health condition below.
Pain
Pain was the most common issue addressed by acupres-
sure studies and covered a range of topics. This
included a systematic review, six RCTs with control
groups and random assignment; 2 with non-randomised
control groups or within-subject controls, and the
remainder either did not have a control or random
assignment. Overall, the evidence for the efficacy of acu-
pressure for pain is fairly strong and can be graded as
category 1 evidence. Although some studies had metho-
dological flaws, studies consistently show that acupres-
sure is more effective than control for reducing pain,
namely dysmenorrhoea (acupressure at SP6) [9,28-30],
lower back pain [31-33] and labour pain [34,35]. The
evidence for minor trauma [36,37] and injection pain
[38,39] is less conclusive and the evidence for headache
is insufficient [40]. Each pain condition is discussed
below.
Dysmenorrhoea
Of 4 papers for dysmenorrhoea, 1 was a systematic
review 2 were RCTs, and one non equivalent control
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group. All studied school or university students, with
sample sizes ranging from 30 to 216. Two used acupres-
sure on SP6, The other used a combination of points.
Both of the RCTs [28,30] compared acupressure to rest,
which does not control for the placebo effect. Jun et al
[29] compared acupressure to light touch, potentially
controlling for non-specific effects but used sequential
allocation which may create bias, although groups were
homogenous in baseline demographics and dysmenor-
rhoea factors. All studies found a significant reduction
in pain. Studies were generally good quality, with low
attrition rates and validated measures (usually VAS).
Only including students may limit generalisability and
create Hawthorne bias. Acupressure procedure was gen-
erally well-reported; all studies reported 12 or 13
STRICTA items.
Labour pain
Two of the three studies of acupressure for labour pain
were RCTs [34,35]. They both compared acupressure to
touch, thus controlling for the effect of human touch;
Chung et al [34] additionally had a conversation only
control group. The third was a one group uncontrolled
study [41]. Two studies usedLI4 [34,41]; Chung et al
[34] additionally used BL67; Lee et al used SP6 [35]. All
studies found acupressure significantly reduced pain,
Back and neck pain
Four studies on back or neck pain were identified, all
RCTs and conducted by two groups of researchers,
Hsieh et al [31,32] and Yip and Tse [33,42]. Hsieh et al
unusually used a pragmatic design of four weeks of indi-
vidualised acupressure compared to physical therapy.
They also used powered samples, blinding where possi-
ble, valid outcome measures and intention to treat ana-
lysis to protect against attrition bias. A no treatment
group was not included, limiting assessment of specific
effects. Yip and Tse also compared acupressure to usual
care, although an acupressure protocol was used. They
also had powered sample sizes but no blinding. Compar-
ison groups of aromatherapy and electroacupuncture,
limit specific effects of acupressure. All four studies
showed a significant reduction in pain.
Minor trauma
Two double-blind RCTs evaluated acupressure for
minor trauma pain during ambulance transport [36,37].
Both used sham acupressure as a control, with Kober et
al [36] additionally comparing to no treatment. Both
studies showed significant reductions in pain, anxiety
and heart rate. Limitations include fairly small sample
and lack of no-treatment control.
Injection pain
Two studies evaluated acupressure for pain of injection
[38,39]. Both studies showed reduction in pain but both
weresubjecttolimitations-Araietal[39]only
included 22 subjects although it was powered and
randomised, with a sham treatment; Alavi et als [38]
trial was larger and randomised, but used a within-sub-
jects crossover design which can create practice bias.
Headache
Only one study investigated headache [40], comparing a
course of 8 sessions of acupressure to medication, which
reduced pain. Although this used an RCT design, power
calculation, intention-to-treat analysis, blinding and long
follow up, there is very little detail on intervention (only
7 STRICTA items), randomisation, recruitment or
limitations.
Dental pain
One RCT for dental pain [43] compared acupressure at
LI4 to medication or sham acupressure, showing reduc-
tion in pain 4 and 24 hours after the first orthodontic
treatment but not after second treatment. Although an
RCT and well reported, only 23 patients completed the
study, despite a power calculation specifying a sample of
156.
Nausea & vomiting
Nausea and vomiting (N&V) was the second most com-
monly investigated health issue. The evidence was some-
what inconsistent and varied with type of nausea
investigated. Post-operative nausea had strongest evi-
dence, graded as Category 1 evidence mainly due to a
Cochrane systematic review and update [8,44] and a
meta-analysis [45]. The two systematic reviews [46,47]
of chemotherapy-induced N&V give additional quality
evidence, although little is true acupressure. Little reli-
able evidence is added by the RCT [48]. The three stu-
dies of acupressure for nausea in pregnancy are of
variable quality. Although one has a small sample and
uncontrolled study design [49], a well conducted RCT
[50]and meta analysis [51] provide Category 2 evidence
for nausea in pregnancy.
Post-operative
A Cochrane review [44] (update of a previous review
[8]) and meta-analysis [45] indicate the extensive evi-
dence for acupressure in treating postoperative N&V.
All the studies in the review and the majority in the
meta-analysis used acupoint PC6. The review concluded
that acupressure reduced the risk of both N&V com-
pared to sham, and reduced the risk of nausea but not
vomiting compared to antiemetic medication. The meta-
analysis concluded that all modalities of acupoint stimu-
lation reduced postoperative N&V compared to control,
and were as effective as medication. Both reviews were
very high quality with comprehensive search terms and
pooling of data.
Chemotherapy
Acustimulation, including acupressure, for nausea as a
side-effect of chemotherapy also has been reported in a
Cochrane review [46], as well as an RCT published
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subsequently [48] and a non-randomised trial [52]. Chao
et al [47] also covered N&V as part of their review of
adverse effects of breast cancer treatment.
The Cochrane review identified 11 trials and pooled
data demonstrated significantly reduced vomiting but
not nausea [46]. It was very good quality, with inten-
tion-to-treat analysis of pooled data and controlling for
duplicate and language bias.
TheRCT(n=160)[48]wasbasedonapilot[53]
included in the Cochrane review. It found significant
reductions in delayed N&V but not acute N&V, results
facilitated by the unusually long follow-up period. The
main limitations are the lack of sample size calculation
(despite conducting a pilot study) and patients breaking
the blind.
The non randomised study [52] of self-acupressure on
PC6 compared to anti-emesis medication found signifi-
cant reductions in severity of N&V, duration of nausea
and frequency of vomiting compared to control. How-
ever, these results are limited by a small and conveni-
ence sample.
Pregnancy
Three studies investigated N&V in pregnancy: one RCT
[50]; one uncontrolled study [49] and one meta-analysis
[51]. All used acupressure on PC6 (neiguan).
As concluded by the meta-analysis [51], the RCT
found improvements compared to sham or control. Shin
et als RCT [50] is excellent quality with double-blind-
ing, powered sample size, objective and subjective out-
comes and good reporting. Markose et al [49] also
found improvements in nausea, vomiting and retching,
but due to lack of control group, small sample, high
attrition and poor reporting the evidence is limited.
The meta-analysis included studies on all forms of
acustimulation and was generally well conducted,
although it did not attempt to find unpublished material
and only 3 databases were used.
Renal disease
Five papers (based on four RCTs) investigated the use of
acupressure for symptoms of renal disease. Due to lim-
itations, repeated in all studies due to the common
research team, evidence is category 2. Three compared
acupressure to sham points/electrical stimulation and to
usualcare[54-56],thefourthtousualcareonly[57].
The studies used different points for different symp-
toms, including fatigue [55,57], depression [56,57] and
sleep [54,56]. All studies showed improvements com-
pared to control but also found improvements in the
sham/electrical stimulation group compared to control,
suggesting that the effects of acupressure on these
symptoms are non-specific. Sample sizes were between
62 (powered) and 106 and had low attrition rates. One
study used blinding [54], the others may have been
subject to placebo or observer bias. Between 9 and 15
STRICTA items were reported and interventions and
outcome measures were validated.
Sleep and alertness
Five studies investigated acupressure for sleep in elderly
long term care facilities [58-62], and one investigated
alertness in the classroom [63]. Evidence for improving
sleep quality in institutionalised elderly is consistent
from a number of high quality studies and is category 1.
Four of the sleep studies were RCTs [59-62], an addi-
tional single-group pilot study of only 13 people contri-
butes little to the evidence base [29]. The four RCTs all
used different acupoints. Two compared acupressure to
sham points and control (conversation [62]or routine
care [60]) but only one found significant improvements
in sleep for acupressure compared to sham [62], giving
limited evidence for specific effects. Three of the studies
had powered and randomly selected samples (between
44 and 246) [60,62], validated procedure [62], intention-
to-treat analysis or triple blinding [60].
The one study on alertness in the classroom [63]was a
crossover study, randomly assigning 39 students to
either stimulation-relaxation-relaxation or relaxation-sti-
mulation-stimulation. Compared to relaxation, stimula-
tion acupressure improved alertness. Although students
were blinded, the majority correctly discerned the treat-
ment. This did not significantly affect the results,
although it raised p to 0.0484. Potential Hawthorne
effect, small sample size (39) and low generalizability
reduce the quality. Crossover design should reduce
effects of retesting, carryover or time-related effects,
although practise effect may be present (especially with
self-report).
Mental health
Five studies investigated mental health, specifically
dementia [64,65] and stress or anxiety [66-68]. The
quality was very variable, with two pilot studies with
sample sizes of 12 and 31 [64,68], a small one group
study of 25 women [67] and two larger RCTs [65,69].
Category 2 evidence was present for anxiety related to
surgery, although this was compared to sham only[69].
Fairly good evidence existed for agitation in dementia
compared to control, although generalisability was lim-
ited by small sample size, lack of control and high attri-
tion[65]. Evidence for reducing stress, anxiety and heart
rate and thus enhancing spontaneous labour is promis-
ing, but limited by lack of control and a small, volunteer
sample [67].
Chronic respiratory conditions
Six studies on respiratory conditions were identified,
chronic obstructive pulmonary disease (COPD)[70-73],
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chronic obstructive asthma [74] and bronchiectasis [75].
Overall, the evidence is Category 2, as studies were well
designed but had a number of methodological flaws.
Study designs included two controlled trials using ran-
domised blocking design, matching groups for demo-
graphic and clinical factors [71,72]; one crossover design
[70]; two pilot RCTs [74,75] and an RCT [73]. Results
showed improvements in dyspnoea and decathexis com-
pared to sham, although limited by high attrition, poor
blinding and a small sample [70]. The pilot studies (with
thesameauthors)showedimprovedqualityoflifefor
asthma patients [74] and sputum and respiratory scores
for bronchiectasis compared to control [75], but are lim-
ited by small sample sizes, high dropout and lack of
blinding. The matched studies [71,72] provided high
quality evidence for improvements in dyspnoea and
related outcomes, with valid and reliable interventions
and outcome measures, and blocking design giving
more powerful treatment effects for small samples.
Anaesthesia/consciousness
Three studies investigated the effects of acupressure on
levels of anaesthesia or consciousness. These levels include
the acoustic evoked potential (AEP), changes in which
reflect the depth of anaesthesia and transition from awake
to anaesthetised [76]; bispectral index (BIS) and spectral
edge frequency (SEF) which are measures of the level of
consciousness during anaesthesia/sedation [77,78]. Over-
all, the evidence is Category 3 as only three studies were
identified, all had repeated measures designs and small
sample sizes (between 15 and 25), although one was pow-
ered [68,76-78]. Patients acting as their own controls in
these studies can cause practice and carryover effects,
although reduced by counterbalancing/randomising of
treatment order. However, lack of control group and lack
of details on sample selection limit the evidence.
Stroke
Three studies investigated acupressure for stroke
[79-81]. All three were RCTs; Shin and Lee [80] used a
blocked randomised design comparing acupressure to
acupressure plus aromatherapy, Kang et al [81] rando-
mised to acupressure or control groups; McFadden and
Hernandez [79] used a crossover design comparing acu-
pressure to control. Although studies used good designs
and results suggested significant improvements in pain
[80], motor power [80], limb function [81], daily living
[81], depression [81], and heart rate [79], all findings
were limited by small unpowered samples and poor
reporting, so evidence is rated at Category 2.
Body weight
Two randomised studies investigated the effect of acu-
pressure on body weight, although for very different
conditions - weight loss [82] and weight gain in prema-
ture babies[83]. Elder et als [82] RCT compared Tapas
Acupressure Technique
®
(TAT)
1
, qi gong and control
(self directed support). TAT resulted in greater weight
loss than both qi gong and control. Chen et als[83] RCT
compared acupressure and meridian massage to routine
care, resulting in significantly more weight gain. The
weight-loss study was high quality with a large sample,
design-adaptive group allocation (equivalent to randomi-
sation, but balanced for demographic and clinical fac-
tors). The weight gain study was randomised and
matched for weight and gestation age and used blinding
(although details are not clear), but had a small sample
size and lack of information on randomisation, allocation,
drop outs, harms and ethics. The evidence for weight
loss/gain is Category 2 as more studies are needed.
Visual impairment
Two non-randomised studies from China and Taiwan
evaluated acupressure for schoolchildren with visual
impairment [84,85]. Both found improvements com-
pared to control but were limited in reporting of study
design and findings and did not randomise. With only 2
studies, both with significant limitations, the evidence
for acupressure for improving eyesight is Category 3.
Other conditions
The remaining 11 articles on acupressure investigated
distinct health conditions which could not be grouped.
A systematic review evaluated the effect of acupoint
stimulation for side effects of breast cancer treatment
[47]. 26 studies were identified, concluding that evidence
is high quality for nausea and vomiting but weak for all
other adverse effects. It was well conducted with appro-
priate inclusion criteria, Jadad scale for rating and two
independent raters.
Ballegaard et al [86,87] studied acupressure for angina.
The 1999 study [86] was a cost benefit analysis and used
non-equivalent control groups, a volunteer and conveni-
ence sample and used co-interventions of acupuncture
and the self-care program. The 2004 study [87] had a
good sample size although subjects were not randomised,
the follow-up period was long, but no equivalent control
group or blinding. Again, it was difficult to isolate the
effects of acupressure from co-interventions. At baseline
the sample did not significantly differ to Scandinavian
heart patients. This quality control review, is subject to
selection, expectation and social biases.
Gastrointestinal motility was studied by Chen et al
[88,89], with significant improvements demonstrated. In
[88], although the intervention was well reported, rando-
misation is not described (although groups were homo-
genous for a range of variables). In [89] the sample was
small and not powered and the study was single-blind,
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although groups were homogenous. Significant effects
were observed.
A poorly reported study observed that acupressure on
PC6 significantly reduced gagging in 109 dental patients
[90]. The study was described as double-blind although
blinding procedures were not described. Details of the
sampling were not available.
In a comparison of acupressure with oxybutinin for
nocturnal enuresis in children[91], the main flaw was
the very small sample size, with no details of sampling,
comparison of groups or randomisation, potential selec-
tion bias and no placebo/sham group.
A controlled trial of acupressure for 30 patients with
peripheral arterial occlusive diseases (PAOD) reported a
significant reduction in transcutaneous oximetry[92].
This is a poor quality study with an apparent lack of
randomisation and non-equivalent control group, poor
reporting and no comparison of groups, although out-
comes are objective and intervention is well reported.
A high quality RCT of acupressure for symptoms of
diabetes found improvement in Hyperlipidemia, hyper-
trophy and kidney function [93] Acupressure was given
regularly for 3 years, an unusually long follow up period
and showed improvements in hyperlipidemia, ventricular
hypertrophy, kidney function and neuropathy. The sam-
ple size was appropriate (although fairly high attrition)
and group allocation was random. Very good description
of treatment was provided (14 STRICTA items
reported) although discussion is limited.
Yao et al [94] conducted a single group study of mas-
sage combined with acupressure for 85 patients with
chronic fatigue syndrome. Treatment was effective in
91.8% of cases. This study did not use any clear out-
come measures, had no control, and only reported 7
STRICTA items, and given its poor reporting it is low
quality.
An uncontrolled pilot study was conducted of vaginal
acupressure for sexual problems[95]. This showed signif-
icant improvements in symptoms, physical health, men-
tal health, sexual ability and quality of life. This study is
severely limited by small sample, lack of control, no
details of recruitment, unvalidated and subjective out-
come measures and poor reporting of acupressure. In
addition the intervention did not appear to be based on
meridian theory.
Sugiura et al [96] conducted an uncontrolled study
with 22 healthy volunteers of the effects of acupressure
on yu-sen, souk-shin and shitsu-min on heart rate and
brain activity. Heart rates decreased. This study investi-
gated mechanisms rather than effectiveness.
Analysis/Summary of quality
Twenty-two of the 80 included studies were graded C
(the lowest quality grading). All five of the studies in
Chinese language were graded C (or ungraded), and
most of the Shiatsu studies were graded C. Analysis of
results over time suggests some improvement in the evi-
dence base. Figure 2 shows an improvement in the aver-
age number of STRICTA items reported by studies,
shown by the line of best fit. Figure 3 indicates a reduc-
tion in the percentage of C graded papers over time,
and an increase in those graded B. Figure 4 shows the
numbers of studies and numbers of studies for each A/
B/C grading for the different countries. This shows no
obvious trend, although countries publishing more stu-
dies (Taiwan, USA and Korea) seem to have better qual-
ity studies, compared to countries with only one or two
publications. Regarding quality appraisal, in a third of
papers, a third reviewer was need to reach agreement
on quality grading.
Discussion
Summary of evidence
These findings provide an important addition to the
existing knowledge base on Shiatsu but are very limited
in providing any evidence of efficacy for Shiatsu. To our
knowledge this is the first systematic literature review
for shiatsu.
The strongest evidence for acupressure was for pain,
post-operative nausea and vomiting, and sleep.
Study design & quality
While much of the research is of insufficient quality to
provide consensus on Shiatsu or acupressure use, some
high quality clinical research (particularly around pain)
does exist. The methodological limitations of the studies
reported in this systematic literature review included
small sample sizes, non-reporting of follow up, insuffi-
cient details on sampling, high drop-out rates, uncon-
trolled design and lack of blinding. Many studies were
also underpowered.
Although most studies were RCTs, many studies used a
controlled design but controls were non-randomised (8),
Figure 2 STRICTA scores over time.
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crossover (5) or within-subjects (6) or they were uncon-
trolled (10), or observational (1). Lack of randomisation,
allocation concealment and comparable treatments can
create bias as non-randomised controlled trials can be
subject to confounding factors such as time-related or sea-
sonal bias. Evidence for Shiatsu is thus severely limited as
only 3 of the 9 studies used a control group, one of which
was non-random, with two pilot studies. Crossover designs
may be subject to practice effect, especially for self-admi-
nistered acupressure. Within subjects repeated measure
designs can also be subject to learning, and are only useful
for stable populations such as those with a chronic disease
or healthy volunteers (as used by studies on anxiety,
dementia and consciousness in this review). One-group
uncontrolled studies are of limited value due to a range of
potential confounding variables. Longitudinal designs such
as [7] are useful to evaluate effects of a treatment, but
again causality cannot be implied, and there is increased
risk of Hawthorne effect or conditioning. Well-conducted
randomised trials are therefore more likely to have internal
validity and thus accurately estimate the causal effects of
interventions than non-randomised studies [15]. However,
certain study designs are more appropriate for certain
interventions and populations[97] and contention is emer-
ging about how complementary medicine should be evalu-
ated[98-103]. The complexity of interventions such as
Shiatsu, including their patient-centred and individualised
nature, practitioner and non-specific effects, the influence
of patient choice, and potential synergistic effects require
innovative evaluative approaches.
Most studies used a small number of acupoints for a
specific condition or symptom in a protocol approach,
which facilitates replicability[104]. MacPherson et al
[105] identify three levels of individualisation in acu-
puncture: explanatorytrials which use the protocol
approach; partially individualised treatments using some
fixed points plus some flexible point choice; and prag-
matictrials which use fully individualised treatment
unique for each patient, as used in Shiatsu/TCM treat-
ment[105]. Pragmatic trials can be highly valuable, for
example the trial of acupuncture for back pain which
informed NICE clinical guidance in the UK[106].
There was an improvement in the quality/reporting of
papersoverthetimeperiod searched. This may have
been due to a greater appreciation of research amongst
practitioners, advances in research methods in acupres-
sure/shiatsu and the recent publication of a number of
guidelines on presenting research such as the CON-
SORT, STRICTA and TREND statements used in this
review [11,12,14].
The reporting of studies was very limited for many
papers, with items most commonly missing from the
CONSORT checklist including: 1a (identification as RCT
in title); 16 (numbers of participants included in each
analysis); 6b (changes to trial outcomes); 8,9 and 10
(details of randomisation procedure); 14b (why the trial
was ended); and 23 and 24 (registration number and full
protocol access) [12]. The average of 10.09 (63%) of
applicable STRICTA items reported is similar to a pre-
vious review (53.4%) [107]. Theincreaseinthenumber
of STRICTA items reported over time is likely due to the
gradual adoption of the STRICTA guidelines published
in 2001 [11,107]. In common with this previous review
the items most commonly missing were details of practi-
tioner background, setting/context and explanations to
patients, as well as amount of pressure used (equivalent
to depth of insertion of needle), style of acupressure, de
qi or the extent treatment was varied, perhaps less rele-
vant to acupressure than acupuncture. Awareness of
STRICTA guidelines is likely to be the key factor[107].
Implications for practice
For conventional practitioners
Many of the conditions with the strongest evidence
(pain, post-operative nausea and vomiting, and sleep)
are side effects of or challenging symptoms for
Figure 3 Chart of study quality over time.
Figure 4 Country of study.
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conventional medicine suggesting that an integrated
treatment approach may be of benefit. Conventional
healthcare practitioners may therefore consider acupres-
sure, in particular: SP6 for dysmenorrhoea; PC6 for
N&V postoperatively, in chemotherapy and pregnancy;
combinations of ST36, SP6, KI1, KI3, HT17, KI11 and
GB34 for renal symptoms; a range of points for COPD;
HT7 and other points for sleep in elderly residents; and
perhaps GB20, GV20, HT7, PC6 and SP6 for agitation
in dementia. The evidence for protocol-based treatment
supports suggestions that nurses incorporate acupres-
sure and Shiatsu into their practice, in particular for
pain relief, fatigue in cancer, augmenting effects of med-
ication, providing comfort and improving breathing
[108-110]. Shiatsu could be effectively delivered in gen-
eral practice but further research in clinical and cost
effectiveness is warranted [111].
For shiatsu/CAM practitioners
While much of the research carried out with Shiatsu or
acupressure as an intervention is of insufficient quality
to inform practice, the high quality evidence for pain,
post-operative nausea and vomiting, and sleep may be
of use to Shiatsu and acupressure practitioners. These
symptoms highlight the value of acupressure/Shiatsu as
a complementary approach
to conventional treatment. The findings relating to
protocol-based acupressure may not directly inform the
evidence base for more individualised and holistic treat-
ments. However, the evidence for a specific acupoint for
a specific symptom/condition can be integrated into an
individualised treatment by combining with points sui-
ted for the individual. Hsieh et al provide pragmatic evi-
dence for individualised treatment for low back pain
and headache [31,32,40]. Some studies also supported
the long-term effects of acupressure/Shiatsu, for exam-
ple for headache [40], low back pain [31,32], and nausea
and vomiting [48].
This review has highlighted the contention around the
specificity of CAM treatments. Acupressure was often
effective compared to control but not sham or medica-
tion, suggesting that effects are non-specific. Examples
include labour pain [34], dysmenorrhoea [112], renal
symptoms of fatigue, depression and sleep [54-56,59]
and nausea and vomiting [8]. However, other studies
found effects compared to sham treatment for similar
conditions [8,35-37,47,62], and patients belief in treat-
ment may not affect results [63], suggesting specific
effects. This review therefore provides little clarity on
specificity of effects.
Shiatsu is an inherently safe treatment [113]. Four sin-
gle case reports of adverse events occurring following
Shiatsu massage were identified (not included in review)
[114-117] as this review focussed on efficacy rather than
safety these findings were incidental and there are likely
to be more reports on safety. This is an important area
for the profession regarding safety issues and possible
causal links between Shiatsu and adverse events. Profes-
sional bodies for Shiatsu may need to consider the
development and piloting of an adverse event reporting
system for Shiatsu. Work by Andrew Long provides a
useful typology of adverse effects [118]. These are: Type
1: Responses unconnected to the CAM modality; Type
2: Transitional effect (client-perceived and theory-con-
sistent); Type 3: Transitional effect (theory and experi-
entially consistent); Type 4: Undesired, but not unsafe
event or effect; Type 5: Potentially adverse event or
effect and possible risk to client safety. This typology
could be utilised in future studies.
Implications for research
The research base for Shiatsu is still very much in its
infancy and the profession will need to work closely
with practitioners and researchers in order to build up a
larger body of evidence. Given the prevalence of Shiatsu
used in the UK (820 registered practitioners/teachers/
trainee teachers
2
), the need for high quality research is
imperative. Shiatsu practitioners should be encouraged
to engage in research using well designed and reported
studies, in particular with large samples and controlled
designs.
Results have highlighted that alternative RCT designs
may be necessary, such as:
Whole systems research, which includes qualitative
and quantitative methods to include the broader
aspects of treatment, not just the intervention
[119,120]
Mixed-methods research, as qualitative data can
provide additional information on patientsand/or
practitionersviews on the effectiveness of treatment.
Many studies are including such qualitative data as
part of their design to provide a broader picture of
patient outcomes [119].
Preference trials, which include patient choice of
treatment, often important in CAM, producing more
generalisable results, such as in the study by Lucini
[20],
Early phase research or pilot studies to generate
hypotheses, identify the most appropriate health
conditions, patient groups and treatments to test in
full clinical studies[121], given the limited evidence
base for Shiatsu.
A pragmatic design as used by some studies in this
review. Pragmatic trial design overcomes some of
the barriers of conducting RCTs in CAM, including
improved recruitment and providing patient-centred
treatment as usual. Only six studies used a prag-
matic design; three for shiatsu [7,19,86] and three
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for acupressure [31,32,87]. Examples of pragmatic
trials are the cohort multiple randomised controlled
trial [122] and health services research [101]. There
is promising research using both a pragmatic
approach to evaluate Shiatsu as part of an integrated
or massage intervention [19,21,123]. A flexible pro-
tocol approach could be used to improve replicabil-
ity[104].
One of the main issues in RCTs of complementary
approaches is the control treatment, for example the
limitations of blinding and sham acupressure. The
included studies have confirmed that shamacu-
pressure including light touch at acupoints does
have an effect. The highest quality evidence was
from three armed trials which use sham treatment
and an inert control, as advocated in acupuncture
research[124]. Shiatsu (as distinct from acupressure)
presentsfurthercomplexitiesastreatmentsare
based on Hara diagnosis and rarely if ever standar-
dised. This needs to be adequately reported in
papers, following guidelines such as CONSORT or
TREND.
Although excluded from this review due to resource
constraints, qualitative studies provide additional infor-
mation on patientsand/or practitionersviews on the
effectiveness of treatment [125-127]. Many studies now
include such qualitative data as part of their design to
provide a broader picture of patient outcomes.
Particular areas to focus research, commonly treated
with Shiatsu/acupressure include psychological and
musculoskeletal conditions, in particular neck/shoulder,
lower back problems, arthritis, depression, stress and
anxiety[6]. There is also good evidence for sleep and
symptoms of renal disease, but studies to increase the
generalisability of these findings is necessary.
Taiwanese researchers appear to have been most pro-
lific in this area, as well as Korea and the USA. Given
the increasing use of CAM in Europe more research
based in European countries may be needed. Given the
prevalence of Shiatsu used in the UK, the need for
research is imperative.
Use of quality guidelines such as STRICTA and CON-
SORT is advised to improve the reporting of studies,
especially details of interventions, to provide replicability
as well as to inform practice [11].
Strengths and limitations
A wide range of databases was used to maximise the
number of articles captured. This review used recog-
nised quality checklists to evaluate studies and each was
independently assessed by 2 reviewers, with fairly high
inter-rater agreement, and with a third reviewer for
adjudication.
The checklists used to calculate the quality of the
reporting of studies (CONSORT, TREND etc) were use-
ful but do have limitations. In particular with such a
broad range of study designs other than RCTs, the
appropriateness of checklists for specific study designs is
limited. For example the TREND checklist for nonran-
domised study designs may require additional specific
criteria for specific types of nonrandomised designs [14].
Searches were restricted to UK/USA databases due to
resource constraints; including Asian databases may
have added to the evidence. Language bias may also
have been present, although some Chinese language stu-
dies were included. There was no attempt to find grey
literature except searching for UK postgraduate theses;
no contact was made with individual authors due to the
large numbers of authors.
As this review was not limited by health condition, the
breadth of the included studies necessitated limiting
inclusion by excluding studies prior to 1990. This may
have created bias.
As the quality assessment in a systematic review
depends on contextual and pragmatic considerations, it
was necessary to limit the number of articles reviewed
due to time and resource constraints [97]. In particular,
purely qualitative studies were excluded, which may
have limited results given the now recognised value
given to qualitative outcome measures, particularly in
complex interventions such as Shiatsu.
Conclusions
This review identified very little Shiatsu research, sug-
gesting well designed studies are needed. The evidence
for acupressure and pain is generally consistent and
positive. There is also evidence for acupressure
improving sleep in institutionalised elderly. Acupres-
sure studies for nausea and vomiting have been some-
what inconsistent, with strongest evidence for post-
operative nausea, and may merit further research. Evi-
dence for pain, nausea and vomiting and sleep support
an integrated approach using acupressure for condi-
tions problematic to conventional medicine. There is
limited evidence for chronic respiratory conditions,
especially COPD, and psycho-social aspects of health,
anaesthesia and other health conditions. Evidence on
specific vs non-specific effects is inconclusive. This
review highlighted the challenges of conducting rigor-
ous research into CAM, which are complex, individua-
lised and patient-centred, but illustrates useful study
designs such as pragmatic/flexible protocol, 3 armed
with sham and no treatment, longitudinal and
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preference trials. Evidence appears to be improving in
quantity, quality and comprehensive reporting, but
there is still much room for improvement.
Endnotes
1. http://www.tatlife.com/
2. Personal correspondence with Shiatsu Society UK
Additional material
Additional file 1: Table 1. This table contains details of each of the
included studies
Acknowledgements
This study received funding from the Shiatsu Society, UK.
We would like to thank Julie Donaldson for her help with the literature
searching and reviewing.
Author details
1
Allied Health Sciences Department, Faculty of Health and Social Care,
London South Bank University, 103 Borough Road, London SE1 0AA, UK.
2
Institute of Basic Research in Clinical Medicine, China Academy of Chinese
Medicial Sciences 16 Dongzhimeng, Nanxiaojie, Beijing, 100700, China.
Authorscontributions
XL conducted the searches and retrieved the articles. XL and AL reviewed
the articles and NR was the adjudicator. XL and AL compiled the evidence
tables. AL and NR wrote the introduction and discussion section. AL created
the tables and graphs in the main text. All authors read and approved the
final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 20 July 2011 Accepted: 7 October 2011
Published: 7 October 2011
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Supplementary resource (1)

... e treatment is based on dredging the obtrusion of these meridians [5]. Acupressure on the meridians and collaterals is a noninvasive and straightforward technique, embracing the principle of Yin and Yang and the close relationship between Qi and blood circulation [6]. Acupressure from fingers, palms, or elbows on the appropriate acupoints helps promote the circulation of Qi and blood in the meridians of the lower back, relaxing muscles, and alleviating LBP [7]. ...
... e systematic review and meta-analysis included 23 RCTs with 2400 participants with LBP. Consistent with previous systematic reviews [6,40], moderate-quality evidence revealed an association between acupressure and greater pain relief compared with physical therapy. Although rated as very-low to low, poor quality evidence suggested that acupressure, with or without combinative acupuncture therapy, contributed to a greater amelioration of pain and functional disability from LBP compared with usual care, tuina massage, or acupuncture. ...
... Recording these details could improve assessments of the effectiveness of acupressure, but few studies have collected such information. Sparse and mild adverse events were reported in the RCTs, consistent with findings in the previous reviews [6,40,44]. However, the unclear methodological protocols for assessing adverse events, the unclear predictors of these events, and the limited number of RCTs reporting them contribute to a low overall apparent incidence of adverse events. ...
Article
Full-text available
Objectives: To evaluate the effectiveness and safety of acupressure on low back pain (LBP). Methods: We searched 7 electronic databases and 2 trial registries through December 28, 2020. Randomized controlled trials (RCTs) of acupressure on LBP were considered for meta-analysis with Revman 5.3 and Stata 15.0 software. Methodological quality was evaluated using the Cochrane Collaboration's tool. Trial sequential analysis (TSA) was used to quantify the statistical reliability. HETRED analysis and GRADE were used to determine the heterogeneity and quality of the results, respectively. Results: Twenty-three RCTs representing 2400 participants were included. Acupressure was superior to tuina massage on response rate (RR 1.25; 95% CI, 1.16 to 1.35; P < 0.00001) and in the standardized mean difference (SMD) for pain reduction [SMD -1.92; 95% CI, -3.09 to -0.76; P=0.001]. Likewise, acupressure was superior to physical therapy [SMD, -0.88; 95% CI, -1.10 to -0.65; P < 0.00001] and to usual care [SMD, -0.32; 95% CI, -0.61 to -0.02; P=0.04] in pain reduction. The Oswestry Disability Index was significantly improved by acupressure compared with usual care [SMD, -0.55; 95% CI, -0.84 to -0.25; P=0.0003]. The combination of acupressure with either manual acupuncture or electro-acupuncture showed significant improvements over the adjuvant therapies alone in response rate [RR 1.19; 95% CI, 1.13 to 1.26; P < 0.00001], pain reduction, and the Japanese Orthopedic Association score (JOA). However, each study displayed substantial heterogeneity. Through subgroup sensitivity analysis and -HETRED analysis, the heterogeneity of acupressure compared with manual acupuncture decreased while the results maintained significance with respect to pain reduction [SMD -0.9; 95% CI, -1.21 to -0.6; P < 0.00001] and JOA [SMD, 0.66; 95% CI, 0.33 to 0.98; P < 0.00001]. Similar results were obtained comparing acupressure with electro-acupuncture with respect to pain [SMD, -1.07; 95% CI, -1.33 to -0.81; P < 0.00001] and JOA [SMD, 0.89; 95% CI, 0.51 to 1.27, P < 0.00001]. TSA demonstrated the effectiveness of acupressure as a standalone or as a combinative treatment (with manual acupuncture or electro-acupuncture) for LBP. Conclusion: Acupressure is an effective treatment for LBP. However, GRADE assessments downgraded the evidence in the trials, indicating that additional investigations are needed to confirm these observations.
... Les quatre études dont la méthodologie est de la plus haute qualité (score Jadad = 5) ont montré des effets importants sur la douleur et/ou l'anxiété après des interventions en réflexologie, massage ou acupression (Beikmoradi et al., 2015;Jane et al., 2011;Sharifi Rizi et al., 2017;Tsay et al., 2008) Ernst et al., 2011;Edzard Ernst et al., 2006;Kim et al., 2010;Ling et al., 2014;McVicar et al., 2016;Pan et al., 2014;S. Wilkinson et al., 2008), qui ont suggéré que même si la plupart des études tendent à trouver des effets positifs du massage ou de la réflexologie sur les symptômes du cancer, l'hétérogénéité des méthodes, la petite taille les essais pragmatiques (contexte clinique réel) pourraient s'avérer complémentaires pour évaluer les questions "sans réponse ou impossibles à répondre" dans les ECR, en particulier dans les MCA (Robinson et al., 2011). ...
Thesis
Les Interventions Non-Médicamenteuses (INM), et autres procédures qui peuvent leur être associées (Médecine Traditionnelle, Médecines Complémentaires et Alternatives), sont aujourd’hui d’une prépondérance à ne pas sous-estimer dans l’optique d’une santé intégrative. Une évaluation scientifique robuste est nécessaire afin de trier les pratiques néfastes ou inefficaces, de celles attestant de réels bénéfices. Dans ce domaine, les essais randomisés contrôlés (ERC) font loi, à un titre discutable du fait de leurs limites intrinsèques. Par le biais d’une revue systématique de littérature centrée sur les pratiques de manipulation corporelles comme soins de support proposés en oncologie, nous confirmons la difficulté qu’ont les ERCs de tirer des conclusions fermes et bien appuyées. Nous présentons alors une méthode interventionnelle différente et peu enseignée, les protocoles expérimentaux à cas unique, et proposons leur illustration à travers quatre études. Celles-ci portent sur l’évaluation de différentes interventions dans des contextes de maladies chroniques ou de problèmes de santé variables : 1) Jeu vidéo thérapeutique dans le cadre de la réadaptation physique de la maladie de Parkinson, 2) Intervention musicale en Soins Palliatifs, 3) Hypnose face aux restrictions hydriques de patients sous hémodialyse et 4) Séances de shiatsu face à la dysménorrhée primaire. Ces études rendent compte de résultats intéressants, et permettent de discuter des forces et faiblesses de cette méthode. Nous plaidons alors en sa faveur du fait de ses principes expérimentaux légitimes ainsi que son adéquation avec la pratique fondée sur la preuve. Nous profitons enfin de la faible qualité des études que nous avons menées pour dresser une liste de recommandations et d’écueils à considérer afin de les employer de façon optimale.
... It is reported that the energy cycle is provided through meridians in the body and that signs, symptoms, and discomforts occur as a result of blockage of this energy flow for any reason. With the acupressure application, which has an important place in Traditional Chinese Medicine, it is aimed to remove this blockage, relieve existing symptoms, provide relief and maintain well-being [17,18]. It has been reported that acupressure has a positive effect on fatigue and is an inexpensive method that has no side effects and can be easily applied by oneself if taught [19]. ...
Article
Aim This study was conducted as a randomized controlled study to evaluate the effect of self-acupressure on fatigue in patients with Multiple Sclerosis (MS). Method The sample of the study consisted of 123 patients (41 in the experiment group, 40 in the sham group, and 42 controls) who were admitted to a neurology clinic in a university hospital. To collect data a patient information form, Fatigue Severity Scale (FSS), Expanded Disability Status Scale (EDSS), and Mini-Mental Status Examination were used. Depressive mood and sleep quality, which may affect fatigue, were evaluated using the Beck Depression Scale (BDI-II) and Pittsburg Sleep Quality Index (PSQI), respectively. The patients in the experimental group were applied acupressure by use of LI4 (He Gu), SP6 (San Yin Jiao) and ST36 (Zu San Li) points. Results The majority of patients were female (67.5%) and the mean age was 41.18. In addition, the mean BDI-II score of the patients was found to be 15.54, and the mean score of PSQI was 6.78 and the mean scores of these scales were similar in all groups. When the baseline FSS score means were examined, there was no significant difference among the groups (Acupressure:5.54 ± 0.87, Control:5.40 ± 0.92, and Sham:5.50 ± 0.99; p = 0.816). In the 4th week, there was a significant decrease in the mean score of fatigue of the experimental group compared to the other two groups (Acupressure:4.15 ± 1.09, Control:5.47 ± 1.11, Sham:5.34 ± 1.14, p < 0,001). Conclusion Our results suggest that acupressure might be an effective method to reduce fatigue in patients with MS.
... The results indicated that during the study, the mean rates of LBP in the group who was treated with topical hot sand were less than the controlled group which was similar to the findings of Robinson et al.'s study about the effectiveness of techniques such as doing William flexion exercises in the treatment and the relief of LBP. [32] Other studies also revealed increased power, dynamicity of pelvis belts, and improved performance in individuals who are suffering from chronic back pain after doing William flexion exercises. [31] In this study, the group who was received hot salt treatment showed a greater decrease in pain compared with the group who was treated with hot sand. ...
Article
Bacground: Low back pain (LBP) has been regarded as one of the musculoskeletal problems which is affecting more than three-quarters of individuals in their lifetime. Nowadays, various pharmacological and nonpharmacological therapies are employed for relieving and treating LBP. This study was conducted to compare the effects of topical hot salt and hot sand on patients' perception of LBP. Materials and methods: In this, quasi-experimental study patients with LBP referring to the orthopedic clinic of Shahrekord educational hospital were divided randomly into two interventions and one control group in 2020. All three groups were received naproxen cream and daily physiotherapy in the same manner, the interventional groups in addition either topical hot salt or topical hot sand. Data gathering tool for measuring patients' perception of LBP was the McGill Pain Short Form Questionnaire to be completed at the beginning, immediately at the end, and 2 months after the intervention. The data were analyzed using SPSS statistical software (version 21.0). Results: Totally, 90 patients were randomized based on the table of random numbers (mean age 51.1 + 11.1), and finally, 87 patients completed the study. Patients' perception of LBP before the intervention was homogenous in hot salt, hot sand, and the control group The mean score of total pain experience before the intervention was 14.1 ± 11.3 for hot sand, 13.9 ± 10.7 for hot salt and 13.7 ± 10.1 for control group The mean scores of these three groups were not significant before the intervention (P > 0.05). The mean score of total pain experience immediately after the intervention was 6.7 ± 4.2 for hot sand, 5.2 ± 3.1 for hot salt and 13.9 ± 9.8 for control group. The mean scores of the hot sand group and the hot salt group were significantly decreased compared with control group (P > 0.05). The mean score of total pain experience two months after the intervention was 5.6 ± 3.27 for hot sand, 4.21 ± 2.14 for hot salt and 13.8 ± 10.4 for control group. Mean score of total pain experience in both intervention groups had significantly reduced two months after the intervention compared to control group (P ≤ 0.001); so that the effect of hot salt treatment on reducing total pain experience was larger than hot sand (P ≤ 0.001). The same trend was observed for VAS and Present pain intensity variables. Conclusions: The findings have revealed that the topical treatments with hot salt and hot sand could have a significant effect on the perception of LBP compared to those in the control group; whereas hot salt might be stronger effects than hot sand on reducing LBP.
... (47)(48)(49) Shiatsu, a Japanese bodywork, translates to 'finger pressure'. (50) It uses comfortable pressure to maintain health and treat chronic and acute conditions. (51)(52)(53) It aims to correct and maintain the body's physical structure while restoring and maintaining its energy. ...
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Background: Dementia is a progressive neurological condition that affects over 50 million people. It impacts quality of life for those diagnosed, their care partners, and the relationship between the two. Strategies to enhance quality of life and relationships are needed. Shiatsu may improve care partners' well-being. Using touch through shiatsu may offer a meaningful way for care partners to interact with their partners living with dementia. Purpose: The purpose of this study was to explore care partners' experience of using both self-shiatsu and shiatsu with their partner, as well as to explore care partners' perceptions of the impact of shiatsu on the quality of their relationship. Setting: This study took place at a centre providing programs for persons living with dementia and their care partners. Participants: Participants were current and former attendees of the centre's programs. Research design: This was a qualitative study with an interpretive/descriptive approach. Care partners were taught self-shiatsu to manage stress and a simplified, short shiatsu routine to use with their partner. Semi-structured interviews were conducted to elicit care partners' experiences and explore their ongoing use of shiatsu at two and six weeks post-workshop. Findings: Four care partners completed the study. A wide range of experiences with shiatsu were described, representing four key themes: Enhanced Awareness, Integrating Shiatsu into the Relationship, Barriers and Facilitators, and Potential and Possibility. Two found self-shiatsu beneficial. Using shiatsu with their partner was a favourable experience for only one, who found it a pleasant way to connect and interact. None of the participants felt using shiatsu with their partners affected their relationship quality. Conclusions: The findings of this study are inconclusive. Self-shiatsu may be a helpful self-management approach for some care partners, but not for others. Shiatsu for persons living with dementia may not fit into the routines of many care partners. For others, however, it may offer a means to connect.
... Acupressure is a non-invasive complementary and alternative technique that shares common characteristics with acupuncture [9]. It is defined as the stimulation on acupuncture points located along meridians (also known as "acupoints") using fingers, hands, knuckles, or dull instruments to exert pressure, leading to a sensation of soreness, numbness, and distention [10]. According to the core concept of traditional Chinese medicine (TCM) theory, acupressure stimulates the meridian. ...
Article
Background: Depression is recognized as a major public health problem with a substantial impact on individuals and society. Complementary therapies such as acupressure may be considered a safe and cost-effective treatment for people with depression. An increasing body of research has been undertaken to assess the effectiveness of acupressure in various populations with depression, but the evidence thus far is inconclusive. Aim: To examine the efficacy of acupressure on depression. Methods: A systematic literature search was performed on PubMed, PsycINFO, Scopus, Embase, MEDLINE, and China National Knowledge (CNKI). Randomized clinical trials (RCTs) or single-group trials in which acupressure was compared with control methods or baseline in people with depression were included. Data were synthesized using a random-effects or a fixed-effects model to analyze the impacts of acupressure treatment on depression and anxiety in people with depression. The primary outcome measures were set for depression symptoms. Subgroups were created, and meta-regression analyses were performed to explore which factors are relevant to the greater or lesser effects of treating symptoms. Results: A total of 14 RCTs (1439 participants) were identified. Analysis of the between-group showed that acupressure was effective in reducing depression [Standardized mean differences (SMDs) = -0.58, 95%CI: -0.85 to -0.32, P < 0.0001] and anxiety (SMD = -0.67, 95%CI: -0.99 to -0.36, P < 0.0001) in participants with mild-to-moderate primary and secondary depression. Subgroup analyses suggested that acupressure significantly reduced depressive symptoms compared with different controlled conditions and in participants with different ages, clinical conditions, and duration of intervention. Adverse events, including hypotension, dizziness, palpitation, and headache, were reported in one study. Conclusion: The evidence of acupressure for mild-to-moderate depressive symptoms was significant. Importantly, the findings should be interpreted with caution due to study limitations. Future research with a well-designed mixed method is required to consolidate the conclusion and provide an in-depth understanding of potential mechanisms underlying the effects.
... Mind-Body Therapies from Traditional Chinese Medicine (MBTTCM), as interventions for pain conditions, showed positive effects for headache, joint pain, chronic pain, and low back pain (64-67) Also, potentially positive effects were related to general pain, dysmenorrhea, neck pain, hemorrhoid pain, labor pain, post-operative pain, myalgia, and facial neuralgia (48,49,52,(68)(69)(70)(71)(72)(73)(74). ...
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Background: The mind-body therapies of traditional Chinese medicine include several intervention types and combine physical poses with conscious relaxation and breathing techniques. The purpose of this Evidence Map is to describe these different interventions and report related health outcomes. Methods: This evidence map is based on the 3iE Evidence Gap Map methodology. We searched seven electronic databases (BVS, PUBMED, EMBASE, PEDro, ScienceDirect, Web of Sciences, and PschyInfo) from inception to November 2019 and included systematic reviews only. Systematic reviews were analyzed based on AMSTAR 2. We used Tableau to graphically display quality assessment, the number of reviews, outcomes, and effects. Results: The map is based on 116 systematic reviews and 44 meta-analyses. Most of the reviews were published in the last 5 years. The most researched interventions were Tai Chi and Qi Gong. The reviews presented the following quality assessment: 80 high, 43 moderate, 23 low, and 14 critically low. Every 680 distinct outcome effect was classified: 421 as potential positive; 237 as positive; 21 as inconclusive/mixed; one potential negative and none no effect. Positive effects were related to chronic diseases; mental indicators and disorders; vitality, well-being, and quality of life. Potential positive effects were related to balance, mobility, Parkinson's disease, hypertension, joint pain, cognitive performance, and sleep quality. Inconclusive/mixed-effects justify further research, especially in the following areas: Acupressure as Shiatsu and Tuiná for nausea and vomiting; Tai Chi and Qi Gong for acute diseases, prevention of stroke, stroke risk factors, and schizophrenia. Conclusions: The mind-body therapies from traditional Chinese medicine have been applied in different areas and this Evidence Map provides a visualization of valuable information for patients, professionals, and policymakers, to promote evidence-based complementary therapies.
Research
LAY SUMMARY This study tested a no-cost, drug-free technique to promote sleep for Veterans and their family members. The technique, hand self-shiatsu (HSS), had promising outcomes in other studies with chronic pain patients and young athletes after concussion. HSS is easy to learn, takes only 10–15 minutes to perform before bed, requires no equipment, and is best done once in bed for the night. The sleep and daytime fatigue of 30 people who were taught HSS and 20 who were not were compared across a two-month period. The two groups were similar in age and gender. The self-report measures showed that people who did HSS reported less daytime fatigue and less sleep disturbance than those who did not. Also, in interviews at the end of the study, participants were very favorable about how easy and potentially useful HSS was. They also commented on the benefit of feeling more in control of their sleep. Although the study has limitations, the findings are promising. A HSS educational video, handouts, and app are available for free at https://cbotlabs.wixsite.com/handselfshiatsu .
Chapter
Acupressure is the stimulation of acupuncture points (acupoints) using fingers, hands, or devices. Acupressure has been recommended as a therapeutic modality for depression. Acupoint stimulation regulates vital energy in the human body, which is essential to maintain good health, prevent illness, and promote psychological well-being. Acupressure applied manually using fingertip does not require the use of needle or any other devices, thus adverse effects are less likely to occur. Research findings suggest that acupressure had a positive effect to reduce level of depression and psychological well-being. Therefore, acupressure may have potential to promote patients’ well-being in clinical practice. Further studies are required to produce strong evidences, as well to develop standard protocol for acupressure practice.
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Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement--a reporting guideline published in 1999--there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.
Article
In this document, the framework for carrying out systematic reviews is described in three stages: planning, reviewing and disseminating. The need for a review should be established before commissioning or commencing review work. The methodology of the review should be documented and working arrangements should be put in place to ensure that the methods can be followed. Finally, there should be a strategy for putting together a report of the review and disseminating its findings to relevant audiences, and if possible, updating the review. The stages of a review and the phases within them are described consecutively. However, this chronology may vary during the review. It will not always be possible to complete one phase before another has to be started, and sometimes it will be more efficient to work on several phases simultaneously. It is essential that good communication is maintained between those commissioning or supervising the review and those carrying it out. To aid the process, this framework includes agendas for some joint meetings. These meetings help set a timetable and ensure that the review work receives the required direction and support. The number of meetings and their schedule may have to be tailored to suit the requirements of a given review. The content of this report draws on information from several sources. All the steps necessary to undertake a systematic review have been listed, but it is not possible to provide definitive advice on all of the methods. This is because the science of systematically reviewing the literature is relatively young, and many methodological issues are still being explored. Therefore this guidance is to assist those conducting reviews to reach a minimum standard based on the understanding of the subject at the time of writing. Reviewers wishing to obtain up-to-date information in this area should look at the Cochrane Methodology Database and systematic reviews of empirical methodological research in the Cochrane Library. New advice is incorporated in updates of the Cochrane Reviewers' Handbook (URL: http://www.updatesoftware. com/ccweb/cochrane/hbook.htm) and the ‘Resources available at the CRD’ web site (URL: http:// www.york.ac.uk/inst/crd/).
Article
Aim: To observe the effect of improving eyesight brain tonic exercise on preventing and curing myopic eye of 25 students within 3 months and compared with those in control group. Methods: The experiment was completed in 7 middle schools and primary schools in Jiaozuo from March to June 2003. Results of 20 000 cases were compared with multiple-statistical analysis. In this study, 40 cases were selected randomly and divided into training group (n=25) and blank control group (n=15). Data were analyzed with significance test among multiple-statistical analysis. 1 Improving eyesight brain tonic exercise in details: There were 6 parts in total: pressing Yannei, Yanshang, Yanwai and Yanxia acupoints, scaling orbit alternatively and pressing Fengchi acupoint, and turning eyeball to gaze into the distance. And then, examinates closed their eyes for relaxing, and imaged that their eyeball was dragged backwards with rope. When they felt their eyeballs were dragged flatly, they opened eyes to look far away green plant so as to make the eyeballs round. Examinates stared at distance just only for making eyeballs round. Deep breath was made at the end of eye exercise. 2 Cases in training group did the exercise as mentioned above, once a day for 3 months. Cases in blank control group did not do any exercise. 3 Whether eyesight was improved before and after improving eyesight brain tonic exercise or not was analyzed with rank sum test, and improved degree of eyesight was compared with significance test of multiple-statistical analysis before and after study. Results: According to intension, data of 40 students were analyzed with multiple-statistical analysis. 1 Results of eyesight in training group with rank sum test before and after exercise: Average naked vision was improved 0.08 after 3-month training, and the increasing rate of eyesight was 32.89%; poor rate of eyesight was decreased 8.94% after 3-month training (U=4.7648, P < 0.01). 2 Random samples of students in blank control group before and after experiment: Poor rate of eyesight was increased 1.71% after 3-month training, but there was not significant difference from that before experiment (U=0.7577, P > 0.05). Conclusion: Multiple-statistical analysis shows that improving eyesight brain tonic exercise is an effective method to prevent and cure myopic eye for students by themselves.
Article
English This article reports a pilot study on an intervention group which integrated behavioral treatment and non-pharmacological Chinese medicine to reduce the problem of insomnia for older Chinese adults. Findings showed that the six-session group intervention was effective. The highlight of each session was presented and implications for social work practice discussed. French Cet article présente les résultats d'un projet pilote en intervention de groupe, mené pour répondre aux problèmes d'insomnie de la population âgée de Hong Kong. Ce projet a fait appel à des traitements comportementaux et à la pharmacopée traditionnelle chinoise. Les résultats indiquent que les interventions de groupe ont été concluantes. On aborde également les implications pour le travail social en Chine et ailleurs. Spanish Se informa sobre un estudio piloto de una intervención de grupo para tratar los problemas de insomnio entre personas mayores en Hong Kong. Esta intervención integra los tratamientos de conducta y medicina china no farmacológica. Los resultados sugieren que la intervención de grupo fue efectiva. Se exponen las implicaciones para el trabajo social en China y en otros lugares.