Alternative Medicine: Expanding Medical Horizons ~ Manual Healing Methods
 
   

Alternative Medicine:
Expanding Medical Horizons

A Report to the National Institutes of Health on Alternative
Medical Systems and Practices in the United States
 
   

Manual Healing Methods


PANEL MEMBERS Barbara Brennan, M.S.--Cochair
Anthony Rosner, Ph.D.--Cochair
Alan Demmerle, M.S.E.E.
Michael Patterson, Ph.D.
Nelda Samarel, R.N., Ed.D.
CONTRIBUTING AUTHORS Beverly Rubik, Ph.D. -- Lead Author
Richard Pavek -- Lead Author

Osteopathy
Robert Ward, D.O.

Chiropractic
Dana Lawrence,D.C.

Massage
Elliott Greene, M.A.

Cranial-Sacral
John Upledger, D.O.

Biofield Therapeutics
Richard Pavek

Physical Therapy
Elsa Ramsden, Ed.D.

Introduction

Touch and manipulation with the hands have been in use in health and medical practice since the beginning of medical care. Whether in comforting a child by stroking or rubbing a body stiffened by the cold, touch was the first and foremost of all diagnostic and therapeutic devices. Hippocrates discussed the benefits of therapeutic massage and instructed his students in its use and in spinal manipulation. The Chinese also included massage in its ancient healing practices and touch in its diagnostic methods (see "Alternative Systems of Medicine" chapter); the practitioner's taking of the pulse with the fingertips was considered to be the most important diagnostic tool of the ancient Chinese physician (Veith, 1949). Entire healing systems of touch based on the meridian system (see the glossary) were developed centuries ago and remain in use today in the United States as well as in Asia.

The hands once were the physician's greatest and most important diagnostic and therapeutic tool. Today the medical and health practitioner retreats further and further from physical contact with the patient, ever more distanced by banks of diagnostic equipment, legal constraints, and time factors. Psychotherapists are admonished not to touch their clients, and the price of medical doctors' time is now so high that they cannot even massage the stiffness from a patient's back; instead, the doctor or psychotherapist must write a prescription for a massage therapist, a person with therapeutic skills no longer taught in medical schools. It is skills of this type--ancient traditional healing skills that are now called "alternative"--that this chapter addresses.

All the manual healing methods addressed in this chapter rely on the practitioner's hands as a primary modality both to access information from (that is, to diagnose) and to treat the patient. Nevertheless, many manual healing methods are highly individualized; there is much art in this field, much individualization. Many practitioners have developed unique systems, in some cases teaching them to others. Consequently, there are many more systems than can be discussed here; no slight is intended by the omissions.

This chapter is divided into four sections. The first discusses methods that use physical touch, pressure, and movement. The second discusses those that are described as using a biofield, or "energy." Therapies that appear to rely on both physical and biofield elements are described in the third section. The fourth section illustrates how manual healing methods are becoming included in mainstream health care. Recommendations and references follow at the end.


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:

  1. 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.

  2. 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.

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

  4. 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.

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).

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._ 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).

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.


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

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.

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.

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:



Chiropractic

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:

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

  2. 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.

  3. 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.

  4. 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.

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:

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).

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.

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.

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.

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

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

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 ParJ, 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.

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.

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.

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:

  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.

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).

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:

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:

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

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

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

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.

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

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."
  • 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).

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.

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.

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

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.


Biofield Therapeutics

Overview

Biofield (see the glossary) therapeutics, often called energy healing or laying on of hands, is one of the oldest forms of healing known to humankind. Discovery, partial characterization, and use of the biofield have risen independently among peoples and cultures in every sector of the world (see table 1).

The earliest Eastern references are in the Huang Ti Nei Ching Su WLn (The Yellow Emperor's Classic of Internal Medicine), variously dated between 2,500 and 5,000 years ago (Veith, 1949). The earliest Western references are in hieroglyphics and in depictions of biofield healings dating from Egypt's Third Dynasty._ Hippocrates, a major figure in Western medicine, referred to the biofield as "the force which flows from many people's hands" (Schiegl, 1983). Franz von Mesmer, an Austrian physician who investigated and popularized this process in the late 18th century, referred to the biofield as "animal magnetism" to differentiate it from "metal magnetism," which he understood to be a similar but different medium (Mesmer, 1980). In the United States, use increased after Mesmer's "magnetic healing" became popular in the 1830s. (Among others, both Andrew Still (founder of osteopathy) and Daniel Palmer (founder of chiropractic) practiced for a time as magnetic healers (Gevitz, 1993).

Historically, beliefs about causation in this type of healing have clustered around two views that remain active today. The first is that the "healing force" comes from a source other than the practitioner, such as God, the cosmos, or another supernatural entity. The second is that a human biofield, directed, modified, or amplified in some fashion by the practitioner, is the operative mechanism. Some of the terms presented in table 1 are devoid of religious or spiritual overtones, while others carry religious aspects common to the culture in which they were or are used.

Therapeutic application of the biofield is a process during which the practitioner places his or her hands either directly on or very near the physical body of the person being treated. In so doing, the practitioner engages the perceived biofield from his or her hands with the recipient's perceived biofield either to promote general health or to treat a specific dysfunction. The person being treated, who is usually clothed, reclines in some forms of the process but is seated in others.

The process is not instantaneous, as it is in "faith healing." (Faith is not a factor in the biofield process.) Treatment sessions may take from 20 minutes to an hour or more; a series of sessions is often needed to complete treatment of some disorders.

The ability to perform biofield healing appears to be universal, although most people seem unaware of possessing the talent. As with any innate talent, practice and learning appropriate techniques improve results.

There is consensus among practitioners that the biofield that permeates the physical body also extends outward from the body for several inches. Therefore, no real difference is seen between placing the hands directly on the body (either by direct skin contact or through clothing) or in close proximity to the body. In either case, the practitioner's biofield is understood to come into confluence with the recipient's biofield. There are advantages and disadvantages to each approach in clinical applications._

Extension of the external portion of the biofield is considered variable and dependent on the person's emotional state and state of health. Practitioners describe the external portion, sometimes called the "aura," as tactilely detectable (see the "Biofield Diagnostics" section) and less dense than the portion permeating the physical body.

Biofield practitioners have a holistic focus, for most treatment sessions produce results that encompass more than one aspect of the person's health. Within that focus there is, however, a range of therapeutic intents:

  • General (e.g., stress relief, improvement of general health and vitality).

  • Biologic (e.g., reduction of inflammation, edema, chronic and acute pain; change in hematocrit and T-cell levels; and acceleration of wound healing and fracture repair).

  • Vegetative functions (e.g., improvement of appetite, digestion, and sleep patterns).

  • Emotional states (e.g., changes in anxiety, grief, depression, and feelings of self-worth).

  • Dysfunctions often classified psychosomatic (e.g., treatment of eating disorders, irritable bowel syndrome, premenstrual syndrome, and posttraumatic stress disorder).

Some practitioners incorporate mental healing, or focused intent to heal, as part of their biofield treatments. This is also called psychic healing, distant healing, nonlocal healing, and absent healing. Mental healing can also be performed by itself at a considerable distance from the recipient. It is an active process on the practitioner's part, involving centered, focused concentration; it may include various imagery (visualization) techniques as well. (See the "Imagery" section and the "Prayer and Mental Healing" section in the "Mind-Body Interventions" chapter.)

A related mind effect sometimes used in biofield healing is described as the practitioner, by effort of will, extending the biofield (principally from the hands) into the recipient's body with increased force, sometimes from a distance of several feet. Chinese qigong masters are considered especially adept at this. The process appears to be draining; interviews with practitioners who do this procedure indicate they are limited in the number of treatments they can perform in a day.

Some practitioners meditate before giving a treatment in order to enter a so-called healing space; some others maintain a meditative state during treatment.

Biofield diagnostics.   Detailed diagnostic methods have been developed to determine the condition of the patient's general health and present disorder by sensing, with touch, subtle perturbations in the biofield (clairsentience). Janet Quinn, researcher of the therapeutic touch method, writes that "assessment [of the external portion] focuses on perceiving the way this energy is flowing and is distributed in the patient" (Krieger, 1992). Patricia Heidt adds that areas of "accumulated tension" or "congested energy" are detected (Heidt, 1981b). Barbara Brennan, developer of the healing science method, describes the use of "high sense perception," which includes other subtle perceptions of the external biofield (Brennan, 1987).

Biofield researcher Richard Pavek writes of similar subtle tactile cues detected when the hands are placed directly on the body during SHEN _therapy as "changes in temperature . . ., tingles, prickles, `electricity' (sensation of light static), pressure or `magnetism' . . . sensations are usually different over an area of physical pain, inflammation, tension and/or when release of emotion occurs" (Pavek, 1987, p. 57).

Many practitioners develop their treatment plans entirely by interpreting these various tactile sensations. Others use biofield diagnostics to supplement conventional methods, such as nursing diagnostic forms or chronic pain evaluation forms.

Current status.   Considerable interchange of technique occurs between Europe and the United States and some between the United States and Asia.

United States. The process of using biofields has been treated with a reflexive mixture of awe and disgust, reverence and fear, and belief and disbelief, but this situation appears to be changing as more and more people seriously investigate the process from a critically neutral perspective.

No formal census is available, but reasonable estimates suggest that some 50,000 practitioners in the United States provide about 120 million sessions annually (Pavek, 1994). Of these, about 30,000 have trained in therapeutic touch (Benor, 1994). For some, it is a major part of their vocational activity; others use the process occasionally to help family and friends. Many practitioners have had no formal training in the process, and many have independently discovered biofield effects. Others learned rudimentary techniques from friends or trained in one of several schools that teach various forms of the process. Reviews of school enrollment records indicate that most practitioners are women.

Some practitioners, often those who have independently discovered the process, and some teachers ascribe to it a religious or spiritual basis. A few link the process with specific religious activities.

No State has licensing requirements for biofield practitioners. Because legal constraints in many States prohibit the use of the terms patient and treatment, most practitioners use the terms receiver and session in describing their work.

Some, possibly because they fear being charged with practicing medicine without a license, have cloaked themselves by incorporating under the name of a healing church. They often deny attempting to treat biological disorders and describe their process as "healing the spirit," from which "healing of the physical" will follow.

In the past 20 years or so, formal training in the process has emerged in considerable strength in this country. At this time several teaching establishments with standardized training programs teach different forms of the process; most grant certificates. Schools differ considerably in curriculum, focus, length of training, extent of internship, and certification requirements. Some schools are semistructured associations of instructors trained in a particular method; others are more centrally organized.

The major biofield therapies used in the United States are summarized in table 2.

At least four forms of biofield therapy--healing science, healing touch, SHEN therapy, and therapeutic touch--have been taught in a number of medical establishments. Currently, student nurses are trained in one or another system in more than 90 colleges and universities around the world. Acupuncturists, massage practitioners, and nurses who pass these courses receive continuing education credit from several State bureaus for training in these four forms.

Most of the practitioners of this process work independent of conventional medical and health practitioners. The conventional practitioner may occasionally be aware that his or her patient-client is seeing a biofield practitioner collaterally, but most are not.

However, while much of the current activity in this discipline can be considered separate and alternative, the process is beginning to seep upward into mainstream medical and health practices. It is likely that several thousand practitioners of conventional therapies currently combine one or another of the biofield therapy processes with their primary approaches. Among these are nurses, counselors, psychotherapists, chiropractors, and massage practitioners who at least occasionally use a form of biofield therapy as an adjunct.

At least three forms are currently in use in hospitals: healing touch and therapeutic touch are used for a variety of reasons in several hospitals (Quinn, 1981, 1993), and SHEN therapy is used in alcohol abuse, drug abuse, and codependent recovery programs in a few hospitals (Sunshine and Wright, 1986).

Europe. The United States falls far behind other countries in legal recognition of biofield therapy. Currently, more than 8,500 registered healers in the United Kingdom (British Medical Association, 1993) "are permitted to `give healing' (a term for the process in common usage in the United Kingdom) at the request of patients" (p. 92). Approval has been obtained to use the process at the 1,500 government hospitals. In some situations, biofield healers are paid under the U.K. National Health Service (Benor, 1993). Physicians receive postgraduate education credits for attending courses in the biofield process, and healers are able to purchase liability insurance policies similar to those covering physicians (Benor, 1992).

In Poland and Russia, biofield healing is being incorporated into conventional medical practice; some medical schools include instruction in the process in the curriculum. In Russia, the process is under investigation by the Academy of Science. In Bulgaria, a government-appointed scientific body assesses abilities and recommends licensing for those who pass rigorous examinations (Benor, 1992).

Asia. China leads the rest of the world in research on therapeutic application and methods of increasing biofield effects. Biofield healing is called wei qi liao fa, or "medical qigong" (chi kung), in China, where proficient practitioners are called "qigong masters." Qigong masters are described as having developed their qi (biofield) to a high degree through qigong exercises._ (A few qigong masters are reported to be able to anesthetize patients for surgery solely with this method [Houshen, 1988]). Reduction of secondary cancers by medical qigong masters is commonly reported; there are clinics for that purpose alone.

Departments of medical qigong research exist in every college of traditional Chinese medicine in China. Both national and regional governments sponsor periodic international conferences on medical qigong. American researchers are frequently invited to present papers at these conferences.

Explanatory models.   No generally accepted theory accounts for the phenomena of biofields. As one might expect of a discipline often perceived as bordering between superstition and random process on the one hand and science and technique on the other, there are profound differences--both inside the discipline among practitioners and researchers, and outside among theoreticians--as to the exact nature of the phenomena. In many cases, the view of the biofield is not a clearly defined one; it often mixes concepts of physics and metaphysics, or ancient and modern wisdoms (see the glossary).

The current major hypotheses are that the biofield is

  • metaphysical (outside the four dimensions of space and time and untestable),

  • an electromagnetic field effect, and

  • a presently undefined but potentially quantifiable field effect in physics.

There are three metaphysical approaches:

  1. Spiritual energy. Practitioners of some methods believe that they are channeling a spiritual energy that has innate intelligence or logic and knows where and to what extent it is required (Baginski and Sharamon, 1988). Reiki and also "radiance," a form of reiki, are examples of this view (Ray, 1987). Reiki teaches that the practitioner is merely a conduit for spiritual energy. After training, the practitioner is initiated and given the power to heal; sacred symbols are often used to give added power to the process (Jarrell, 1992). Another system with a similar approach, mari-el, incorporates the use of angels or spiritual guides in the healing practice.

  2. Interacting human and universal energy fields. Heidt and others have postulated that both the healer and the healed are vibrating fields of energy (Heidt, 1981b) that interact with the environmental energy field around them for healing purposes. Brennan describes a similar process as one of "harmonic induction" (Brennan, 1987).

  3. Repatterning of resonant vibratory fields. Going further, Quinn and nurse-theorist Rogers state that current assumptions (about Therapeutic Touch), which remain "untested" and "untestable," [are that] people are energy fields. We are not saying that people have energy fields in addition to what they are. . . . [Instead they are] open systems engaged in continuous interaction with the environmental energy field. [Therefore] when a person is "sick" there is an imbalance in the person's energy field, [and] when a person uses his or her intent to help or heal a person, the energy field of the person may repattern towards greater wellness. . . . The Therapeutic Touch practitioner knowingly participates in . . . "a healing meditation," facilitates repatterning of the recipient's energy field through a process of resonance, rather than "energy exchange or transfer" (Quinn, 1993).

The healing intervention is seen as a "purposive patterning of energy fields, a mutual process in which the nurse uses his or her hands as a mediating focus in the continuing patterning of the mutual patient-environment energy field process" (Rogers, 1990).

In addition, certain models in physics may offer some explanation of biofield phenomena. Although quantum physics, the branch of physics that treats atomic and subatomic particles, has been proposed to explain the effects of a related phenomenon, mental healing at a distance (see the "Mind-Body Interventions" chapter), it has not proved to be a useful model to explain biofield healing. For example, Brennan states, "I am quite unable to explain these experiences without using the old [classical physics] frameworks" (Brennan, 1987, p. 26).

Classical physics is a model that is applied with high precision to large-scale phenomena involving relatively slow motion, such as the flow of fluids, electromagnetic currents and waves, hydraulics, aerodynamics, and atmospheric physics. It appears to be a reasonable model to apply in studying biofield phenomena.

Indeed, much of the terminology used by biofield practitioners to describe their work--while somewhat imprecise and variable--clearly describes quantitative and qualitative factors similar to those in fields of classical physics. For example, qi appears to be equivalent to flux in electromagnetic fields, for it describes direction and quantity of field. Polarity between the hands and between different bodily regions appears to be equivalent to polar difference in electromagnetic fields and to pressure differential in hydrodynamics. Pavek describes the biofield as having "circulating [flux] patterns . . . similar in formation and function to magnetic fields or electrostatic fields" (Pavek, 1987, p. 61). (See table 3 for other analogies.)

Around 1850, Karl von Reichenbach (discoverer of kerosene and paraffin) demonstrated apparent biofield polarities and determined apparent velocity through a copper rod to be about 4 meters per second (von Reichenbach, 1851)._ In 1947, L.E. Eeman demonstrated a polarity through the arms and hands and another through the spine with his device known as an Eeman screen (Eeman, 1947). (See fig. 2.)

In about 1950 Randolph Stone, developer of polarity therapy, determined that flux density showed polarities within the physical body (Stone, 1986).

In 1978, Pavek compared paired-hand placements and reversed paired-hand placements on patients by hundreds of trained and untrained practitioners; he noted that one arrangement consistently resulted in relaxation and feelings of well-being but that the other set consistently produced agitation and anxiety. From this he deduced normal (healthy) qi polarities and movement patterns in the body (Pavek, 1987). (See fig. 3.)

In 1985 Pavek expanded on these findings by demonstrating coherent linkages between qi patterns, emotional holding patterns, and autocontractile pain response while developing biofield treatments for disorders often classified as psychosomatic (Pavek, 1988b; Pavek and Daily, 1990) and correlating emotional holding patterns with Chinese five-phase theory (Pavek, 1988a).

In 1992, Isaacs conducted a double-blind study using Eeman screens, which confirmed polarity at the spine and arms (Isaacs, 1991).

It is unclear at this time whether the biofield is electromagnetic or some other presently unmeasured but potentially quantifiable medium. It is popularly hypothesized that the biofield is a form of bioelectricity, biomagnetism, or bioelectromagnetism._ This may well be the case but has yet to be established. Some researchers discount the possibility._

Some Chinese researchers have conducted experiments indicating that when wei qi (the external biofield) is used in fa qi (healing), electro-magnetic radiation in the infrared range is produced; others found indications of infrasonic waves. However, both phenomena appear to be minor secondary effects (Shen, 1988; Xin et al., 1988).

Research base.   Rigorous research on biofield healing has been hindered by the belief, held by many, that nothing more than a placebo effect is the operative factor. This belief has affected funding, publishing, and status of researchers. Because funding organizations and scientific communities believed that any effects obtained were largely placebo effects, not real effects of biofields, research has been considered pointless. Moreover, many researchers have been unwilling to study biofield effects that they would otherwise be interested in, because they fear being ostracized by other researchers. Publication of research by the journals has been limited for similar reasons.

Notwithstanding these limitations, a number of studies have been implemented. In the United States, there are more than 17 published studies on biofield therapeutics.

Published U.S. studies. Because no comprehensive database of studies on biofield therapeutics exists, the following are considered to be only a sampling.

In two controlled studies on therapeutic touch, Krieger found significant change in hemoglobin levels in hospitalized patients (Krieger, 1975, 1973). In a similar study, Wetzel found significant change in hematocrit and hemoglobin levels of 48 subjects receiving reiki, and no significant change with 10 controls (Wetzel, 1989).

Wirth found significant change in the healing rate of full-thickness skin wounds in a carefully controlled, double-blind study of therapeutic touch (Wirth, 1990), while Keller and Bzdek found highly significant decreases in pain scores recorded on the McGill-Melzak Pain Questionnaire by patients with tension headache in a controlled study of therapeutic touch (Keller, 1993; Keller and Bzdek, 1986).

Although Meehan found no significant difference on the Visual Analog Scale and Pain Intensity Descriptor Form between postoperative patients receiving therapeutic touch and controls, secondary analysis showed patients receiving therapeutic touch waited longer before requesting analgesia (Meehan, 1985, 1988). Similarly, Heidt found significant changes in anxiety levels of hospitalized cardiovascular patients receiving therapeutic touch versus controls as measured on the A-State Self-evaluation Questionnaire (Heidt, 1979, 1981a; Spielberger et al., 1983). Quinn (1983) found similar results in a study of therapeutic touch versus mimic therapeutic touch without centering and intention to assist.

In a replication study on patients before and after open heart surgery, using therapeutic touch versus mimic therapeutic touch and no-treatment groups, Quinn found no significant differences between the groups. Yet changes occurred in the expected direction, and there was a significant reduction in diastolic blood pressure among the therapeutic touch group that was not seen in the no-treatment group (Quinn, 1989). In another study of therapeutic touch versus mimic therapeutic touch, Parkes showed no significant differences among elderly hospitalized patients (Parkes, 1985).

Collins (1983), Fedoruk (1984), and Ferguson (1986) found significant relaxation effects of therapeutic touch with various subjects in different studies, and Quinn (1992), in a pilot study of four bereaved people, found significant reduction of suppressor T cells in all four after therapeutic touch. Moreover, Kramer found significant differences in stress reduction between treatment and control groups in a study of therapeutic touch with hospitalized children (Kramer, 1990).

Other U.S. studies. A number of pilot and case studies in fruitful areas have shown interesting results that are worthy of further investigation. These studies were conducted without controls, usually because of the severe limitations on funding.

In four uncontrolled cases, Pavek found that white cell decrease during chemotherapy reversed and rose significantly after single SHEN therapy treatments at the thymus gland (Pavek, unpublished, 1984-85). In a pilot study on SHEN therapy and premenstrual syndrome, Pavek noted significant long-term symptom relief and behavioral change with 11 of 13 subjects (Pavek, unpublished, 1986).

Beal, in an unpublished study of 12 hospitalized major depressives, found no statistical difference in time of release from the hospital between 6 subjects randomized to receive SHEN therapy and 6 controls receiving sham SHEN therapy. However, in analyzing both subject and counselor reports, Pavek found significant change in dreaming, emotional expressiveness, and interpersonal contact with subjects receiving SHEN therapy and much less change among controls (Beal and Pavek, 1985).

Other therapeutic touch research with promising indications includes research on rehabilitation (Payne, 1989), helping patients to rest (Heidt, 1991), mental patients (Hill and Oliver, 1993), symptom control in acquired immunodeficiency syndrome (AIDS) (Newshan, 1989), and severe burn patients (Pavek, unpublished observations).

Promising research with SHEN therapy includes research with occupational therapy clients, third-trimester abdominal pain, reduction of pain during birthing without pain medication, irritable bowel syndrome, posttraumatic stress disorder, anorexia, bulimia, phobias, and chronic migraine.

International research.   There has been considerable research on biofield therapeutics in other countries. In China, more than 30 controlled studies on effects of fa qi on both humans and animals were reported in the proceedings of just one meeting, the First World Conference for the Academic Exchange of Medical Qigong. At the same meeting, 32 studies were presented on effects on health of qigong exercises that raise qi (Proceedings, 1988).

In an overview report, Daniel Benor has compiled data on 151 healing studies from around the world (Benor, 1992). In many of these studies, mental healing efforts were combined with the biofield processes. However, 61 were controlled, published studies of biofield healing effects without the confounding factors of mental intent. These studies are shown in tables 4 and 5.


Research Recommendations

Promising clinical results. While technique, focus, and range of treatments attempted vary considerably, a number of results are common to all forms of the biofield process:

  • Acceleration of wound healing.

  • Reduction of the pain of thermal burns and acceleration of healing time.

  • Reduction of sunburn pain and coloration.

  • Reduction of acute and chronic pain.

  • Reduction of anxiety.

  • Release of pent-up grief.


In addition, practitioners of some forms of the process report consistently good results with

  • recurrent panic attacks;

  • premenstrual syndrome;

  • posttraumatic stress disorder;

  • irritable bowel syndrome;

  • nonbiological sexual dysfunction;

  • drug, alcohol, and codependence recovery;

  • migraine;

  • anorexia and bulimia; and

  • third-trimester pregnancy and birthing.

Characterization of the biofield. That the biofield has definable form, flux pattern, and polarities seems clear to practitioners from the wealth of empirical evidence available. However, characterization of the biofield is far from complete, and determining its nature is paramount to its further development among the healing arts.

Two hypotheses should be tested: first, that the biofield is a field in physics other than an already known field, and, second, that the biofield is bioelectromagnetism. One approach that would support the first hypothesis would be development of a device (transducer) that would react with the biofield so as to exclude the possibility of bioelectromagnetism. Research projects in China have shown that application of the biofield affects lithium fluoride thermolumi-nesence detectors, polarized light beams, Van de Graff generators, and silicone crystal plates (Proceedings, 1988). These preliminary experiments suggest possible approaches toward further characterization.

Research design considerations.   The following should be considered in planning well-designed studies to evaluate potential effects of biofields on health:

  • Mental healing techniques. Since mental healing techniques are often mixed with biofield techniques, care must be taken in all research designs to separate out the two factors. Unless this is done, unclear results will prevent reasonable analysis.

  • Sham treatments. Unlike placebo pills, biofield healing cannot be faked. According to the observations of practitioners, it is not possible to touch subjects in a clinical study in a purely physical way for any period of time without resulting in some effect from the practitioner's biofield. Nor is there a way to shield the biofield emitted by one person from another person's; this renders the notion of a "sham control" meaningless. This particular confounding factor has adversely affected results in several studies of biofield therapeutics (Beal and Pavek, 1985; Meehan, 1988; Parkes, 1985; Quinn, 1989). In these studies, controls were established by effecting a mimic, or sham, of the primary method. The practitioners' hands were brought into close proximity with the subject in a "sham treatment." In all such cases, some positive effect was obtained with the mimic or sham treatments that was greater than could be reasonably expected from no-treatment controls.

  • Double-blind studies. Although it is not possible for a biofield healing practitioner to perform in a strict double-blind situation, it is possible to design studies in which the evaluators are blinded to the treatment method and subjects are blinded to the method and to the specific intended outcome.

  • Science and metaphysics. Because the metaphysical model lies, by both definition and practice, outside the usual confines of science, research on metaphysical explanatory models will be difficult. However, outcome studies of clinical effect could be designed and executed.

  • Collaborations. The process could be speeded up if experienced researchers sympathetic to energy healing work together with researchers experienced in developing appropriate criteria. These criteria must (1) provide the established medical and health communities with valid, reproducible data and (2) be constructed so as not to negate the operative treatment mechanism.


Barriers and Key Issues

Hindrances. For various reasons, biofield healing has been hindered from reaching its fullest potential. Principal among these reasons are the following:

* Until recently, few testable hypotheses.

* Few theoreticians who are also practitioners.

* The disdain of currently established scientists.

* Lack of a solid research base.

* Lack of an adequate outcomes database.

* Unsystematic accumulation of empirical evidence.

* Obscuring of the extent of efficacy by a plethora of conceptual confusions and conflicting claims as to causal factors, best methods, and procedures.

Placebo and efficacy. Some people have attributed any successful applications of biofield therapeutic to a high probability of placebo effect. This assumption has inhibited reviewers and editors from accepting as valid the usual, smaller pilot studies that would be acceptable for other types of therapy.

No studies that have been done, however, indicate that placebo factors are any higher with biofield therapies than with other healing methods. In fact, a number of situations in which placebo effects would have been highly unlikely cast doubt on the concern. Some such studies have had marked, positive results (Benor, 1992) with animals and with small children below the age of reason. There are also numerous anecdotal reports of children receiving treatments while asleep and awakening with marked change. Fevers have broken during such treatments, panic attacks have ceased, and comas have ended (Pavek, 1988).

Such evidence suggests that the reason why biofield treatments are effective is other than the placebo effect.

Peer review. At this time, there are no peer review groups that actually include "peers." True peers, who have a hands-on understanding of biofield therapeutics, should be included on review committees. (See the "Peer Review" chapter.)


Recommendations

Because the stigma associated with "faith healing" has been attached to biofield therapy, it has not been seriously considered as a viable treatment method. Consequently, the discipline languishes in a research doldrum. The following steps are recommended:

1. The biofield should be characterized. Reasonable approaches exist, some of which have been described in this report.

2. Simple and appropriate instruments should be developed to begin the process systematically collecting clinical data. With properly designed forms, individual case studies could be statistically sorted and grouped by disorder, treatment process, and results. This sorting would begin to establish relative efficacy in the various categories, suggesting productive avenues for future research. To implement this process, OAM should establish a small study group, including members familiar with intake and outcome forms and data collection and representative members of the discipline.

3. Studies should be undertaken to determine how much of biofield therapeutics is attributable to mental healing and how much is attributable to quantity and proper directional application of the biofield flows.

4. Appropriate review panels with actual peers should be established.

5. A number of open technical questions in the discipline should be resolved. OAM should invite the leaders of the various systems to a general meeting to discuss and compare techniques and methods and to begin resolving these questions. Resolving these differences will enhance the techniques of all biofield healing methods.

6. A number of clinical studies that have been done in Europe and in Asia could be replicated here. Replication is necessary to assure the American research community that the studies are valid and to point the way for further research here.

7. A wealth of serious study proposals are available. These should be reviewed, and the most promising should be implemented.


Conclusion

Biofield therapeutics and diagnostics have been struggling to cross the border from metaphysics to physics and gain mainstream acceptance for a long time. In spite of considerable difficulties, biofield methods are gaining acceptance from health professionals and the general public in two areas--(1) the medical clinic and (2) hospital and psycho- therapeutic settings. In both, biofield treatments are reported to be of benefit for many people.

Biofield therapeutics are a low-cost, noninvasive, nondrug approach, and applications have been reported in many medical and health situations as alternatives or as complements to mainstream medicine. The potential reward-to-risk ratio is great, and relatively small amounts of money are needed to start a validation process, which should be done with dispatch.


Combined Physical and Biofield Methods

The following methods are described by their practitioners as combining physical and biofield aspects. The list, which is not all-inclusive, tends to be descriptive; little research is available as a basis for judging the usefulness of these methods. Most of them would benefit from research on their efficacy and their scientific bases.

Applied Kinesiology

Applied kinesiology, or "touch for health," consists of both a diagnostic method of determining dysfunctional states of the body and related therapeutics. Based on principles of physiology and the meridian system mentioned earlier, it was developed in the 1960s by George Goodheart. It uses both the meridian qi and the biofield qi in its diagnostics and therapeutics.

Neurolymphatic holding points, neurovascular holding points, meridian holding points, and the biofield external qi are all said to be incorporated in the process. A session starts with various "muscle testings" that are used to determine the state of qi flow through the meridians. Muscle testings give an indication of the area to be worked on and are a necessary part of the treatment.

A number of applied kinesiology practitioners use the process in conjunction with more established practices, such as chiropractic.


Network Chiropractic Spinal Analysis

Network chiropractic spinal analysis (NCSA) merges conventional chiropractic mechanical or structural approaches with biofield approaches to evaluate and correct anomalies of the spine and nervous system. At the clinical core of NCSA is the classification of spinal subluxations into two categories: (1) structural subluxation that involves mechanical dislocation of spinal sections and (2) soft-tissue subluxation that involves tension in the muscles and other soft tissue connected to the spinal sections. NCSA does not address structural subluxations until after a reduction of soft-tissue subluxations has occurred. (It has been noted that structural subluxations often self-correct shortly after soft-tissue subluxations have been adjusted.) Application of the biofield is included for the soft-tissue adjustments and is applied first. Conventional chiropractic adjustments follow, as required, for structural adjustments.

The clinician uses a phased system to introduce order to the subluxated segments. Since the body often creates movement from a tense, restricted state, a spontaneous discharge of tension often occurs as the spinal distortions are resolved; this is a common occurrence. A wide range of responses is then observed with certain common elements. Among the unique individual responses typically seen is a period of deep and full respirations; other responses include periods of muscular movements and naturally occurring postures as the body and mind seek to purge mechanical tension or stored memories of traumatic experiences.


Polarity Therapy

Polarity therapy is a natural health system based on the idea of a "human energy field." Drawing from oriental and Indian sources, it asserts that well-being and health are conditions determined by the nature of the flow of this human energy field and that the flow can be affected by various natural methods. Polarity therapy incorporates a variety of strategies to enhance the flow of the energy field, including touch, diet, movement, and self-awareness. (Polarity practitioners generally believe that the energy field that they are enhancing is electromagnetic, but this point has not been established.)

The central concepts of polarity therapy are as follows:

* All phenomena have a fundamental structure involving charged particles in a relationship of expansion-contraction or attraction-repulsion. In East Asia this relationship is called the tao, or relationship of opposites (yin and yang).

* An "energy anatomy" precedes and creates physical anatomy, and this energy anatomy exists in several layers that are affected, and possibly distorted, by life experience.

* These distortions may be corrected by several methods, including touch, holding pressure points, and using the practitioner's hands to link various "polarities" in the client's body.

Commonly reported benefits of "polarity energy balancing" include relaxation, pain reduction, reduction of nervous conditions, heightened self-awareness, and improvement in range of motion.

Polarity therapy was developed in the 1950s by Randolph Stone, a chiropractor, osteopath, and naturopath. Today the American Polarity Therapy Association, which was founded in 1983, organizes and supports training and certification of practitioners; the association also is developing a research arm. At present there are more than 500 practitioners of polarity therapy, trained at several levels of proficiency.


Qigong Longevity Exercises

The qigong longevity or health exercises are a fairly recent addition to alternative health practices in the United States. Qigong exercises are similar in appearance to tijijuan (tai chi chuan), a rhythmical nonaerobic form of exercise; however, this appearance is only superficial. Qigong movement exercises do not flow from one position to another as in tai chi; they are done in shorter movement groups that are repeated many times. This, however, is not the essence of the practice, but only the visible form.

Qigong exercises combine repetitions of coordinated physical motions with mental concentration and directive efforts to move the qi in the body. During these exercises, which are based on slow, repetitive movements of the arms, legs, and torso, the exerciser's mind is focused on moving the qi (biofield flux) through the meridian pathways and nonmeridian pathways that were developed by the ancient Taoist (Daoist) sages.

This mental effort is coordinated with specific movements; for example, qi may be directed up the back as the arms are raised and down the front as the arms are lowered. Large amounts of internal qi are said to be developed in the process. It is estimated that there are more than 100 different forms of qigong health exercises. There are considerable differences in the styles, but all consider the mental effort to be crucial. Qigong exercises are used daily for health improvement by several million Chinese, both in the People's Republic and in Chinese communities throughout Southeast Asia.

Qigong exercises are also used by qigong masters (see the "Biofield Therapeutics" section) to increase the quantity of qi available for healing; some use it in various forms of martial arts such as gongfu (kung fu).

In China, qigong exercises have been under study for their long-term effects on a number of medical conditions, such as cancer and arthritis, and for their effects on general health. More than 32 studies were recently presented at just one major conference on the effects on general and specific states of health of exercises enhancing qigong qi (Proceedings, 1988).

Several schools and organizations in this country focus entirely on these practices. The principal ones are China Advocates, the Chinese National Chi Kung Institute, the Qigong Academy, and the Qigong Institute. The practice of qigong is gaining in popularity in the United States, both with Asians and non-Asians.


Craniosacral Therapy

Craniosacral therapy is a gentle, hands-on treatment method that focuses on alleviating restrictions to physiological motion of all the bones of the skull, including the face and mouth, as well as the vertebral column, sacrum, coccyx, and pelvis. Concurrently, the craniosacral therapist focuses as well on normalizing abnormal tensions and stresses in the meningeal membrane, with special attention to the outermost membrane, the dura mater, and its fascial connections. Attention is also paid to alleviating any obstacles to free movement by the cerebrospinal fluid within its membrane compartment and to normalizing and balancing perceived related energy fields. This approach is derived from experiments of John Upledger, an osteopathic physician and researcher (for example, see Upledger, 1977a and 1977b, which are discussed below).

As usually practiced, this therapy is a noninvasive treatment process that requires an uninterrupted treatment session of at least 30 minutes; often the session is extended beyond an hour. Practitioners indicate that successful treatment relies largely on the therapist's ability to facilitate the patient's own self-corrective processes within the craniosacral system. Postgraduate training in craniosacral therapy has been undertaken by a wide variety of physicians, dentists, and therapists. In the United States during 1993, 2,738 health care professionals completed the Upledger Institute's introductory-level workshop and seminar; 1,827 received training at the intermediate level, and 80 completed the advanced level. Training outside this country is available through the Upledger Institute Europe in the Netherlands and on a smaller scale in Japan, New Zealand, France, and Norway by American Upledger Institute teachers.

The most powerful effects of craniosacral therapy are considered to be on the function of the central nervous system, the immune system, the endocrine system, and the visceral organs via the autonomic nervous system. This therapy has been used with reported success in many cases of brain and spinal cord dysfunction. Although these successes have not been documented in formal studies, they have been observed subjectively or anecdotally by both patients and therapists. Most prominent among these success reports are cases of brain injury resulting in symptoms of spastic paralysis and seizure. Other areas of claimed success include cerebral palsy, learning disabilities, seizure disorders, depressive reactions, menstrual dysfunction, motor dysfunction, strabismus (a vision disorder), temporomandibular joint problems, various headaches, chronic pain problems, and chronic fatigue syndrome.

Research on tissues has documented the potential for movement between skull bones in adult humans, and pilot work with live primates has shown rhythmical movement of their skull bones. Interrater reliability studies, which look for correlations in the observations of two or more independent raters (see the "Osteopathic Medicine" section), have shown agreement between "blinded" therapists evaluating preschool-aged children ("blinding" means that the therapists making the observations did not know which children had received craniosacral therapy, nor did they know the history or problems of the children) (Upledger, 1977a). Controlled studies have shown high correlation between schoolchildren with various brain dysfunctions and specific dysfunctions of the craniosacral system; that is, the craniosacral exam scores correlated with recorded school teacher and psychologist opinions of "not normal," behavioral problems, motor coordination problems, learning disabilities, and obstetrical complications (Upledger, 1977b). Moreover, Upledger reports that a few pilot studies by dentists have demonstrated significant changes in the transverse dimension of the hard palate as well as in occlusion in response to craniosacral therapy.

At present, work is under way that appears to demonstrate fluctuations in what are called energy measurements in circuits between craniosacral therapists and patients. The circuits are established by attaching electrodes to the patient and the therapist with an ohmmeter and a voltmeter interposed in the circuits. In observations with 22 patients, measurements have ranged from more than 30 million ohms at the start of a treatment session to 448 ohms with a brain-injured child; voltages have fluctuated between 10 and 254 millivolts. Upledger's interpretation is that the elevation in resistances read with the ohmmeter correlate with the palpable resistances that craniosacral therapists feel with their hands and that the energy put into overcoming these resistances is reflected by elevations in the millivolt readings. On the basis of these preliminary studies, plans are under way to explore further whether the energetic changes measured in the circuits accompany specific landmarks in treatment processes.


Physical Therapy: An Example of Transition to Mainstream Health Care

Physical therapists are health care professionals who diagnose and treat problems related to physical function. While physical therapy is considered to be a part of mainstream medicine in this country, its practitioners frequently use manual healing methods that are categorized as alternative. Many of the methods identified in other sections of this chapter are part of the standard repertoire of physical therapy. The development of the profession and its transition into mainstream health care are discussed in this section. Some of the alternative procedures and the difficulties encountered in training for them are noted.


Background

Physical therapy is a relatively young profession in comparison with medicine and nursing, although its roots lie in ancient Rome and Greece. Its modern embodiment appeared at about the time of World War I, through the creation of the Women's Auxiliary Medical Aides, renamed Medical Aides and then again Reconstruction Aides, in the Office of the Surgeon General of the Army. Physical therapy training programs existed in France and England at this time under the name physiotherapy, a term that is still used in most Western nations outside the United States. It quickly became apparent that the United States also needed to train its own people in new ways to assist the war wounded. Few, if any, professionals who were trained in medicine or nursing at that time could deal with physical, vocational, and psychological problems associated with injuries sustained in war (Ramsden, 1978).

Educational preparation in 1917 consisted of 4-month sessions after graduation from high school but quickly moved to 12-month sessions that followed preparation in nursing or physical education. Since the 1920s, preparation for practice has shifted from an apprentice model to an academic model and from clinic-based education to universities. Currently, 50 percent of entry-level degrees are awarded at the master's degree level. Not included are master's degrees in physical therapy awarded to people already trained in the field. The professional doctorate--the D.P.T.--is available at three universities.

Adversity stimulated the growth of the profession, with major spurts during both world wars and during the polio epidemics in 1914, 1916, and the 1940s. Then a new creativity in prosthetics and orthotics in conjunction with physical therapy treatment evolved in response to the problems of thalidomide-affected babies after the belated recognition in 1961 that thalidomide was a teratogen (a substance affecting embryonic development). Thalidomide was given to pregnant women, primarily in Great Britain, to treat nausea, or "morning sickness."

The startling growth of physical therapy as a profession in the 1980s and 1990s may be explained by many factors, including documented effectiveness of treatment of patients of all ages. The targets of treatment include virtually all problems affecting normal function resulting from trauma and illness as well as those resulting from genetically transmitted disease, trauma sustained in childbirth, developmental delay, and normal and abnormal consequences of aging.

The number of schools in the United States preparing men and women for the profession of physical therapy is now 140, with approximately 5,000 graduates each year (American Physical Therapy Association, 1993). There are additional schools at various stages in the accreditation process. Previously made up entirely of women from physical education and nursing, the professional ranks today include approximately 30 percent men. The curriculums draw applicants from a wide variety of academic backgrounds, including fine arts, basic science, humanities, behavioral sciences, engineering, and business. Membership in the American Physical Therapy Association is approximately 60,000, which is half the total number of practicing physical therapists in the United States.

The number of graduates from academic programs does not begin to meet society's need for physical therapy services. Because professional practice is relatively autonomous, physical therapists frequently work in private practice. Growing sophistication and autonomy have led to a nationwide effort by members of the profession to seek legislative changes in State practice acts to permit practice without referral. Twenty-eight States have enacted such legislation. Real shortages of physical therapists exist in many health care institutions; it is one of the professions having the greatest number of vacant positions in the Nation.


Current Practice

Physical therapists are licensed health care professionals. The therapist's normal scope of work for any given client involves evaluating the patient, identifying potential problems, and determining the diagnoses that are related to physical function; then the therapist establishes objectives or goals, provides treatment services, evaluates the effectiveness of treatment, and makes any modifications necessary to achieve the desired outcome.

Therapeutic interventions focus on posture, movement, strength, endurance, cardiopulmonary function, balance, coordination, joint mobility, flexibility, pain, healing and repair, and functional ability in daily living skills, including work.

Among the therapeutic activities included are therapeutic exercise; application of assistive devices; physical agents, such as heat and cold; ultrasound; electricity, such as electromyography and electrical muscle stimulation; manual procedures, such as joint and soft-tissue mobilization; neuromuscular reeducation; bronchopulmonary hygiene; and ambulation training with and without assistive devices.

This professional activity may take place in a wide variety of settings, including neonatal nurseries, intensive care units, bedside acute care, rehabilitation units, outpatient clinics, private offices, private homes, physical fitness or sports facilities, and schools. In addition to providing direct service, physical therapists are also involved in health maintenance programs and illness prevention programs, health policy development, administration, education, research, consultation, and other advisory services.

Physical therapists also apply many of the therapeutic interventions identified and discussed elsewhere in this chapter. Therapists using these procedures consider them fundamental tools in their repertoire. Among these procedures are acupressure, myofascial release, craniosacral therapy, massage techniques, Alexander technique, Feldenkrais method, and therapeutic touch.

Such procedures are rarely included in the academic preparation of physical therapy students. Rather, they may be learned through special programs with a select group of practitioners who conduct continuing education experiences throughout the country. Perhaps the inclusion of these procedures in the clinical practice of physical therapy is evidence of the belief by a growing segment in the profession that mind and body are connected, but we do not know or understand all the connections.

Several of these systems seem to share common threads. The therapy is aimed at restoring the homeostasis of a person's body-mind-spirit, using a comprehensive and holistic approach. The emphasis is on promotion of health, prevention of illness, and education approaches.


Philosophy

The philosophy of physical therapy is based on an educational model; the objective is to help individual patients help themselves to attain the maximum level of function they are capable of. The decisions about treatment--what to do, when to do it, and how much--are not made only on the basis of experience with what "works." A general understanding of the effects of an approach for a given condition is not adequate justification for applying that method.

The professional literature of physical therapy that appears in several refereed journals documents evidence of the efficacy, or lack thereof, of particular treatment interventions. Both quantitative and qualitative research methods are used with increasing sophistication. A major effort by physical therapists in academic and clinical leadership positions and by the professional association has contributed to the prominence of this kind of documentation for a wide variety of physical therapy interventions.


Current Research

Responding to a research mandate may be difficult for some physical therapists who are using procedures that are less well-known and not generally included in the traditional academic preparation (Hariharan, 1993). Research may be even more difficult for therapists whose work is entirely clinical and whose academic preparation did not include training in research methodology appropriate for clinical practice (Soderberg, 1991). Nevertheless, the research mandate for the profession today is clear: do it if it works, document carefully what has been done, develop careful research studies to determine the mechanisms involved, publish the results, and continue the research until everyone understands what is being done and why. As a corollary, a corresponding need has arisen for physical therapists to obtain training in research methodology.

Physical therapist researchers currently publish in major medical journals as well as the journal Physical Therapy. The research covers a wide range of subjects related to clinical practice and the underlying mechanisms of function (Bohannon, 1986). Recently published work on the following subjects illustrates the range: physical therapy treatment of peripheral vestibular dysfunction based on clinical case reports; impact of three posting methods on controlling abnormal subtalar pronation; a comparison of three different respiratory exercises in prevention of postoperative pulmonary complications after upper abdominal surgery; motor unit behavior in Parkinson's disease; a study of age and training on skeletal muscle physiology and on performance; a study of the factors associated with burnout of physical therapists working in a specific work environment; and a study of the discrete behaviors that differentiate the expert from the novice physical therapist.


Summary

Physical therapy began with a few women who trained briefly and learned on the job how to help care for seriously injured soldiers. The group grew dramatically, and the length of training increased as the scope of work became apparent and the amount of knowledge to impart expanded. With the knowledge and technology explosions, physical therapy became more sophisticated and moved into the mainstream of health care, contributing in significant ways to patient care and to the literature of research and practice.

Overall Recommendations

Research on manual healing methods is needed in four parallel and interactive directions:

* To determine the range of clinical benefits for the many common physical complaints and problems treated by therapists using these methods (e.g., back pain, headache, whiplash, and chronic fatigue syndrome).

* To determine the degree to which a general sense of well-being is enhanced by the various manual healing methods.

* To evaluate the effect of structural manipulation on body awareness (both visceral and external); regulation of motion; range of movement; ability to cope with stress; muscle tone and flexibility; growth, development, and aging; autonomic function (neural control systems); electrical patterns in muscles; immune system response; and cardiovascular and respiratory function.

* To determine the physiological and neurological mechanisms associated with specific manual healing methods.



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Table 1. Some Equivalent Terms for Biofield

Term Source

Ankh Ancient Egypt

Animal magnetism Mesmer

Arunquiltha Australian aborigine

Bioenergy United States, United Kingdom

Biomagnetism United States, United Kingdom

Gana South America

Ki Japan

Life force General usage

Mana Polynesia

Manitou Algonquia

M'gbe Hiru pygmy

Mulungu Ghana

Mumia Paracelsus

Ntoro Ashanti

Ntu Bantu

Oki Huron

Orenda Iroquois

Pneuma Ancient Greece

Prana India

Qi (chi) China

Subtle energy United States, United Kingdom

Sila Inuit

Tane Hawaii

Ton Dakota

Wakan Lakota

Source: Provided courtesy of the Biofield Research Institute.

Table 2. Brief Features of the Major Biofield Therapies in the United States

Therapy_Year originated_Developer_Theoretical basis_Diagnostic procedures_Certification_Placement of hands_Mental healing at a distance_Therapeutic intent__



Healing science_1978_Barbara Brennan_Open system, incorporates chakras and psychic layers_High sense perception_Yes, after completion of advanced study_Both on and near the body_Yes_Treat the whole person and specific disorders__

Healing touch_1981_American Holistic Nurses Association_Elements of therapeutic touch, healing science, and Brugh Joy's and other work_Tactile assessment_Yes_Both on and off the body_Yes_Whole person, specific disorders__

Huna_Traditional Hawaiian__Involves mana (universal force) and aka (universal substance)_Various_No_Both on and near the body_Yes_Heal mind and body__

Mari­el_1983_Ethel Lombardi_Vibrational energy is transmitted from a higher source through the practitioner to the patient, affecting cellular memory and the endocrine system_Tactile assessment_No_Usually off the body_Yes_Heal and harmonize the life of the individual__

Natural healing_1974_Rosalyn Bruyere_Operates on a belief in a universal principle of energy_Tactile assessment_Graduates are ordained___Effect symptomatic relief, assists in proper use of energy__

Qigong_Traditional Chinese__Qi flows through the body in meridians and other patterns; Qi is delivered with great force by many practitioners called qigong masters_Varies with practitioners_Not usually_At the meridian points or at a short distance from the body_Yes_Healing of biological disorders__

Reiki_Japan, 1800s; USA, 1936_Mikao Usui (introduced by Hawayo Takata)_Spiritual energy with innate intelligence, channeled through the practitioner; the spiritual body is healed, it in turn is expected to heal the physical; Uses rituals, symbols, spirit guides_Varies_Spiritual initiation (i.e., the power to heal is given after training)_A few standard hand placements (usually side by side; on the physical body)_Yes___

SHENR therapy_1977_Richard Pavek_Biofield conforming to natural laws of physics, with a discernable flux pattern through the body_Conventional medical and psychotherapy instruments with questions designed to discover repressed emotional states_Yes, after internship. Practitioners meet requirements of U.S. Department of Labor Occupational Code 076.264-640._Sequence of paired­hand placements, directly on the body, arranged according to flux patterns, usually with one on top and one underneath_No_Primarily emotional disorders and somatopsychic dysfunctions__

Therapeutic touch_1972_Dora Kunz and Dolores Kreiger_Practitioner restores correct vibrational component to the patient's universal, unitary field_Tactile assessment_None_Generally near the body_Yes_Nonprescriptive healing of the whole person__

Note: Polarity therapy was omitted from this table but is discussed in the "Combined Physical and Biofield Methods" section of this chapter.

Table 3. Rough Equivalencies in Applied Physics

Atmospheric Biofield

Physics Physicsa Electromagnetics Hydrodynamics

Air Qi Flux Liquid

Density Denseness Charge Viscosity

Wind Flow Current Stream

High pressure Sending handb Negative terminal Source

Low pressure Receiving handb Positive terminal Slump

Friction Resistance Reluctance Friction

System Biofield Field Flow­field

Pressure Force Electromagnetic field Pressure

Pressure gradient Polarity Polar difference Pressure differential

Source: Provided courtesy of the Biofield Research Institute.

aProposed category

bIn some systems

Table 4. Controlled Studies of Biofield Therapeutics With Humans

Subject No. of studies Significant resultsa +

Anxiety 9 4 (+2)

Hemoglobin 4 4

Skin wounds 1 1

Asthma and bronchitis 1 0

Tension headache 1 1

Postoperative pain 1 0

Neck and back pain 1 (?+1)b

Total 18 10 (2)

Percent of total 56% (11%)

Source: Benor, 1993.

aSignificance p<<.01; for values in parentheses, p<<.02-.05.

bPossibly significant results, but faulty reporting or design prevented proper evaluation of the studies.

Table 5. Other Controlled Biofield Studies

Subject No. of studies Significant resultsa

Enzymes 8 3 (+2) (?+3)b

Fungus/yeast 6 4 (+1) (?+1)b

Bacteria 2 ?

Red blood cells 1 1

Cancer cells 3 1 (?+2)b

Snail pacemaker cells 4 4

Plants 10 7 (?+2)b

Motility

Flagellates 2 0 (?+1)b

Algae 2 1

Moth larvae 1 1

Mice

Skin wounds 2 2

Retardation of goiter

growth 2 2

Total 43 26 (3)

Percent of total 61% (7%)

Source: Benor, 1993.

aSignificance p<<.01; for values in parentheses, p<<.02-.05.

bPossibly significant results, but faulty reporting or design prevented proper evaluation of the studies.
  • Robert Ward, an experienced osteopathic physician-researcher, estimated that 10 percent of osteopathic physicians use manual diagnosis and treatment a great deal and that some 60 percent use them in selected cases. Ward believes most patients receiving primary care from osteopaths probably receive a diagnostic workup involving manual diagnosis at some time, particularly if neuromusculoskeletal problems have been reported (Ward, 1994).

  • The energetic and oriental manual techniques are categorized by some as massage techniques. However, in this chapter the energetic techniques are addressed in the "Biofields Therapeutics" section and the "Combined Physical and Biofield Methods" section, and the oriental techniques are addressed in the remainder of the "Physical Healing Methods" section. The energetic methods are considered to affect the biofield--a field that is described as surrounding and infusing the human body--by pressure and/or manipulation of the physical body or by the passage or placement of the hands in, or through, that energetic field. These methods are based on traditional Ayurvedic, Eastern or Western esoteric, modern therapeutic, or other recognized and accepted systems of healing. Examples are polarity therapy and therapeutic touch. The oriental methods of treatment use pressure and manipulation based on traditional East Asian medical principles to assess and evaluate the energetic system (Jwing-Ming, 1992) or to provide actual treatment that affects and balances the energetic system. Examples are tuina (or tui-na), shiatsu, acupressure, an-mo, and jin shin do.

  • These depictions can be seen in the Third Dynasty exhibit in the National Museum, Cairo, Egypt.

  • The differences between direct and indirect contact are analogous to the two methods of illuminating a neon light. The first is to place the neon bulb in a strong electromagnetic field. This is the simpler way, as it requires no wiring or particular orientation; the bulb will glow wherever it is placed. However, a great deal of power is required for a given light output, and the light fluctuates sharply with small fluctuations in the field. The second method is to connect the neon bulb into an electric circuit. This method requires wires and knowledge of how to connect the bulb correctly; it produces much more light with far less power, but the light is less likely to fluctuate. Similarly, the biofield is described as having both external field and internal circuitry.

  • SHENR stands for Specific Human Energy Nexus. SHENR therapy is described by Pavek as a biofield method of treating the so-called psychosomatic and related disorders by releasing repressed and suppressed debilitating emotions directly from the body.

  • Qigong exercises are repetitive physical motions coordinated with breath and mental efforts to move the qi through meridians and other "channels." They are gaining popularity in the United States. (See the "Combined Physical and Biofield Methods" section.)

  • Flow is much slower through human tissue and varies with the person's health and emotional state.

  • An erroneous report, "New Technologies Detect Effects of Healing Hands," in Brain/Mind Bulletin, vol. 10, no. 16, contributed to this supposition when it stated that one researcher, John Zimmerman, had measured electromagnetic effects of healers' hands during healing with a SQUID (superconducting quantum interference device); actually, he made his measurements at the healers' heads while measuring very low-amplitude electromagnetic brainwave activity.

  • No one has yet been able to detect either current flow or electromagnetic flux emanating from the hands of a practitioner. Dry skin electrical impedance at the hands is quite high, >10 megohms (10 million ohms). Silver/silver chloride electrodes, as used in biofeedback, measure skin conduction, not flux emanations.


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