The Role of Shiatsu in Complementing Conventional Breast Cancer Treatment
This is a look at how conventional medicine can be integrated with complementary and alternative medicine (CAM). The focus here will be on the role Shiatsu (a CAM therapy) plays in the treatment and healing of breast cancer. Although CAM may be used by a small yet increasing number of women as a sole treatment for breast cancer, Shiatsu’s role here will be assessed alongside conventional treatments.
Introduction to Breast Cancer
Breast cancer is the most common cancer in women in England. 1 in 9 women are diagnosed with breast cancer each year with four out of every five new cases being women aged 50 years and over (Office for National Statistics, 2010). The risk factors which are known are: age; a woman’s exposure to oestrogen throughout her life; an early first period; a late first pregnancy; fewer births; late menopause; oral contraceptives; hormone replacement therapy; obesity; and alcohol consumption (Office for National Statistics, 2010). There is a three-yearly screening service for women aged between 47 and 73 years.
According to NHS Choices (2010) breast cancer can be divided into non-invasive forms, invasive forms and rarer types of breast disease associated with breast cancer such as Paget’s Disease. Macmillan (2008) further describes the different types of breast cancer that women experience; non-invasive breast cancer includes ductal carcinoma in situ (DCIS) in which breast cancer cells have developed in the breast ducts and have not spread to surrounding breast tissue; invasive breast cancer is where breast cancer has spread from the breast ducts or lobes to surrounding breast tissue and includes: HER2 positive, invasive ductal, invasive lobular, inflammatory and triple negative breast cancers.
Treatments for breast cancer range from chemotherapy, radiotherapy, surgery and endocrine pharmacotherapy. Sometimes only one of these options may be chosen, or sometimes a combination of some or all of them will be adopted for treatment. Table 1 below outlines the different treatments, their role in breast cancer treatment and when they are used.
|TREATMENT||WHAT IT IS||ROLE IN TREATMENT||WHEN USED|
|RADIOTHERAPY||The treatment of disease with the use of ionizing radiation. The radiation destroys cancer cells.||When used after surgery, it helps to reduce the risk of the cancer returning or if the surgeon feels there is a risk after a mastectomy that not all the cancer cells were removed. It is sometimes used before surgery as a way of reducing tumour size to allow for more conservative surgery.||Usually after surgery. Sometimes used before surgery or instead of surgery.|
|SURGERY||Two types of surgery: removal of the tumour and/or lymph nodes (lumpectomy or segmental incision), and mastectomy with/without breast reconstruction.||Lumpectomy is used to remove the tumour and a margin of non-cancerous cells around it. Segmental incision is used to remove a larger portion of the breast in the case of a larger tumour. Mastectomy is the removal of all the breast tissue and is recommended in women with multiple cancerous sites in the breast, if the lump is large in proportion to the breast, if there is a widespread area of DCIS. During surgery the surgeon will also check if the lymph nodes in the axilla have been affected.||Surgery often used as initial treatment followed by radiotherapy and/or chemotherapy.|
|CHEMOTHERAPY||Cytotoxic drugs administered intravenously or orally to destroy cancer cells.||To shrink tumour size before surgery. To reduce risk of recurrence post-surgery.||Sometimes given before surgery to shrink the tumour (neo-adjuvant chemotherapy). Often given after surgery if there is a risk of the cancer returning (adjuvant chemotherapy).|
|ENDOPHARMACOTHERAPY||Drugs which reduce the amount of oestrogen and/or progesterone in women whose cancer is oestrogen and/or progesterone positive.||Reduce risk of recurrence.||Given after surgery, chemotherapy and radiotherapy.|
|HERCEPTIN (TRANSTUZUMAB)||It is a monoclonal antibody. It attaches to HER2 receptors on breast cancer cells and stops the cells from growing and dividing.||Reduce risk of recurrence in women who has breast cancer which is HER2-positive.||In women with early breast cancer. Given after surgery and adjuvant chemotherapy. Used in women with advanced breast cancer or secondary breast cancer in conjunction with chemotherapy or on its own.|
Overall, the incidence of breast cancer is increasing and the mortality rate is decreasing as shown in the table titled “Incidence rates rise, mortality rates fall” showing the age-standardised incidence of and mortality from female breast cancer (Office for National Statistics, 2010).
(“Incidence rates rise, mortality rates fall” Office for National Statistics, 2010).
There is a large body of evidence supporting the efficacy of conventional treatments and their contribution to the falling mortality rates. The first aspect of treatment which reduces mortality is screening. Despite screening not being a form of treatment (it is diagnosis), its dramatic effects on breast cancer survival merits exploration here of the evidence base highlighting the efficacy of screening. The NHS Breast Screening Programme was introduced in 1988 and has showed since 1988 an increase in levels of incidence, which is to be expected initially, and falling levels in mortality. Reddy and Given-Wilson (2006), reported in their paper ‘Screening for Breast Cancer’ the existence of eight randomized controlled clinical trials which with a meta-analysis of the combined findings showed that mammography alone “reduces the mortality from breast cancer by 24%”. Surgery for breast cancer has changed dramatically over time with a shift in preference from more radical surgery (such as the Halstead radical mastectomy) to breast conserving surgery such as lumpectomies, segmental incisions and mastectomies where necessary. A randomised trial with a twenty year follow-up by Fisher et al (2002) which compared the survival rates for lumpectomy, lumpectomy with radiotherapy, and mastectomy, showed there wasn’t a great deal of difference between the three groups. However, the hazard ratio for death for women who underwent lumpectomy alone compared with total mastectomy was 1.05 (95% CI of 0.90-1.23, p=0.51) compared to a hazard ratio of 0.97 (95% CI of 0.83-1.14, p=0.74) in women who underwent lumpectomy followed by radiotherapy compared with total mastectomy, Concluding that “lumpectomy followed by breast irradiation continues to be appropriate therapy for women with breast cancer.” Women are not only undergoing more conservative surgery but are experiencing better survival outcomes with the introduction of checking for clean margins following lumpectomy, and checking for spread to the lymph nodes with lymph node removal where necessary. With various trials like the one detailed above, women are now being offered various surgical options with the appropriate combinations of radiotherapy and/or chemotherapy to improve survival outcome. With the addition of new and improved pharmaceuticals in both chemotherapy and endocrine drugs, women are experiencing greater survival rates. The ATAC trial gives a wonderful example of how this improvement is always evolving and improving. The ATAC trial compared tamoxifen to anastrozole. Tamoxifen is an oestrogen receptor antagonist and used in women who have a breast cancer which is ER positive (meaning that the breast cancer cells have oestrogen receptors and are sensitive to circulating oestrogens). Jordan (1997) describes how in 1997 tamoxifen is “the gold standard for antiestrogen treatment. Over the last 25 years, the drug has revolutionised breast cancer therapy”. However, with advances in medical science and the discovery of new treatments, anastrozole is now on the market and through the ATAC trial has shown a larger reduction in risk of recurrence of breast cancer in women who have taken anastrozole compared to tamoxifen (Cancer Research, 2011). Radiotherapy is a specialty which is always evolving with the introduction of treatments which are more accurate and comprehensive. An example is Intensity Modulated Radiotherapy (IMRT) according to Cancer Research (2011).
Introduction to Shiatsu
For a full comprehensive introduction to Shiatsu and CAM, please see Appendix 1; the introduction taken from Helen Hunt’s previous SSC assignment on “Shiatsu in Obstetrics and Gynaecology.”
Shiatsu is a CAM therapy which originated from Japan. It is a form of bodywork which uses a range of techniques such as acupressure, moxa, stretches, manipulation, palming and holding. Shiatsu is similar to acupuncture in that they are both based on the same meridian system that runs throughout the body. See the picture below taken from Tuberose, date unknown) which illustrates the path of some of the meridians in the upper body:
(Tuberose, date unkown).
Shiatsu is a very versatile treatment as it can be performed in almost any position and the recipient remains fully clothed throughout, making it a very accessible treatment for women who may be feeling self conscious after breast surgery.
On describing acupuncture and meridians, Pert (1999, p.222), a research professor in the department of physiology and biophysics at Georgetown University Medical Centre, explains that:
“[Acupuncture] looks very promising despite its having been dismissed because knowledge about the points and meridians, evolved over five thousand years of empirical medicine, do not correspond to any existing Western concepts of anatomy. But absence of proof is not proof of absence. In my mind, meridians may be the pathways that are followed by immune cells as they move up and down an anatomical highway, a discovery that could be just one experiment away. The peptide-containing skin-cells, called Langerhans cells, could provide the clue, but no-one has ever looked at their distribution.”
Shiatsu’s role in the treatment and healing of women with breast cancer
There are various ways in which Shiatsu can play a role in conventional breast cancer treatment; complementing surgery (of different types), chemotherapy and radiotherapy. How Shiatsu can complement endocrine pharmacotherapy will not be discussed here. The side-effects of these treatments can affect women in a number of ways and with different severities. A treatment such as Shiatsu may be able to ease many of the symptoms that are experienced by these treatments. The cartoon below by Harris (2011) depicts how some women feel about their cancer treatment:
(Harris, S (2011)).
A consistent role that Shiatsu plays throughout any of the conventional treatment choices is the support it provides on an emotional and spiritual level. It has been documented that the conventional treatment pathway, although very effective in treating the physical aspects of breast cancer, is not always as effective in adequately supporting women through an emotionally and spiritually challenging time with patients often feeling “unsupported or dismissed by their healthcare providers” (Brown, 1999). Wanchai et al (2010) showed that a qualitative study of nine breast cancer survivors saw complementary and alternative medicine as “coping with disease and treatment, holistic care, and emotional support…” whereas conventional medical treatment was negatively associated with a perception of something “they had to go through.” It has become increasingly apparent that “Patients’ disappointment at the absence of a deeper, caring relationship, in connection with an unclear responsibility for the care of the patient as a whole human being, emerges clearly. The suffering related to health care has an essence of neglect and uncaring” according to research carried out by Arman et al (2004) highlighting the experience some women have had with the conventional medical system. CAM therapies have been known to provide women with an environment where all aspects of their wellbeing are considered and they have more time to explore what it is they are concerned or fearful about. Women’s emotional and spiritual wellbeing is paramount for effective treatment and to ensure a certain level of quality of life: “assistance with managing spiritual struggle are necessary to promote QOL [Quality of Life] and life satisfaction among those facing difficult health problems” (Manning-Walsh, 2005). CAM is used for a variety of reasons; according to Wanchai et al (2010) who conducted a systematic review and found that the most common reasons women accessed complementary medicine was due to: recover or healing from breast cancer; boosting the immune system; reducing side effects of conventional treatments; improve emotional health; reducing physical and psychological distress; dissatisfaction with conventional treatments; and to supplement conventional treatments. Shiatsu, as discussed previously, aims to treat women holistically by acknowledging that the physical, emotional, spiritual and environmental factors are all interlinked and impact on eachother.
Chemotherapy is a mixture of cytotoxic drugs administered intravenously. Cytotoxic drugs “inhibit cell division and are therefore potentially useful in cancer chemotherapy” (Rang et al, 2007, p721). They consist of a mixture of alkylating agents, antimetabolites, cytotxic antibiotics and plant derivative such as vinca alkaloids, taxanes and campothecins (Rang et al, 2007, p722). Chemotherapy is sometimes used as a sole treatment or in conjunction with other treatments (such as surgery and radiotherapy). “Adjuvant chemotherapy reduces the risk of breast recurrence and death by about 30% and 20% respectively” (Early Breast Cancer Trialists’ Collaborative Group, 2005, cited in Cancer Research UK, 2009). There are numerous side effects with chemotherapy and women respond differently to chemotherapy with varying degrees of severity of the symptoms. The most common side effects include nausea, hair loss/ hair thinning, sore mouth, diarrhoea, menstrual changes and sore eyes (Cancer Research UK, 2011). Chemotherapy can decrease the number of red blood cells, white blood cells and platelets, meaning there is an increased risk of infection, anaemia (causing tiredness, lethargy and breathlessness), bleeding, bruising and blood clots (Macmillan, 2010). As well as diarrhoea, other changes to the digestive system can take place including constipation and loss of appetite (Macmillan, 2010). When working with cancer patients who are undergoing chemotherapy, it is essential that the Shiatsu practitioner is sensitive to the energy levels of the patient and have adequate knowledge of the implications that chemotherapy can have on the body allowing them to practice safely and effectively; suggesting that a more experienced Shiatsu practitioner should be recommended as suggested by Beresford-Cooke (2003, p10): “the decision on what is appropriate is best made by an advanced practitioner”. Shiatsu can play a fundamental role in reducing the side effects of chemotherapy. Shiatsu uses many acupressure points during treatments making it suitable to use research conducted on acupressure. Utilising acupressure points has the added advantage of patients being able to learn how to stimulate the points themselves; Shiatsu practitioners can teach patients the location of these points. Dibble et al (2007) found that “Acupressure at the P6 point is a value-added technique in addition to pharmaceutical management for women undergoing treatment for breast cancer to reduce the amount and intensity of delayed CINV [Chemotherapy induced nausea and vomiting]… Acupressure is a safe and effective tool for managing delayed CINV and should be offered to women undergoing chemotherapy for breast cancer.” Studies have also shown that chemotherapy-induced vomiting which is resistant to the classical antiemetic drugs has seen a 68% reduction with the use of acupressure according to Gardani et al (2007). Improvement in fatigue associated with chemotherapy was shown to be improved by 19% with acupressure according to Molassiotis et al (2007).
The Oxford Concise Medical Dictionary defines radiotherapy as “the treatment of disease with penetrating radiation, such as X-rays, beta rays, or gamma rays…beams of radiation may be directed at a diseased part from a distance” (The Medical Defence Unit, 2007). Radiotherapy is often used post-surgery in the treatment of breast cancer to reduce possibility of recurrence and is occasionally used instead of surgery according to Macmillan (2008). The side effects of radiotherapy consist of: reddening and soreness of the skin; fatigue; and nausea. As we have already seen, acupressure is particularly effective in treating nausea and fatigue. The recommendations given by breastcancer.org for Shiatsu to be avoided during radiotherapy due to there being areas of soreness needs to be addressed as Shiatsu treatment is based on the meridian system in which meridians are not located in an isolated area of the body, but travel throughout the entire body. The implications of this means that the treatment of the meridians to impact on a specific area of the body can be accessed elsewhere on the body (meridians in the breast can be accessed in the arms, hands, legs, feet and head). The soreness and pain can be treated with Shiatsu; there has been many studies conducted on the efficacy of pain in a number of different situations such as back pain, childbirth, and dysmenorrhoea. This research is transferrable and can be applied to the pain and soreness that is encountered as a result of radiotherapy; Matsubara et al (2011) concluded that “acupressure significantly improved pain conditions” with a use of local and distal acupoints. This is an area which requires further research however. Lymphodema is a common side-effect of radiotherapy and following surgery to the lymph nodes. A systematic review carried out to assess the efficacy of acupoint stimulation for six different conditions (of which lymphodema was one of them) which are therapy-related adverse events in patients with breast cancer showed that 88% of trials reported positive outcomes in at least one of the six conditions examined according to Chao et al (2009). The Shiatsu Society (date unknown) states that “Shiatsu moves the lymph helping to minimise the risk of lymphodema.”
There are a numerous ways Shiatsu can support women who undergo surgery. Different types of surgery are performed, depending on the diagnosis; lumpectomy, mastectomy, lymph node removal, sentinel lymph node biopsy and breast reconstruction (Cancer Research UK, 2011). Shiatsu has a pre and post-operative role. Pre-operatively, Shiatsu supports women in: reducing the anxiety and stress associated with surgery, preparing for surgery to promote a positive outcome, and allow women the opportunity to see surgery as an opportunity for healing. Pre-operative anxiety impacts on surgery and research has shown it has adverse effects on the outcomes of surgery; Törer et al (2010) found that raised pre-operative anxiety and depression in breast cancer patients having mastectomy resulted in increased levels of postoperative pain, increased risk of complications and a longer duration of stay in hospital. Fehder (1999) acknowledges the need for a reduction in stress-induced immunosuppression as the “anxiety associated with anaesthesia and surgery produces alterations in immune function through several mechanisms which affect recovery from surgery and wound healing.” Reducing anxiety prior to surgery has many known health benefits as Huddleston (1996, p.4) explores; it “soothes your nervous system and strengthens your immune system…balances your endocrine and cardiovascular systems”. Many benefits exist when someone is actively preparing themselves for surgery such as less pain, less complications and a shorter duration of stay in hospital as explored by Rogers and Reich (1986) cited in Huddleston (1996, p.2). There are certain acupoints that can be taught to a woman and her loved ones so that they can treat the acupoints themselves without a practitioner present. Acupoints for nausea, pain and anxiety can be taught to women. Shiatsu supports women post-operatively by reducing nausea, pain, anxiety and increase the healing potential of the surgery on all levels; emotionally, physically and spiritually. Physically, Shiatsu can support wound healing; emotionally, it can support with adjustment after surgery and some of the emotional and psychological struggles that are experienced; spiritually it can provide a space to allow women to explore their journey and what it means for them. Post-operative nausea has been found to be treated successfully with acupressure; Gieron et al (1993) found that “acupressure is an effective method of preventing nausea and vomiting [in gynaecological surgical patients and patients with chemotherapy-induced nausea and vomiting] without any side-effects. It is a valuable addition to the prevention of postoperative nausea and vomiting.” Shiatsu can be used to aid wound healing and promote scar-health. Beresford-Cooke (2003) describes how trauma to tissues through surgery can cause “local Stagnantion of Ki or Blood, which may cause problems, either immediately or in the long term.” She advises that Shiatsu “can be very effective in minimising the effects of trauma” and comments on how treatment above and below the scar, treatment on the same site but on the opposite side of the body can encourage the free-flow of ki through the traumatised area. Off-the-body work over the scar can be “soothing and helpful”. This localised treatment can have the added advantage of helping someone integrate what has happened to their body and become familiar with the changes of their body. (look for research regarding women who find it difficult to look, touch, feel their breast post-surgery).
The emotional and spiritual aspects of breast cancer are being explored more and more. Pert (1999) has conducted research on the relationship between mind (emotions) and body, as well as the effects of touch. In her book ‘Molecules of Emotion’ she discusses the research that she and others have conducted and the subsequent links that have been made with regards to health. Pert (1999, p.191) describes how in 1990, Hall conducted research that showed how the immune system could be consciously controlled; “that psychological factors, that is, conscious intervention, could directly affect cellular function in the immune system.” His experiments were in measuring how the stickiness of white blood cells could be increased with the use of cyberphysiologic (cyber meaning “that which steers”) preparation, with the use of several control groups. According to Pert, the link between cancer and emotions has been around since the 1940s when Wilhelm Reich proposed the possibility that “cancer is a result of the failure to express emotions” (Pert, 1999, p.191). It has since been shown by Lydia Temoshok (Pert, 1999, p.192) that “the immune systems were stronger in and tumours smaller for those in touch with their emotions”; the research showed its results were particularly significant in those who “kept emotions such as anger under the surface, remaining ignorant of their existence…self-denial, stemming from an unawareness of their own basic emotional needs.” Pert recognises that “since emotional expression is always tied to a specific flow of peptides in the body, the chronic suppression of emotions results in a massive disturbance of the psychosomatic network” following on from the work of David Spiegel. Pert makes it clear that it’s not all about suppressed anger; “I believe all emotions are healthy emotions, because emotions are what unite the mind and the body…To repress these emotions and not let them flow freely is to set up a dis-integrity in the system…takes the form of blockages and insufficient flow of peptide signals to maintain function at the cellular level.” Shiatsu places a strong emphasis on how the emotional aspects of one’s wellbeing impacts on their physical health (they are not independent of eachother in TCM theory), therefore these clinical observations which have existed for thousands of years pre-date the research detailed above as mentioned by Pert.
Cancer-related fatigue is one of the factors which effects women’s quality of life massively with the prevalence ranging from 17% to 56% and there being “a lack of complex treatments that take the multifactorial character of fatigue causation into account” (Reif, 2010). One recent study by Zick et al (2010) found that “self-administered acupressure holds significant potential for being a cost-effective, low-toxicity, self-care treatment for PCRF [persistent cancer-related fatigue]” with results showing up to a 70% reduction in fatigue. According to NICE (2009) guidelines, the only options available for the treatment of PCRF are: treating any causative factors, provide information about cancer-related fatigue and support groups/organisations, and information about access to an exercise programme. Shiatsu showed significant improvements in fatigue levels (Long, 2008). One of the greatest advantages with Shiatsu is that if someone is only wanting ways to manage symptoms such as fatigue, nausea and anxiety, it is possible for acupoints to be taught by a Shiatsu Practitioner to the woman and/or her loved ones for them to be able to do themselves. This way of self-management of some of the health problems experienced by women offers women a way of being able to have some control over their problems, during a time which potentially feels out of their control and where they place a great deal of reliance on medication and medical procedures. It can be an empowering experience.
Stress is a major factor that is present from the start of a woman’s journey, throughout diagnosis, treatment, and even post-treatment. There has been much research on the effects of stress on health. Antonova et al (2011) reviews the evidence which proposes a link between stress and breast cancer onset and development; they provide a summary in figure 2 which shows the ‘mechanisms of stress signalling in breast cells and of stress-induced breast cancer development” which looks at the role of cortisol; “The suppressive effect of cortisol on the apoptotic ability and DNA repair capacity of cells, as well as its negative effect on immunity, suggests that a connection between stress signaling and tumor development is biologically plausible.” When looking at Shiatsu’s effect on many symptom groups, Long (2007) found the greatest reduction in symptoms were for those of ‘tension or stress’.
Shiatsu in cancer treatment is often contraindicated for cancer (Beresford-Cooke, 2003, p10) due to the risk of the disease spreading due to increased venous and lymphatic flow. “However, since physical exercise or deep breathing also increases venous and lymphatic flow, and both these are considered beneficial, the Shiatsu giver may choose to treat nevertheless. There are many cases where appropriate Shiatsu has greatly helped the symptoms of cancer patients” (Beresford-Cooke, 2003, p10). Some organisations advise against Shiatsu during chemotherapy, radiotherapy and if you suffer with lymphedema (BreastCancer.org, 2008) due to: the risk of bruising as Shiatsu uses pressure applied to the body; radiotherapy causes localised areas to be sore; and Shiatsu can worsen lymphedema. The Shiatsu Society (date unknown) states that “Shiatsu offers a drug free solution to reduce side effects such as pain, nausea and lethargy associated with surgery, radiotherapy and chemotherapy and may help to reduce hot flushes in hormone therapy.” Shiatsu is a highly flexible and adaptable treatment which caters to each individual’s needs making it unlikely that a vigorous Shiatsu treatment that uses a lot of pressure will be used on an individual undergoing chemotherapy. Due to the other side effects that are associated with chemotherapy, gentle Shiatsu should be administered with a focus on therapeutic touch and acupressure which is sensitive to the depleted energy levels of individuals; this is highlighted by Bailey, cited in The Shiatsu Society (date unknown): “the relief which gentle Shiatsu enables is profound… it is now recognised how positive such relaxing and stress relieving effects of Shiatsu are, in conjunction with other ongoing treatments.” Thea Bailey is an internationally renowned Shiatsu Practitioner who has been instrumental in the delivery of Shiatsu to cancer patients, and has had doctors, nurses and midwives access her services in her private practice as they have become aware of the benefits of Shiatsu and the use of therapeutic touch in their own cancer treatment (The Shiatsu Society, date unknown).
It is important for practitioners to work within their limits of competence. Treating women with breast cancer brings not only physical challenges to the Shiatsu practitioner, but also emotional and spiritual challenges. It is paramount that if practitioners are working with women diagnosed with cancer, that they themselves are receiving adequate support and supervision. It is not for the Shiatsu Practitioner to impose any personal views on treatment choices but to support with the decision making process to allow women to feel empowered, supported and respected in whatever they decide. It is important to point out at this stage, that this does not only apply to Shiatsu practitioners but also medical professionals working in breast cancer treatment services. Refreshingly, Northrup (2006, p.673), an advocate for both conventional and complementary medicine, who was previously the Clinical Assistant Professor of Obstetrics and Gynaecology through the University of Vermont College and the president of The American Holistic Medical Association, says that due to the negativity surrounding surgery, it needs to be renamed “Creating Health Through Surgery” as she has seen countless times women putting their life on hold for years at a time while trying to cure their problems “naturally”. She highlights “surgery should always be considered along with other healing modalities” (2006, p.673). This is why it is so important for complementary and conventional medicine to be integrated, for no one practitioner to be working in isolation, and no one practitioner (conventional or complementary of origin) to impart their personal views on treatment choice.
It is very important that Shiatsu practitioners are clear on what it is they are offering to women who have breast cancer. No practitioner, whether they are a medical practitioner or a Shiatsu practitioner can offer the guarantee of a cure. Sered and Agigian (2008) explored in their paper: “Holistic Sickening: breast cancer and the discursive worlds of complementary and alternative practitioners” the type of language used by CAM practitioners and their theoretical models. It is becoming increasingly popular for the notion of self-responsibility to be applied in the complementary medical world; someone is responsible for their own ill-health. This is dangerous to any woman with a diagnosis of breast cancer when this theory is applied out of context. It is not designed to place the woman with illness into a state of shame, guilt and worry, but instead needs to be used as a tool for self-empowerment and healing. This is where people from the conventional medical world have difficulty in interpreting the language of many complementary practitioners, and where (rightly so) there are complementary practitioners not making themselves clear in the meaning of their words and practicing in a dangerous way. CAM focuses on ‘healing’; healing has a very different meaning to what is usually taught in conventional medical schools, which is more geared towards: “fixing” or “curing”. Healing can take place without a cure of the physical problem.
Shiatsu is regulated here in the UK, by The Shiatsu Society, part of the European Shiatsu Federation. It sets the standards for the curriculum in the Shiatsu schools throughout the country. The training for a Shiatsu practitioner takes a minimum of three years to be awarded with the diploma in Shiatsu. A further postgraduate year of training allows the practitioner to be awarded with MRSS status (Registered member of The Shiatsu Society). Practitioners are required to have professional indemnity insurance. It is therefore advisable that when patients select a Shiatsu practitioner it is important for them to enquire about their training, qualifications, membership and insurance.
Shiatsu is there to support women at any stage of their treatment for breast cancer as it is a safe, gentle and effective treatment for a number of the problems women encounter during their journey with cancer.
Breast cancer treatment can seem to some a simple step-by-step process, a conveyor belt system of protocols. When considering the physical aspect of treatment, for many this is the case, backed up by a large body of research and success. However, when we consider the whole person, the whole woman, the healing from cancer is not confined to the treatment of the physical; this is where the treatment becomes much more complex. It could potentially be thought that conventional medicine proves to be superb in the treatment of breast cancer, however, healing the deeper wounds which are left by such an illness are not considered by conventional medicine adequately enough. It would be absurd to think that in today’s age of economic downfall, that the NHS could provide a service that is adaptable and flexible to every woman’s unique needs, especially when thousands of women are being diagnosed each year. This is why the integration of CAM and conventional medicine is so important, evident by its increasing popularity.
The physical treatment of breast cancer has been proven to be very successful, however, often not catering for women holistically. It is evident that neither type of medicine can work in isolation as neither therapy can tick all the boxes.
Not only is greater research needed to look into the effects of Shiatsu, but also in how health is understood. There is a body of research which is emerging which is beginning to explore the links between the mind and the body; this will aid in understanding the approach of many CAM therapies also as well as the development of treatment policies in conventional medicine. The more that we look at health as merely the absence of disease, the more we limit ourselves to sub-standard treatments, and the more women who will want to look beyond the limitations that exist with conventional medicine. Both conventional and complementary medicine have limitations in what it offers women, the sooner practitioners acknowledge and communicate that their mode of treatment has limitations, the sooner women are empowered to make informed decisions about their treatment. Integration, not only supports women who are already engaged with conventional medicine, but may also be beneficial to those women who blindly refuse all treatment whether through fear or ignorance.
Integrated medicine is about complementary medicine and conventional medicine working together. It has been proven how superbly breast cancer is being treated in conventional medicine and how advances in this field continue to support women in the physical treatment of breast cancer. Complementary medicine on the other hand is slowly growing in strength in the western world with a much smaller body of research. Although it has a smaller body of research, Shiatsu has evolved over thousands of years and offers women relief from symptoms of cancer treatment, and the support to overall health and wellbeing, including emotional and spiritual support. It is not about women having to choose one or the other, or there being a competition between complementary and conventional medicine, but seeing the two modalities working together to give women a more holistic system of treatment and healing. Integrative medicine for breast cancer treatment requires the application of common sense by all practitioners involved; there is not enough evidence to suggest that Shiatsu can cure breast cancer and for anyone to recommend purely a course of Shiatsu treatment would be wholly irresponsible in the present day. To suggest however, that Shiatsu treatments (or other CAM therapies) could be used alongside conventional treatments for breast cancer, to aid alleviation of symptoms, provide support, enhance overall health and wellbeing, reduce stress and increase immune function, is so far supported by a small body of evidence. Shiatsu offers women the opportunity for deeper healing of the wounds left by breast cancer. The picture below highlights the need for practitioners of both complementary and conventional medicine to recognise their limits of competence, and the limits of the treatments they are offering.
(Mike Baldwin, date unknown).
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Appendix 1- “Shiatsu in Obstetrics and Gynaecology” by Helen Hunt.
About Complementary and Alternative Medicine (CAM)
Complementary and Alternative Therapies is defined as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine” (National Centre for Complementary and Alternative Medicine, 2010). CAM is becoming more popular in the United Kingdom, with the rise in the number of people accessing complementary therapies; the NHS reports that a survey carried out by the Office for National Statistics in 2001, showed that one in ten people had accessed some form of complementary medicine in the previous twelve months (NHS Careers, 2010). Sheffield University conducted a survey which showed that the number of GP practices which offer some form of CAM therapy has increased from 39% in 1995 to 49% in 2001 (Sheffield University, 2001, cited in NHS Careers, 2010). This indicates the increased interest in CAM therapies and their increased need.
Integration of Conventional Medicine and CAM
“We need to end the Berlin Wall between complementary and conventional medicine and integrate them. It is not that one is better than the other but that there can be synergy between them both” (Hain, 2004, cited in Dooley, 2006). Thomson (2005, p.6) points out that there is now emphasis on the “NHS as a health service, rather than a sickness service.” This potentially highlights the need for preventative medicine and treatments that can be offered to patients without a long list of side-effects attached. The need for integration of conventional and complementary medicine has now been recognised officially (UK. House of Lords, 2005) with recommendations for further integration from the House of Lords. As an example of integration working harmoniously, Traditional Chinese Medicine (TCM) and Western medicine are practised together in hospitals in China where “Doctors of Western medicine will often invite a TCM practitioner to consult on a particular case, and vice versa” (Zhao, 2006, p.xiii). Patients in China seek out TCM practitioners and Doctors of Western medicine for different reasons according to what their health problem is; further highlighting how Western and TCM can and do work successfully together, as can conventional and complementary medicine.
According to Lundberg (1992, p.11) Shiatsu is a Japanese word which means “finger pressure” and he summarises Shiatsu as “…hand pressure and manipulative techniques to adjust the body’s physical structure and its natural inner energies, to help ward off illness, and maintain good health.” However, Shiatsu uses a range of techniques beyond finger and hand pressure, as explained by Jarmey and Mojay (1999, p.7); a combination of stretching, holding, applying pressure through hands, feet, thumbs, forearms and knees, and “leaning body weight into various parts of the recipient’s body to improve energy flow, blood circulation, flexibility and posture.” See image 1 (The London Women’s Shiatsu Clinic, 2010) showing a Shiatsu Practitioner carrying out Shiatsu, as an example of Shiatsu in the prone position.
Shiatsu has been likened to acupuncture due to it using the same meridians and the same acupoints as in acupuncture. Beresford-Cooke (2003, p.1) explains that Shiatsu is likely to predate acupuncture “since touch is the most instinctive form of healing, we may suppose that the points and meridians were rubbed and pressed long before they were stimulated with the stone needles found at Neolithic sites in China…simple pressure on a point can and does create the same lines of sensation [as acupuncture]”. Why use Shiatsu instead of Acupuncture? Whilst using much of the same theoretical body of knowledge and philosophy as acupuncture, Shiatsu gives the added advantage of touch. Touch provides many benefits to an individual’s health and well-being which will be discussed in more depth later. There are advantages of using acupressure over acupuncture as it is “non-invasive, does not affect the integrity of the epidermis and can be applied easily” (Fassoulaki et al, 2003, cited in Agarwal et al, 2005), and acupressure can be used on individuals with needle phobia.
Shiatsu is a holistic treatment that treats all aspects of a person’s being: physical, emotional and spiritual. This is achieved through consideration and application of TCM theory. While Western conventional medicine focuses on symptoms and disease as cause and effect in terms of a linear progression, TCM regards symptoms and disease very differently; they are “mutually conditioned, arising together. They are not seen as distinct from the environment in which they occur” (Lundberg, 1992, p.13). Lundberg uses an example which illustrates clearly how the theory of TCM and Shiatsu may be used: “A headache is not just an event in the head, according to Chinese medicine, nor is it merely a pain, or something to be stopped without regard for its origins, nor treated on the same basis as someone else’s headache. Rather, it is an obstruction of Ki, related to the overall energy patterns in the whole body of the particular individual, their circumstances, and lifestyle. Treatment might involve work on the arms or legs as well as (or instead of) the head and will bring more lasting and satisfactory changes than will an attempt to block the superficial symptoms.” The difficulty in explaining TCM to Western minds is that it is a very different way of thinking than Western thought. Zhao (2006) summarises this difficulty; “Biases come into play when we seek to understand TCM through the eyes of Western medicine. The development of TCM began more than 5,000 years ago, 4,500 years before the scientific traditions of the West.” Zhao also goes on to describe how TCM has “withstood the test of time” as it is still used as mainstream healthcare in China. There are a number of key concepts that underpin TCM and Shiatsu, however, only the concepts of Ki and meridians will be discussed here to aid understanding of the content that’s presented. It can be difficult to translate these terms into English as the concepts are very different to Western medical/scientific understanding and as Kaptchuk (2000, p.43) clearly states when trying to describe Ki: “no one English word or phrase can adequately capture Qi’s meaning” (Ki is term used in Japan and Qi is the term used in China). As Beresford-Cooke (2003, p.63) attempts to translate the meaning of Ki to aid western understanding, the term ‘energy’ is used as a “Western approximation” to describe Ki. As a more comprehensive translation of Ki, Beinfield and Korngold (1991, p.30) summarises Ki as “An invisible force known only by its effects…In the human being, all functions of the body and mind are manifestations of Qi.”
The Meridians can be seen as channels or pathways that transport Ki around the body; “they comprise an invisible lattice that links together all the fundamental textures and Organs…these channels are unseen but are thought to embody a kind of informational network” according to Kaptchuk (2000, p.105).
Shiatsu is a very versatile treatment in that it can be performed in a variation of environments and modalities, the most common being: on a futon/mat at floor level; lying on a massage couch; or seated in a chair. However, it can be adapted potentially for any position the client is in making it very useful for those who may be bed-ridden or those who need to move around a lot (in the case of pain or when in labour for example). An aspect which makes Shiatsu accessible to most people is that it is performed through clothes, so there is no need for the client to expose any areas of their body during a treatment. Loose clothes are however needed so that the body can be moved easily and freely.
Shiatsu as a therapy was recognised in Japan in the 20th Century, with the incorporation of newer Western medical knowledge of anatomy and physiology with several older forms of treatment (Shiatsu Society, 2010). Some of these older forms of treatment are Anma (from Japan) and Tuina (from China), both of which are forms of bodywork. Beresford-Cooke (2003) outlines that there are three different sources of Shiatsu theory, which are: Five Element theory, TCM (TCM) and Zen Shiatsu. Although there are three different theories underpinning Shiatsu, all of them are based on the fundamentals TCM (Shiatsu Society, 2010). Kaptchuk (2000, p.2) describes TCM as “a coherent and independent system of thought and practice that has been developed over two millennia. Based on ancient texts, it is the result of a continuous process of critical thinking, as well as extensive clinical observation and testing.”
Aside from the theory that underpins Shiatsu, the other component of Shiatsu touch. Touch is used very little in conventional medicine aside from examinations for a range of reasons including the fear of accusations of inappropriate touch. Touch, which is respectful and caring can have profound effects on people’s health. To illustrate the importance of human touch and the many benefits that touch alone can bring, we look at how premature newborn infants rely on human touch for survival, with a study carried out by Lawn et al (2010) which highlights how skin-to-skin contact “substantially reduces neonatal mortality amongst pre-term babies.”
The power of touch has many positive effects such as: alleviating depression; facilitating weight gain in pre-term infants; enhancing attentiveness; reducing pain; reduce stress hormones; improve immune function (The Touch Research Institute, 2010). Conventional medicine is slowly starting to become aware of the beneficial effects of touch as indicated by Dobson (2006): “Touch, a key component of traditional healing, is being increasingly studied in mainstream medicine, with some trials showing symptom benefits in a number of areas.”
When thinking of the basics of human touch, we all know what touch has the potential to communicate. It can communicate a range of messages including: love; safety; confirming that you’ve been heard; reassurance; encouragement; and kindness. All of these messages are important if someone is to flourish on any level (physically, emotionally and spiritually); and what happens on one level effects all the others, according to TCM.