The role of shiatsu in palliative care

Caroline Stevensen

Caroline Stevensen BA Hons, RGN, MRSS, IFA, Master Iridologist, Macmillan Clinical Nurse Specialist: Complementar'/Therapies, Royal London Hornoeopathic Hospital NHS Trust, Great Orrnond Street, London WC I N 3HR, UK.

Shiatsu is a form of Japanese massage, working on the meridian system of the body; the energetic pathways along which the acupuncture points are placed. The theory for shiatsu is based in the system of traditional Chinese medicine, understood in China for over 2000 years. Shiatsu can be valuable for reintegrating the body, mind and spirit, helping with the general energy level of the body as well as specific symptoms. Its role in western palliative care is little studied to date. This paper explores the potential benefits of shiatsu in this setting and cites a case example where it has been beneficial. Feelings of deep relaxation, support and increased vitality are common following a shiatsu treatment. The method, strength and frequency of treatment can be varied to suit individual need. Shiatsu should be considered when thinking of complementary methods of support in palliative care.

INTRODUCTION

This paper aims to examine the appropriateness of shiatsu, a hands on therapy working on the meridians of the body, as a complementary means of support in palliative care. Due to the holistic nature of the treatment, shiatsu can help reintegrate body, mind, emotions and spirit as well as helping the general energy level of the body (1Lidolfi 1990). It can help with practical problems such as pain, nausea, poor digestion, constipation as well as stabilize the emotional and psychological aspects of illness (Masunaga & Ohashi 1977). It is a treatment which can assist not only the patient but also carers, friends and relatives. It has been found useful in conjunction with other therapies such as counselling where the problems of the psyche are overriding and the individual needs reintegration (Masanaga & Ohashi 1977).

Shiatsu is not a panacea but a very useful ther- apy, the strength and kinds of techniques of which can be adjusted to suit individual needs and conditions making a variety of treatments possible for people depending on their strength or frailty. It can be given by nurses or other practitioners trained in the subject in conjunc- tion with other orthodox medications and treatments and it does not require the recipient to have any particular philosophy or belief.

In choosing a topic such as shiatsu in pallia- tive care there is little to none western research in this area, acupuncture research being the closest available to substantiate its efficacy.

SHIATSU

Shiatsu literally means 'finger pressure' (R.idolfi 1990) in Japanese, but in practice it is much more than that, as a method of treating the body holistically. Its basis coming from tradi- tional Chinese medicine (TCM) which is a coherent and independent system of thought and practice that has been developed over 2 millennia (Kaptchuk 1989).

Shiatsu uses touch along the energetic path- ways of the body called the 'meridians' (Fig. 1). In western medicine the concept of meridian lines has not been scientifically proven. Meri- dian lines are defined as channels of living mag- netic energy in the body which can also be associated with the functioning of the internal organs (Masanaga & Ohashi 1977). These are the pathways along which the acupuncture points are located and are known to transport the energy of the body known as the chi, ki or qi. This ki is the primary substance and the motivating force in life (Lundberg 1992). In Indian yoga philosophy this energy is known as prana. In shiatsu treatments it is the manipula- tion of the energy through touch on the merid- ian pathways which can affect the energy and health of the body.

SHIATSU D IAGNOSIS

In shiatsu, the diagnosis is both visual and by means of touch. The abdomen or 'hara' (Lundberg 1992) and back of the body are seen as diagnostic areas for the meridian energy which can be palpated, not for the organs underlying them but for the energetic quality of the meridians present there (Figs 2 and 3). It is by gently palpating one of these areas that the practitioner is able to diagnose the meridian where the energy is the weakest, called the most 'kyo' and the meridian where the energy

Complementary Therapies in Nursing & Midwifery (1995) I, 51-58 9 1995 Pearson Professional Ltd

52 Complementary Therapies in Nursing & Midwifery

\ \ , , i Figure I Examples of the meridians on the body.

is the tightest or most 'jitsu' (Masanaga & Ohashi 1977). It is through a reaction felt most strongly between these two diagnostic areas when palpating the abdomen that the practi- tioner knows that the correct diagnosis has been made. The diagnosis may vary with each

(2_ /2 ._,

Figure 2 Diagnostic areas on the hara. Liv: Liver, HT: heart, GB: gall bladder, SI: small intestine, HP: heart protector, TH, triple heater, SP: spleen, ST: stomach, Lu: lungs, LI: large intestine, KI: kidneys, BI: bladder.

treatment on the same person, but chronic conditions tend to show a kyo reaction in a particular meridian or its pair (there are 6 pairs of meridians) (Masanaga & Ohashi 1977), until the condition improves.

SHIATSU TREATMENTS

Shiatsu concentrates primarily on the most kyo meridian and sometimes its pair throughout the body. The reason for this is that shiatsu works on the principle of treating the weakest link in the chain which then supports the rest of the body 'from the bottom up'. The treatment is performed with the recipient clothed, best in a T-shirt and tracksuit, preferably made of a nat- ural fibre such as cotton. Socks should also be worn. The reason for the clothing is that the meridian energy is better felt without surface interference from the skin. Treatments are per- formed on a mat or futon on the floor as the shiatsu practitioner requires to be able to have perpendicular pressure on to the meridian path- ways (Masanaga & Ohashi 1977). Treatments should always be done with the two hands in connection with the body. One hand acts as a 'mother' hand, offering support and acting as interpreter for the work being performed with the other hand. The working hand first reads the meridian through a technique called 'palm- ing' where the palm of the hand feels the length of the meridian to be treated for the amount

The role of shiatsu in palliative care 53

C_ s, )

Figure 3 Diagnostic areas on the back.

and flow of the ki, then the meridian is 'thumbed' where more penetration may be given and the ki along the energetic pathway is balanced and enhanced as necessary. Not only the thumbs may be used for this purpose,

m m ~ m

Figure 4 Five elements of support and control cycle. -~ support cycle, --->control cycle

elbows and knees may be used when appropri- ate, on the various parts of the body. Some practitioners describe shiatsu as giving the indi- vidual energetic 'ironing' which balances the ki, allowing it to flow freely through the meridians and organs. The patient's ki is enhanced and manipulated through the use of universal ki by the practitioner, not purely by using the practitioners own energy. An ancient Chinese saying states that 'the ki follows the mind and the blood follows the ki' (Kapchuk 1989), showing the relationship between mind, energy and circulation or physical functioning of the bodily organs.

T IMING AND FREQUENCY OF SHIATSU TREATMENTS

Shiatsu treatments can be given at least weekly in acute conditions for several weeks which can then be reduced in frequency according to individual need. An average session will last for approximately 45 to 60min. Supportive exer- cises and nutritional advice pertaining to the energetic deficiencies of the body may also be given according to TCM theory.

TRADIT IONAL CHINESE MEDIC INE (TCM) THEORY

TCM theory and practice has been in existence for over 2000 years. It is from these roots that the practice of shiatsu developed in Japan sev- eral hundred years ago. In TCM, life is seen to manifest from the Tao, the universal energy, into yin and yang, the feminine and masculine aspects. The ki arises from the interaction of this universal energy between yin and yang (Kapchuk 1989).

In TCM, the theory of the 5 elements describes the imbalances of the body's energies, grouping the meridians into pairs which then relate to the 5 elements of wood, fire, earth, metal and water (Maciocia 1989). As can be seen from the 5 element table (Table 1), the 5 elements or phases not only relate to the sea- sons and weather influences which might affect someone with an imbalance in the meridians relating to that element, but also to physical, mental, emotional and spiritual aspects of that individual. The elements also support and con- trol one another (Fig. 4) (Maciocia 1989) which means that a weakness showing in a par- ticular meridian or element may actually have its origins in another element. Needless to say few of us are prototypes, having all the symp- toms of a particular element, however, individ-

54 Complementary Therapies in Nursing & Midwifery

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Seasons Spring Summer Late summer Autumn Winter Climates Wind Heat Damp Dry Cold Stages Birth Growth Ripening Harvest Storing Colours Green Red Yellow White Black Flavours Sour Bitter Sweet Pungent Salty Yin organs Liver Heart Spleen Lungs Kidneys Yang organs Gallbladder Small intestine Stomach Large intestine Bladder Sense organs Eyes Nose Mouth Tongue Ears Senses Sight Speech Taste Smell Hearing Body tissues Ligaments & tendons Blood vessels Muscles Skin Bones Manifestation Nails Face complexion Lips Body hair Head hair Body fluids Tears Sweat Saliva Mucus Urine Voice Shouts Laughs Sings Weeps Groans Emotions Anger Joy Worry Grief Fear Spirit Ethereal soul Mind Intellect Corporeal soul Will

uals may have a constitutional weakness which leans more towards the characteristics of one element more than another.

Circumstances can also bring out the char- acteristics of an element in an individual more than previously and it is in this respect that the role of TCM and shiatsu is going to be exam- ined in terms of its role in palliative care.

APPROPRIATENESS OF SHIATSU TO THE PALL IAT IVE CARE SETT ING

Not all people in the palliative care setting will respond to the idea of a treatment such as shi- atsu. Body work does not appeal to all people, some may prefer a session of guided relaxation and imagery or art therapy. For those for whom such a treatment does appeal, the therapy may be perceived as beneficial in balancing and har- monising the mind, body and emotions, the relief of stress and discomfort and assistance with pain relief, help in the management of grief and acceptance of loss. Those for whom shiatsu may not be appropriate would include:

1. Patients with multiple bony metastases, occasionally very light techniques may be used in these circumstances

2. Pain worse for pressure or touch 3. People with extreme religious beliefs who

find complementary therapies at odds with their belief system.

THE EXPRESS ION OF GRIEF THROUGH SHIATSU AND 5 ELEMENT THEORY

In TCM the power of the metal element is to die, let go (Lundberg 1992). This element rules

the lung and large intestine meridian, the energy of which govern the emotion of sadness and grief (Maciocia 1989). The lung meridian also rules the breathing in and the large intes- tine rules the outflow of the breath and the let- ting go of emotion and aspects of loss. The sound of the voice of a person with a metal imbalance may have a weeping quality to it, they often sigh frequently and the face is often white or very pale in colour. The spiritual aspect of the metal element is that of the corpo- real soul. The time of day when people are most affected with a lung imbalance is between 03:00-05:00h and for the large intestine between 05:00-07:00h. Early waking in the bereaved is a sign often recognised in western psychology and associated with stress and anxi- ety. The physical characteristics of a grieving person with a metal imbalance may include (Masunaga & Ohashi 1977):

9 lack of vitality, weak voice 9 pale or sallow complexion 9 colds, flu, asthma 9 skin problems, eczema, psoriasis 9 bowel problems: colitis, constipation,

diarrhoea 9 stooping, round shoulderedness, thin

collapsed tight chest, upper back pain 9 oedema in the upper body and around the

eyes.

The psychological associations of the metal ele- ment include:

9 the ability to eliminate mentally, release old structures

9 stasis and rigidity, hoarding 9 connectedness; spirit to body, self to others 9 isolation, grief, emptiness, loss 9 lack of sense of value in self and others, may

seem aloof and separated from others.

In comparison to the features of a person with a lung imbalance who may be experienc- ing a number of these symptoms, the four tasks

The role of shiatsu in palliative care 55

of mourning described by Worden (1992) are interesting to compar e in terms of their content in relation to the TCM theory:

1. To accept the reality of the loss - shock, denial, disbelief, searching, distortion, numbness

2. To experience the pain of gr ie f - anger, persecution, guilt, blame, rage, terror, fear, loneliness

3. To adjust to an environment in which the deceased is missing - role change, facing the future, surviving

4. To withdraw emotional energy and to invest it elsewhere - memories, hopes for the future, growth, there are others to be loved.

It is quite interesting how the western and eastern approaches actually meet in this way over the identification of the factors involved in grief and loss. Naturally many of the emotions mentioned by Worden (1992) actually relate to others of the 5 elements, for example, fear relates to the water element, with which the kidney and bladder meridians are associated, anger relates to the wood element with which the liver and gallbladder meridians are associ- ated. Therefore, the person suffering from grief or loss presenting for a shiatsu treatment may not present with the lung or large intestine meridian being the most out of balance, but it may depend on the overriding emotion and their individual position in the stages of accept- ing the grief or loss.

Through working with shiatsu in either the dying or the bereaved person, it is possible to not only monitor their progress through the different stages of grief, but the treatment offers another dimension to the person to assist them in this process. In shiatsu few words may be necessary when working with a person in this way, as the shiatsu treatment, its balancing and strengthening effects, provide the platform for the individual to work through this grieving process with little verbal input. Naturally this does not apply to all people and the combina- tion of shiatsu with counselling can be more powerful and appropriate in other cases.

PHYSICAL HELP SHIATSU MAY OFFER IN PALLIATIVE CARE

Some specific area of physical care where shiatsu may be a useful tool will now be examined.

Pain

Pain management is of the highest priority in palliative care and the means of both pharma-

cological and nonpharmacological control should be examined together. It is well under- stood that pain is not only a physical phenom- ena, but can have psychological, emotional and spiritual aspects to it as well. Most importantly, as McCaffery stated 'pain is what the patient says it is' (McCaffery 1983) and it is up to the professionals to assist with it as such.

In the first instance, with severe pain, regu- lar and not p.r.n, analgesic cover to meet the needs of the patient must be given first. It may be inappropriate to introduce a shiatsu treat- ment in these circumstances. However, with other types of less severe pain, a physical treat- ment may be more apt.

There are no specific elements or meridian pathways which pain as such is related, however, the description of pains, where they are in the body and the range of conditions which affect them can give the shiatsu practitioner an idea as to the element or meridians which may be out of balance. For example, pains which come and go and move around the body or headaches at the sides of the head are characteristic of a wood element imbalance (Masunaga & Ohashi 1977). Pains which are worse for the damp weather or headaches in the forehead area are characteristic of an earth element problem (Maciocia 1989). Lower back pain can be associated with a weak- ness in the bladder meridian, the energy which 'holds up' the black (Masunaga & Ohashi).

Identifying and treating appropriate meridi- ans may not only help the pain of an illness such as cancer as it releases areas of blocked energy, but it can also be useful in some other condi- tions which the patient may have been suffer- ing from prior to the onset of the condition requiring palliative care e.g. arthritis.

Acupuncture or acupressure points are iden- tified specifically for the general relief of pain in the body:

1. The first is contraindicated in pregnancy, due to the strong downward effect of its energetic force which could induce premature labour. It is on the large intestine meridian, called large intestine 4(LI4). It is situated on the dorsal side 0fthe hand, on the high point of the muscle between the thumb and forefinger (Fig. 5)

2. The second point on the liver meridian, liver 3(Liv. 3) is on a corresponding position on the dorsum of the foot, proximal to the first and second toes, in the soft tissue before the bones meet on the foot (Fig. 6).

Nausea

The treatment of nausea using acupuncture or acupressure has been documented in trials per-

56 Complementary Therapies in Nursing & Midwifery

/ /

/ /

/

Figure 5 Location of large intestine 4.

formed with patients in receipt of chemotherapy on the acupuncture point Heart Protector 6 (also known as Pericardium 6) (HP6/P6) which is the point that 'sea bands' are used on for travel sick- ness. This point is located (Fig. 7) (Dundee 1989) three finger breadths up from the wrist crease on the medial side of the arm, between the two ten- dons flexor carpi radials and flexor carpi ulnaris. Pressure on this point has the effect of sending the stomach energy in the correct direction i.e. down instead of up, 'harmonising the stomach' which relieves nausea and vomiting.

I nsomnia

The treatment of insomnia with shiatsu is again as always discovering the cause of the problem.

9 / ,

/ / / . /

/

,&

Figure 6 Location of liver 3.

f )

Figure 7 Location of heart protector 6.

Imbalance in the fire elements of the body which rule the physical and emotional heart where according to TCM the mine (i.e. the shen or spirit) (Maciocia 1989) rests can cause disturbances in sleep, but so can the anxiety associated with an imbalance in the earth ele- ment, stomach or spleen meridians.

Diet

TCM recommends certain foods to support the energetic imbalances in the body according to individual need. For example, a person suffer- ing from an earth imbalance, weak stomach or spleen (relates to western pancreas) energy would be advised to stay off 'cold' foods such as dairy produce, salads, iced drinks but would be encouraged to eat 'warm' foods which sup- ported the digestive system such as cooked rice, warmed vegetables and chicken (Flaws & Wolfe 1983). The rationale for this is that as the body has to also heat the foods up to body tem- perature, it uses extra energy which could be used elsewhere.

There are many patients, especially in their terminal stages, who might benefit from a more tailor made regime of diet according to TCM theory for easier digestion and assimilation which could also provide them with more energy.

Sp i r i tua l care

Shiatsu can offer assistance with the spiritual care of the individual by assisting in the reinte- gration or realignment of body, mind and

The role of shiatsu in palliative care 57

spirit. As previously stated the mind/spirit is believed to rest in the heart in TCM (Maciocia 1989), and unrest of the mind or spirit and even some mental illness can show as an imbalance in that meridian pathway. By helping the per- son to become more focused, their own spiri- tual needs may become clearer and be addressed appropriately. The help required here may also come from a minister of religion or another member of the caring team.

CASE EXAMPLE

In order to demonstrate the link between shi- atsu theory and nursing practice, it would be useful to site a recent case of a patient attending the Royal London Homoeopathic Hospital (RLHH) NHS Trust for complementary can- cer care.

The patient shall be called Peter, 48, from London. Peter recently gave up work follow- ing a diagnosis of lymphoma of the lung. He had originally presented with shortness of breath on exertion and no other symptoms. Such was the extent of the disease that oncolo- gists at his local hospital could offer no conven- tional treatment and suggested a potential life- span of 3 months. On the strength of this diagnosis he married his girlfriend. Peter has 3 teenage children from a previous marriage, not living with him.

Peter presented to the RLHH in November 1993 feeling frightened and abandoned by the orthodox medical profession and searching for other help. He had already visited the Bristol Cancer Help centre where he had been offered a variety of therapies including counselling, heal- ing and shiatsu which he had found very benefi- cial. He was very angry and resentful at this diag- nosis and had difficulty in accepting it as he felt so well. There were problems with his new wife over his renewed and closer contact with his children since his diagnosis of cancer. She felt threatened in her position by this contact.

Peter was admitted to the Royal London Homoeopathic Hospital (RLHH) for a 5-day stay where he was assessed and commenced on homoeopathy and Iscador | therapy, an extract of mistletoe, as well as being offered relaxation training and shiatsu at his request. He had already followed up the shiatsu with a local practitioner after his time at Bristol, but had found strong physical treatments had aggra- vated his condition. In the RLHH shiatsu assessment it was recognised that the kind of shiatsu treatment which may be required was of a light and relaxing nature, generally bringing the energy 'down' the body to help reintegrate the whole person. Energetically speaking,

when in a state of shock, the mental, emotional and physical aspects of the person could be said to lose their harmony, a condition which shi- atsu can be very helpful in rectifying.

On shiatsu diagnosis Peter presented with the following meridian imbalance: stomach kyo and liver jitsu. This diagnosis in general terms, in this case, reflects the mental anxiety, need for nurturing and caring from the stomach kyo and the anger and frustration with the whole situation from the liver jitsu. After treat- ment this imbalance had settled and Peter felt much calmer and more relaxed. After a 5-day stay and the help of the other therapies Peter was discharged home.

There was no further communication from Peter until his next out patients appoint- ment 4 weeks later despite offers for further communication should he wish it. At this time he had had further upset with his wife over his children, a very distressing visit to the oncologist who could offer no explanation as to why Peter was still as well as he was, expecting his condition to have deteriorated. On this visit Peter said he had been back to his local shiatsu practitioner who he had encouraged to work on him more lightly, which he had found of much greater benefit. He was attending fortnightly visits and his wife had also commenced shiatsu treatments as well.

At this appointment Peter was offered a fur- ther shiatsu treatment which he readily accepted. Again the diagnosis was stomach kyo and liver jitsu. However, on this occasion, Peter found the treatment more beneficial than ever before and he was able to reach a level of relaxation that he had not previously experi- enced. This gave him hope for being able to cope better in the future feeling stronger and more positive in his outlook as a result. Peter, quite naturally, had fear of losing control in his life which had to date been interfering with his ability to relax.

His follow-up appointment was in 8 weeks time.

In Peter's case shiatsu had offered a calming and strengthening influence which enhanced his coping abilities. It has given him calm, relaxation and mental clarity as well as a physi- cal boost in energy. Other people find shiatsu offers them other benefits and for some it may not given them the help that they are looking for and they may need to look to other avenues for help.

CONCLUSION

The appropriate role ofshiatsu in palliative care

58 Complementary Therapies in Nursing & Midwifery

needs assessment according to individual need. Not only patients but supporters and carers

may also find benefit from this treatment.

Physical, psychological, mental and spiritual support can be given through the use of this treatment. The role of the therapeutic rela-

tionship with the nurse practising shiatsu is as much listening through the hands for the patient's response whilst treating as well as

through the ears to what the person is saying. The deep level of support offered by this treatment has to be experienced to be under- stood. It is hoped that the potential benefit

that may be derived from this treatment mode will have a greater place in palliative care in

the future.

REFERENCES

Dundee J W 1989 Acupuncture prophylaxis of cancer chemotherapy-induced sickness. Journal of the Royal Society of Medicine 82:268-271

Flaws B, Wolfe H 1983 Prince Wen Hui's Cook: Chinese dietary therapy. Paradigm Publishing, USA

Kaptchuk T 1989 Chinese Medicine: the web that has no weaver. Rider, London

Lundberg P 1992 The book ofshiatsu, Gaia Books Ltd, London

Maciocia G 1989 The foundations of Chinese Medicine. Churchill Livingstone, Edinburgh

Masunaga S, Ohashi W 1977 Zen shiatsu. Japan Pub. Inc., Tokyo

McCaffery M 1983 Nursing the patient in pain. Lippencott Nursing Series, Harper and Row, London

Ridolfi R 1990 Alternative health: shiatsu. Optima Worden W 1992 Grief counselling and grief therapy,

Routledge, London

"The Murmur Quiet mind, clear chi, makes long life

One who always smiles, never ages

I am air, I am light I am water f lowing with the tide"

(Chinese)