Alternative Medicine:
Expanding Medical Horizons

• 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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