Body and Sprit paradigm
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Perhaps 70% of the world's population uses treatments that fall outside the western, allopathic medical approaches that you are being trained to practice. Many patients use alternative therapies in addition to standard medical treatment (hence the term "complementary and alternative medicine", or CAM). It is very clear that western medicine is by no means the only way to heal people, by no means the only system that works.
Many other developed countries use CAM more than Canada; the rates are higher in Europe and higher still in Asia (East Asia and Middle East). About 10-20% of Canadians use CAM in a year. In contrast, 26-28% of people in UK use CAM/year and 75% in Japan and South Korea use CAM.
In East and South Asian countries there is a long history of culture linked with complementary medicines and there is a generational history of resources for herbalists, etc. This is also true for other areas of the world. In the US, citizens pay for health care largely through private insurance, whether CAM or conventional treatment. In Canada, CAM is often not covered by publically funded health insurance but allopathic medicine is, so citizens choose conventional medicine instead. It is hard for Canadian MDs who use CAM to bill for it.
Nonetheless, Canadians do use CAM therapies. The most common form is chiropractic care, followed by massage, acupuncture, and relaxation techniques.
There are various ways to classify the huge range of complementary and alternative therapies. This introduction builds on a classification proposed by Douglas Tataryn (Faculty of Medicine, U. Manitoba), which divides therapies into four groups lying in a hierarchy, each building on the previous category:
- Body paradigm therapies treat biological factors as the primary determinants of health and which therefore form the main object of treatments;
- Body-mind therapies also include stress, coping styles and social factors as causes of disease;
- Body-energy therapies view health as the result of flow and balance in life energies, whether this is channelled through the mind or body;
- Body-spirit therapies hold that transcendent entities outside the material universe can affect health.
1. Body paradigm therapies are "materially reductionist" in that they assume that alterations in the biochemistry of the body are ultimately causal in the development and maintenance of disease. This approach encompasses our biomedical or allopathic perspective: "influenza is caused by a virus; ulcers are produced by bacterial infections." Variations in susceptibility are explained in terms of immune response, as modified by nutrition, sleep deprivation, etc., but are not systematically studied. Diagnostic approaches include iridology.
Therapies include the whole range of western medicine, plus alternative approaches such as aromatherapy, herbal remedies, naturopathy, macrobiotic diets, and medicinal plants.
2. The body-mind paradigm holds that the mind plays a critical role in health and illness. Some theorists argue that the mind plays a subordinate role, reacting to physical stimuli; this can be termed a dualistic model. Others hold that the mind and physical body are more strongly linked, such that the mind can have a direct and causal role in health and disease.
The body-mind approach to health and disease shifts the focus from the agent to the host. Because many people are routinely exposed to potentially infectious agents but do not get sick, host susceptibility must be a critical factor. The primary factor determining susceptibility is the mind; acting directly or indirectly.
Therapies include psychotherapy, hypnosis, meditation, stress reduction or support groups.
3. The energy paradigm presupposes an underlying energy as an intrinsic and necessary condition of all life. Such energy is recognized in many cultures and is known by various names: chi, prana, or life force are examples. Energy flows through the body along meridians; there are energy centres in the spine called chakras which absorb and emit the life force. Disease arises from a disturbance in the amount or flow of energy, and interventions aim to re-establish the energy balance.
Energy-oriented therapies include acupuncture, therapeutic touch, homeopathy, massage therapy, kinesiology, shiatsu, reflexology, Tai Chi, and others.
4. Body and spirit. This model includes beliefs in the healing power of supernatural beings; God, Jehovah, Tao, Buddha and others. Faith is considered central to healing, and miracle cures are considered possible. Therapies include faith healing, prayer, Ayurvedic medicine, and some First Nations traditional healing approaches.
There is a growing acceptance of the value of alternative therapies, and randomized trials are becoming common. Western medicine is just one of many approaches to healing; it does not do well for problems such as chronic pain, arthritis, or many mental conditions. We need to keep an open mind and to realize that roughly half of all patients visiting a family physician will also be exploring complementary therapies.
The journal Alternative Therapies in Health and Medicine publishes evaluative studies. (It's available through the U of O electronic journals database).
A local source of information on the effectiveness of alternative therapies is from the Canadian Agency for Drugs and Technologies in Health – CADTH. They publish systematic reviews of the effectiveness of therapies; you can search their site for keywords such as "spinal manipulation" or "chiropractic" and find some reviews.
Link to review of Omega-3 fatty acids in treating asthma.
Click here for the paper “Complementary and Alternative Medicine in Canada: Trends in Use and Public Attitudes, 1997-2006” by Nadeem Esmail at the Fraser Institute (source)
"CAM in UME" site from U Calgary on alternative medicine in undergrad medicine. This is trying to raise the profile of CAM teaching.
PPT presentation by Natalie Jonasson (Sept 22, 2005) on Natural Health Products
An article on the Holistic Process: an explanation for how holistic healing works
There's a literature review on Canadian use of alternative therapies from York University
As civilizations emerge, medicine is initially founded on a mixture of magic, religion and empirically tested folk remedies. As magic and religion declined during the middle ages in Europe, medicine sought a new basis. It had to be something that would impress patients, a substitute for the incantations and incense that no longer impressed: something that gave the impression that the healer was doing something.
The answer was the principle of allopathy, which had been developed in the Middle East around the first century B.C. The idea was simple: when the body's workings deviate from normal, the doctor should try directly to restore normal function. Thus, if a man is feverish, he should be cooled down; if constipated, given a laxative. Illnesses were seen as signs of toxins that should be eliminated, so treatments concentrated on cleansing the body of poisons. This led to approaches such as bleeding, leeches, enemas, purgatives and so on. If one harsh treatment failed, another, harsher one might be applied. This was depicted cynically in Molière's plays. The war metaphor became entrenched in early medicine: doctors battled disease and waged war on sickness.
Many doctors worried about the aggressive nature of such treatments, but the alternative of rest and food appeared passive and implied that the doctor had nothing to suggest. Indeed, the only real alternative was homeopathic medicine. Only with Pasteur's discoveries and the microbiological revolution did allopathy develop a scientific basis for at least some of its remedies. Germs offered a good target for allopathic treatments and so the battleground switched to the microbial wars.
By the end of the nineteenth century, a growing consensus arose that allopathic medicine was the ideal approach; homeopathy was losing ground. The label 'allopathic' was discarded to imply that all true medicine followed this approach, and other forms of medicine fell into disrepute. In general they were not regarded as sufficiently threatening to the new orthodoxy to require active opposition.
Disillusionment started around the 1950s when, despite wonderful advances in "conquering infectious disease" and developing new drugs, illness seemed as widespread as ever. Hospitals remained full and waiting lists stayed long. Perhaps the very success of allopathic medicine allowed people to survive to ages at which degenerative diseases afflicted them, but the allopathic approach was less effective against these. Then drug-resistant organisms also developed, so more powerful drugs were developed to combat them, extending the war metaphor. But powerful drugs produce significant side-effects: allergic reactions increased and iatrogenic disorders (those produced by treatments) rose in importance (see Medical Nemesis by Ivan Illich). Events such as the Thalidomide disaster brought the dangers of modern drugs to public attention. Awareness of the need to strike a balance between doing good versus harm stimulated the entire edifice of controlled clinical trials. But the economic foundations of the allopathic approach are powerful: we are all familiar with the pressures exerted by major pharmaceutical manufacturers to prescribe more, to treat actively, etc.
By now, many of the basic tenets of the allopathic approach have been discarded from routine practice. Physicians feel less of a need to treat every condition, even though patients have long been trained to expect a prescription. Helping the body to cure itself, the approach of many alternative therapies, is becoming common, but it is not yet clear what balance will be struck between the allopathic approach and alternatives. As a physician in the allopathic system, you will certainly be caught between the demands of many patients for an antibiotic, even when it will do not good, and the recognition that the best cure may be for the patient to get some sleep, exercise and good nutrition.
A growing trend among physicians is to incorporate elements of both conventional medical practice with alternative therapies. "Integrative medicine is a healing-oriented medicine that takes account of the whole person (body, mind, spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative." (Andrew Weil).
Link to historical material: Rival models of medicine: Osler and Garrod
Aromatherapy is the use of essential plant oils to enhance general health and appearance. It originated in the 1920s from the work of a French chemist, René-Maurice Gattefosse.
In aromatherapy, each oil has its own properties, and is suited to a particular ailment (anxiety, insomnia, acne, etc.) Some are antiseptic or anti-inflammatory; others affect the emotions. For example, camomile has a calming effect, and relieves tension or pain. Eucalyptus oil is antiseptic and can help coughs or rheumatic conditions. Lavender is mildly analgesic and can help with headaches, bruises, insect bites, etc. Jasmine is an antidepressant.
Iridology is purely a diagnostic tool. According to iridologists, the iris of the eye represents a map of the various glands, organs and systems of the body, and a person's state of health can be diagnosed from the color, texture, and location of various pigment flecks in the eye. Problems in the body show up as spots or marks in the iris, at locations that represent the body system involved. This is claimed to work well for arthritis, cardiovascular diseases, allergies and skin problems.
Some also claim that the eye markings can reveal a complete history of past illnesses and previous treatments. Iridology charts -- dozens of which exist -- vary somewhat in the location and interpretation of their iris signs. Sclerology is similar to iridology but interprets the shape and condition of blood
Iridology began in the 19th century, but became more widespread with Dr. Bernard Jensen's publication in 1950 of a chart that shows the location of each organ and system as reflected in the eye.
Many iridologists practice nutritional therapy, or offer herbal remedies.
Iridology is a favourite target of skeptics; some critical reviews are included in the links below.
For positive perspectives, try the Canadian Journal on Iridology or Joyful Living Services information pages on iridology.
For the critical views, start with the Skeptic's Dictionary on iridology or the Quackwatch homepage on iridology.
Naturopathy was developed in Germany, and spread through northern Europe during the 19th century, becoming firmly established also in North America. It is a complete system of alternative medicine, the closest equivalent to some of the South and East Asian systems.
Naturopaths often use a wide array of modalities. These may include botanical medicines, natural health products, acupuncture, homeopathy, nutritional counseling, hydrotherapy, Traditional Chinese Medicine, naturopathic manipulation, lifestyle counseling and more.
Naturopaths support the body in healing itself, so treatment should be designed to support this, rather than to alleviate symptoms. Symptoms are not part of the disease itself, but are signs of the body's attempts to eliminate toxins and regain homeostasis. All treatment should be natural and gentle, and should consider the mental, emotional and social aspects of the person, and not just the physical. Good health is based on clean air, clean water, clean food from good earth, and exercise.
A few examples of therapeutic approaches:
- Good breathing is essential to relaxation; breathing clean air is necessary, but how you breathe is also important. Diaphragmatic breathing is favoured as being efficient, relaxing and more complete. Air purifiers are often recommended, including ionizers which charge the air with negative ions believed to have a healthy effect on many aspects of health.
- Hydrotherapy refers to the use of water to cure. Drinking spring water; visiting a spa; herbal baths; douching with strong jets of water; hot or cold compresses; enemas; massage: all are used. Hot baths are used to improve blood flow; cold baths invigorate.
- Naturopathy encourages a sensible diet of foods that have not been processed. There are numerous diets, but a typical dietary recommendation would comprise 60% raw foods, 20% protein and 20% complex carbohydrates. Tea, coffee, fat and salty foods should be avoided. Macrobiotic diets consider that foods form two groups, associated with yin and yang. Yin foods grow above ground, have a high water content and are soft and cooling. Yang foods are warming; they include roots, stems and seeds. Your diet should be designed to maintain a balance in your body, reflecting your health state, the weather, etc.
- Fasting is believed to help cleanse the system of poisons accumulated from bad eating habits; it also enhances immune function and gives the digestive system a necessary rest. Fasting one or two days a month is seen as valuable in prevention, but specific fasts exist to heal various ailments.
The Canadian College of Naturopathic medicine cites six healing principles (source). As you read them, consider the similarities and differences between naturopathic principles and the principles that guide conventional, allopathic medicine:
1. First, do no harm, by using methods and medicines that minimize the risk of harmful side effects.
2. Treat the causes of disease, by identifying and removing the underlying causes of illness, rather than suppressing symptoms.
3. Teach the principles of healthy living and preventive medicine, by sharing knowledge with patients and encouraging individual responsibility for health.
4. Heal the whole person through individualized treatment, by understanding the unique physical, mental, emotional, genetic, environmental and social factors that contribute to illness; customize treatment protocols to the patient.
5. Emphasize prevention, by partnering with the patient to assess risk factors and recommend appropriate naturopathic interventions to maintain health and prevent illness.
6. Support the healing power of the body, by recognizing and removing obstacles to the body's inherent self-healing process.
Regulation and Licensing of NDs
Naturopathic practice is regulated under provincial law. Naturopathy, and the title of Naturopathic Doctor, is regulated by the Canadian Association of Naturopathic Doctors (CAND) in British Columbia, Alberta, Saskatchewan, Manitoba and Ontario. Nova Scotia has legislation which provides protection for the titles “Naturopath”, “Naturopathic Doctor” and “ND”. All other provinces and territories of Canada lack regulation or title protection; all are seeking regulation at the current time.
To qualify for a licensing exam in the regulated provinces, naturopathic students must have attended three years of standard pre-medical education (i.e. three years on an undergraduate degree) followed by four years at an accredited college program for naturopathy. Licensing exams are run by the North American Board of Naturopathic Examiners (NABNE).
In Canada, the cost of visiting a naturopath is not covered by provincial publically funded health care. It may be covered by private health insurance.
For more information on regulation and licensure of Naturopathic Doctors in each province, read a PDF by the Canadian Association of Naturopathic Doctors.
Quackwatch on Naturopathy
For a more critical view of Naturopathic Medicine, read Britt Hermes’ “ND Confession”, Part I and Part II.
Medicinal plants form some of the oldest forms of therapy known, and are used by many animal species. Up to the twentieth century, most medicines were directly derived from plants; Egyptian records dating back 5,000 years give details of formulating natural healing agents (JF Nunn: Ancient Egyptian Medicine. Normal, Oklahoma, University of Oklahoma Press, 1996). Robert Halberstein has given an excellent summary, from which the following material has been taken.
The most widely-known plant sources include:
• Willow trees (Salix caroliniana), which contains acetylsalicylic acid;
• Poppy flowers (Paver somnioferum) are a source of opium, morphine and codeine;
• Foxglove plants (Digitalis latana) contain digoxin;
• The anti-malarial drug quinine comes from Cinchona (Cinchona officinalis);
• The bark of the Pacific yew tree (Taxus brevifolia) produces the anti-cancer agent taxol;
• There is clinical evidence for the immunity-enhancing and cholesterol-lowering effects of garlic (Allium sativum).
Several methods are used to extract the beneficial components from plants. Boiling helps extract the active component and also helps eliminate impurities. Decoction involves prolonged boiling and steeping of the plant material. Accordingly, teas or infusions are a common route of administration of the plant extract, although inhalation is also often used and solid components such as bark can be chewed.
Halberstein provides detailed information on a range of plants used to enhance fecundity or, conversely, as birth control methods. He also lists a number of sources covering the clinical use of herbs and plant materials. (Halberstein R. Medicinal Plants: historical and cross-cultural usage patterns. Annals of Epidemiology 2005;15(9):686-699).
Acupuncture was developed in China, perhaps four or five thousand years ago. It is designed to adjust the body's life energy (qi or chi); the underlying theory concerns energy balance and flow in the body (there should neither be a stagnation of energy, nor too much or too little). Chi refers to an energy which permeates all things, and is believed to flow through the body along 14 main pathways called meridians. When yin and yang are in harmony, chi flows freely within the body and a person is healthy. When a person is sick, diseased, or injured it is believed that there is an obstruction of chi along one of the meridians. More than 350 acupuncture points lie on meridians, and these affect particular organs. Selected points are stimulated by inserting fine needles to stimulate the flow of energy, and to restore healthy balance to the internal organs. The needles have rounded ends that do not tear the skin, so rarely draw blood.
Variants of acupuncture include acupressure (fingertip pressure on an acupuncture point); moxibustion (applying heat to points); or cupping may be used to apply gentle suction to acupuncture points.
Effectiveness of Acupuncture
There is considerable evidence for the effectiveness of acupuncture. Beginning in the 1970s a strong tradition grew of western physicians visiting China to learn acupuncture. They brought back astonishing pictures of acupuncture being used for analgesia during major surgery - this left the patient conscious and even able to converse with the surgeon! Western medicine awoke to its potential. Acupuncture may also be used preventively and to treat specific ailments.
The Cochrane reviews are beginning to publish meta-analyses of randomised trials of acupuncture. For example, a systematic review of acupuncture treatment for chronic low back pain has shown it to be more effective than other physical therapies (Furlan AD, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Systematic Review 2005(1): CD001351). There are growing numbers of individual reports of acupuncture used for particular diseases; the literature is moving fast, so for an up-to-date review you can PubMed or Google Scholar the literature. However, be careful to consider the quality of the studies. Many appear to be less than perfect, and historically we know very well that flawed studies tend to show therapies to be better than they really are. VanWormer AM, et al, for example, make this point in "The effects of acupuncture on cardiac arrhythmias: a literature review," Heart Lung, 2008; 37(6): 425-31.
How May It Work?
Explanations for how acupuncture works include the involvement of humoral factors (an acupuncture-induced analgesic effect can be transferred from one animal to another) and endorphins. See an article by Ulett GA, Han S, et al (1998). Electroacupuncture: Mechanisms and clinical applications, Biological Psychiatry, vol. 44, 129-138.
MRI has been used in several studies to indicate which areas of the brain are stimulated by acupuncture; the answer appears to involve the limbic system and certain subcortical structures. (See Hui K, Lui J, et al. Acupuncture modulates the limbic system and subcortical grey structures of the human brain: evidence from fMRI studies in normal subjects, Human Brain Mapping, 2000; 9: 13-25. Also, Cho Z H, Chung SC et al. New findings of the correlation between acupoints and corresponding brain cortices using functional MRI. Proc Natl Acad Sci USA, 1998; 95: 2670-73.) Interestingly, obese patients who lose weight appear to exhibit improvements in the circulation of chi energy, as shown by thermographic imaging of acupuncture points (Kwon YD, Lee JH, Lee MS, Int J Neuroscience, 2007; 117(5): 591-5.).
BMJ article on acupuncture (BMJ 1999; 319: 973-976)
Bibliography on acupuncture
UK Foundation for Traditional Chinese Medicine
British Acupuncture Council homepage
American Academy of Medical Acupuncture homepage
The Skeptic's Dictionary on acupuncture
Homeopathy is a holistic form of medicine that helps the body to heal itself; in this way it is fundamentally different from allopathic medicine, which administers external remedies to counteract symptoms. Homeopathy argues that there is little point in treating the physical manifestations of disease (e.g. elevated blood pressure), for these are but symptoms of the underlying condition. To cure the underlying disease, homeopathy seeks to stimulate the body's vital force (in Hahneman's term, Wesen - the spark, presumably equivalent to modern concepts of immune response). In homeopathy it is not the medicine that cures. Instead, the medicine stimulates the body's natural defenses. Hahneman's view was that disease is caused on an energetic level, a disturbance that makes the person susceptible. Note that allopathic medicine has largely moved away from concerning itself with susceptibility, towards treating people after they get sick.
Homeopathy has been known for millennia, but the modern approach was formalized by Samuel Hahneman (1755-1844). He made a name for himself in successfully treating cases of typhus following the battle of Leipzig in 1813.
"Homeopathy" means treating like with like (sometimes called the "law of similars"). Just as immune responses may be triggered by inoculations, so substances that cause symptoms in healthy people may be used to treat those same symptoms when they result from illness. There are several thousand homeopathic remedies; these are used in incredibly dilute preparations. Most homeopathic medicines are made from plant or animal sources. Typically, one part is diluted with 99 parts of water or alcohol; this is shaken vigorously and one part taken and further diluted with 99 parts of water or alcohol (0.1%), and this is repeated again (0.01%), and several more times. The shaking is important and is said to transfer energy to the solution. Paradoxically, the more diluted the tincture, the more potent it is; they may be diluted beyond Avogadro's number such that there are no molecules of the original substance left; this produces the most potent medicine. It may be taken as drops or absorbed into powder and swallowed.
The homeopathic therapist carefully reviews the patient's symptoms, as these indicate the type of disorder in the patient's defences. Different patients experience differing presentations of the same underlying malady and will require different treatments. The diagnostician carefully records all the symptoms (location, intensity, diurnal variation, factors that intensify it...) to decide on treatment. The therapist prescribes for the individual patient, so that different people with apparently similar symptoms may receive different treatments, depending on their constitutional type, physique, even attitudes. One or several medications may be used; computer programs may be used to help the homeopath select the appropriate remedy for the complex pattern of presenting symptoms. Quite a lot of patients self-treat using over-the-counter homeopathic remedies available from health food stores, pharmacies, etc.
The contrasts with allopathic medicine are clear: allopathy is based on the default assumption that people are more alike than they are different. While allopathic medicine generalizes, homeopathy particularizes. Attack, fight, and war are the metaphors of allopathic medicine; support and life force are the metaphors of homeopathy.
Because homeopathic medicine uses very dilute natural extracts, often prepared by the therapist, there is little economic interest for large pharmaceutical companies. So there was a spirited competition in the late 1800s between the two approaches. The American Medical Association was founded in part as a defence against homeopathic medicine. The pharmaceutical industry allied with the AMA to oppose homeopathy, which at the time was consistently more successful than pharmaceuticals in treating disease.
Homeopathic remedies are cheap and have very few side-effects. They may prove effective in treating conditions (allergies, hay fever, asthma) that do not respond well to conventional therapies. Ideally, homeopathy should be complementary: allopathy treats the bug and the symptom; homeopathy helps the body resist infection. A lumpectomy, for example, does not cure cancer, but it buys time for the body to heal. Allopathic approaches work better for injuries.
Does Homeopathy Work?
The answer depends on which papers one looks at, which conditions are being treated and the degree of evidence one requires. Here are a select mix of papers on homeopathy – some positive and others rather negative.
• As reported in the BMJ, the Australian National Health and Medical Research Council did an extensive examination of scientific evidence on homeopathy and found that it was “not an effective treatment for any health condition” [BMJ 2015; 350: h1478]
• In 2011, a study found that homeopathy was found to be no more effective than placebo at helping with insomnia and sleep-related disorders. [Focus on Alternative and Complementary Therapies, 2011; 16(3): 195-9]
• A 2015 study published in PLoS ONE found that homeopathy is as effective and safe as fluoxetine as an anti-depressant in peri- and post-menopausal women. [PLoS ONE 10(3): e0118440. doi:10.1371/journal.pone.0118440]. A 2012 study had found homeopathic treatment to be as effective as fluoxetine in treating depression in a group of patients of various ages and genders [Focus on Alternative and Complementary Therapies, 2012, Vol.17(3), pp.173-174].
• Homeopathy has been found to aid as an adjunct to standard therapy in the treatment of acute otitis media in children [Focus on Alternative and Complementary Therapies, June, 2012; 17(2): 134]. A 2013 paper in the same journal said that homeopathy used in acute otitis media was not effecitive [Focus on Alternative and Complementary Therapies, 2013; 18(3): 151-152]
• In a discussion of the postulated chemical and physical mechanisms of homeopathic treatments, one paper found them to be “physically impossible”. [Focus on Alternative and Complementary Therapies, 2012, Vol.17(3), pp.149-155]
• Ernst published a large systematic review of systematic reviews (covering a total of about 120 studies). This did not show convincing evidence that homeopathic treatments were better than placebo [Ernst E. Br J Clin Pharmacol 2002; 54:577-582]
• Cucherat et al. published positive results. They ran a meta-analysis of 118 clinical trials, showing a highly significant benefit overall. The problem is that many of the trials were of poor quality, and when only the best ones are retained, the benefits of homeopathy appear to fall. [Cucherat M. Eur J Clin Pharmacol 2000; 56: 27-33].
While the CMA says that use of CAM (like all medicines) should be based on “sound scientific evidence as to their safety, efficacy and effectiveness”, it does not provide a specific stance on homeopathy. It does say that “Until CAM interventions are supported by scientifically-valid evidence, physicians should not recommend them.”
An extensive information site named Homeopathy Home includes books, many links to other sites, etc.
National Center for Homeopathy (extensive information on history, etc)
And for those who want the other viewpoint: Homeopathy: the Ultimate Fake
The NIH in Washington has a good web site on alternative therapies
This is an abbreviated version of an article by Doug Alexander, BSc, RMT, an Ottawa-area Massage Therapist. Here is how he describes his work:
Massage therapy uses touch to help people relax and normalize their physiology. However, massage affects the body and mind in many ways beyond relaxing stubborn, stuck muscles.
Core Responses To Massage Therapy
Apes can often be seen in the act of social grooming. They take turns stroking and attending to each other’s fur. The touch says, without words, "I know you and care about you." This comforting social context is at least as important as the pragmatic concerns of bug and dirt removal. Similarly, the context of massage therapy is as important as the mobilization of a particular joint or nerve, a heroic stretching campaign or a gently ruthless search for trigger points.
The massage experience is unique. During the treatment the therapist covers and uncovers, picks up and sets down, pushes, pulls and kneads the client’s flesh. Words are seldom spoken, as the therapist responds to non-verbal cues of held and released breath, muscle guarding and letting go. Most of us have not had this much physical attention since infancy. This nurturing experience is at the core of massage therapy, and is valuable at any age.
Tiffany Field pioneered studies of simple soothing massage routines for premature babies, who tend to be denied regular handling. The babies massaged in neonatal intensive care units gained weight faster, were more alert and were discharged sooner. This has been duplicated in a number of centres (Field T: Massage therapy for infants and children. Journal of Developmental & Behavioural Pediatrics 1995; 16: 105-111).
Field has studied the physiological responses to simple, soothing massage in a variety of health problems, including HIV, Parkinson’s disease, chronic fatigue syndrome, depression, diabetes, and bulimia. Research abstracts are available via Touch Research Institute.
In almost all situations, soothing massage reduces stress hormone levels, elevates immune response, improves sleep patterns, self-image and reduces pain.
Massage Therapy as a Manipulation of Consciousness
The shift of consciousness from goal directed thoughts and feelings to an inner directed reflective state is fundamental to the massage experience. It is a behavioural skill or quality that many people have forgotten. Many of us live our lives like race car drivers. We may pause for an occasional pit stop, but unlike real race cars we do not overhaul our bodies before the next race. It is amazing that our bodies hold up as well as they do. Most of us have forgotten how to shift our consciousness into a state of deep rest and relaxation. In a state of rest and relaxation, muscles naturally relax, and the body heals itself.
The behavioural pattern of not giving the body time to rest and our inability to slow consciousness to a state of rest and recovery makes us vulnerable to sickness and injury. People often suffer non-specific, functional complaints for which physicians cannot identify any pathology. Massage therapy allows people to re-learn the shift to rest and recovery that many of us have forgotten. Massage treatment is very general, but the client gradually makes gains in several functional outcomes such as improved sleep, better concentration and increased ability to function at work. In these cases, the client is usually accessing deeper, reflective states of consciousness during the massage treatments as well as bringing some of the qualities of these states into their lives.
Somatosensory Noise, or Listening to the Symphony
The key to understanding the effects of massage is to recognize the muscle tension that most people carry around day-to-day. For example, a massage client may arrive with tension in their upper trapezius and compression of the cervical spine. The tension escalates towards the end of the day causing a temporal headache through trigger point referral. The neck compression through muscle tension and poor posture irritates facet joints in their cervical spine.
This uncomfortable person senses they have tension in their body but they lack a clear awareness of just where the tension is and of the effects of their body use choices. Perhaps they hold the telephone with their shoulder instead of using their hand; this just adds to the tension.
When people receive their first massage they are often surprised to find that their flesh resembles a very discordant symphony. A client remarked, "I’ve got sore spots in places I didn’t even know I had places!" The more massage the client participates in, the more they sense a rich variety of feelings in their flesh. For example, it is common to feel areas that are dense and tense in close proximity to areas that are stretched and tired, as well as other areas that feel raw and bruised.
The muscle tone is a product of physical factors such as elasticity, viscosity and plasticity as well as the idling contraction of motor units within the muscle. This sense of there being two components – physical and neuromuscular – that contribute to the texture of a muscle is one of the central keys to effective massage therapy.
Muscles are designed to contract and to lengthen in controlled ways, through the contraction of sub-volumes of muscle called motor units. A sustained, weak contraction in the neck muscles in an ideal erect posture is achieved through the rotating contraction of a number of motor units. After a motor unit contracts, it relaxes and another unit within the muscle contracts. This rotation, or sharing, of the work allows the muscle to be working, as well as taking care of its nutritional and other needs. A muscle that is contracting strongly has more motor units activated, and shorter rest periods before any one motor unit is called upon to work again.
The relative activity of working motor units in a muscle is sensed by the massage therapist as a "rubbery" quality in the muscle. As a muscle relaxes the rubbery spot or region is felt to melt or deflate. This is one of the key events in a massage treatment that is specifically addressing neuromuscular tonus. If the spot has been a source of myofascial pain, then the pain will be felt to melt or dissolve to the same extent that the knot dissolves or melts. This melting or dissolving of tension is accompanied by a feeling within the client of letting go or release.
The ability of the client to develop somatic awareness is part of the foundation of successful massage therapy. It is important for the therapist to help the client find effective postures in which to stretch tight muscles and how to strengthen weak and inhibited muscles as well as improve posture.
Myofascial Trigger Points
One of the specific ways massage therapy can help people beyond psychoneuroimmunological change and reduction of somatosensory noise is through the resolution of myofascial trigger points. These are hyperirritable spots within taut bands of skeletal muscle that refer pain in predictable patterns. The palpably dense and sensitive "knot" within the taut band of muscle is thought to be a cluster of electrically active loci in the motor endplate zone of the muscle (Mense S, Simons DG: Muscle pain: understanding its nature, diagnosis and treatment. Philadelphia: Lippincott Williams & Wilkins: 2001). Myofascial trigger points are caused by acute or chronic overload, direct trauma, or exposure to a cold draft. It is important to have the skill to identify trigger points in people’s muscles, as well as to release them with an appropriate strategy. It is also important to understand the context that created the trigger point and is maintaining it. Treatment of trigger points is stock-in-trade for massage therapists, but it is important for clients to realize that not all sore spots in people are trigger points. It is common to find areas that feel overstretched, strained, twisted, weak, congested and/or adhered. These areas need to be treated appropriately, and self-care steps taken to normalize function.
The Nervous System and Double Crush Phenomena
Massage Therapists have long treated myofascial tissue and the nervous system indirectly, through creating therapeutic sensations. We now appreciate that the nervous system is an organ that is amenable to direct, hands-on treatment as well. Craniosacral Therapy (Upledger JE, et al. Craniosacral Therapy. Seattle, Eastland Press, 1983) and Nerve Mobilization (Butler D: Mobilisation of the Nervous System. London: Churchill Livingstone; 1991, 65- 8) are two common and contrasting approaches to approaching the nervous system.
It is becoming clear how much pain may be coming from the sheaths of the spinal cord and the peripheral nerves, as well as the nervous tissue itself. The myofascial system can adversely affect the nervous system and its sheaths. Tight muscles and/or connective tissue can compress nerve sheaths causing a pain that feels almost myofascial (aching, pulling, and tight feelings). Sufficient compression can affect the nerve itself and its conduction properties, causing altered sensation resulting in burning, tingling, numbness and hyper/hypoalgesia.
From a massage therapy perspective, multiple sub-clinical impairments of the nervous system can give rise to neural symptoms. This contradicts conventional wisdom that looks for a single source for a symptom, such as compression of the median nerve in the carpal tunnel. A "single" source for much pain and dysfunction in the body is hypertonicity and lack of elasticity in the myofascial system that is creating multiple sub-clinical compromises of the nervous system.
Massage Therapy for carpal tunnel syndrome illustrates the approach. Treatment usually starts with a relaxing massage to the neck and shoulders. This decreases somatosensory noise and teaches the client how to attend to muscle tension in the body and how to find the metaphorical "control knobs" to turn down alpha motor neuron firing. The therapist examines for muscle tension in a global sense, as well as a specific pattern of tension that will tend to compromise the median nerve. This would include tension in the scalene muscles through which the nerve roots of the brachial plexus pass, under the clavicle and pectoralis minor, in the forearm where the median nerve passes under the pronator teres muscle, and the flexor retinaculum at the wrist. By normalizing the tension and length of muscles and connective tissue at neural interface points the health of the median nerve is optimized. Consequently it is common for signs of neural dysfunction to be gradually alleviated over the course of a treatment series.
In an ideal situation the client gradually learns how to stretch the muscles of the neck, shoulders, forearms and hands. They also learn how to breathe with their abdominal muscles, as the scalenes are often hypertonic and short due to constant recruitment during breathing. This tense pattern of breathing needs to be gradually dismantled and the client needs to begin to breathe predominantly with their diaphragm again.
For clients suffering from frank neurological disease or trauma, massage therapy is not curative, but is often helpful nonetheless. For many of these people touch has been withdrawn as a result of people’s reaction to their condition and/or attendant isolation and loneliness. Massage Therapy can be a nurturing link to the world of human touch and facilitate touch in the person’s relationships.
Body Image, Self-Connectedness and Self-Care
One of the commonest subjective outcomes during a massage is a feeling of "returning home" to the flesh. Stressful thoughts and ideas are gradually set aside as a comforting and grounded sense of awareness of the body occurs. Massage Therapists encourage clients to cease talking, and pay attention to their breath and somatic awareness during the treatment.
The acceptance and nurturing of the client’s body by the massage therapist can be a powerful factor in healing and prevention of disease. People who have undergone disfiguring surgeries (or any surgery) often cut off their awareness from the part of their body that was treated. Similarly, people who have been traumatized physically, sexually, and/or emotionally often dissociate from the body part (or their body wholly). Touching a traumatized region can activate memories of the experience. A lot of people don’t perform breast self-exams, basic dental hygiene, or have pap smears performed as a result of post-traumatic reactions.
Massage Therapy is both a simple and a complex intervention. Built around the natural impulse to touch a person to comfort and bond, it has powerful effects simply on the basis of caring, respectful and boundary-conscious touch. It has the systemic effects of immune system enhancement and physiological normalization, and lessens excessive muscle tonus in the body. By reducing the somatosensory noise of muscle tension and compression in the body, as well as quieting the chattering of the mind, Massage Therapy often makes it possible for people to notice the effects of their body use choices, and make changes that are not of a recipe nature, but arise spontaneously from an accurate awareness of how their body feels.
Evaluative evidence on massage therapy is accumulating. A meta-analysis of massage therapy for low back pain, for example, by Furlan and others is available in Spine. An RCT of massage for osteoarthritis of the knee showed it to significantly improved all outcomes measures (range of motion, mobility, pain): Arch Intern Med 2006; 166(22): 2533-8. Massage therapy may also improve swelling, constipation, and concentration. See Clifford and Andrade (Outcome-based Massage. New York; Lippincott Williams & Wilkins; 2001) or Rattray and Ludwig (Clinical Massage Therapy. Toronto: Talus Incorporated; 2000).
Regulation Of Massage Therapy
Massage Therapy is variably regulated throughout the world. In Canada, Massage Therapists are regulated in only Ontario and British Columbia.
In Ontario, the Ontario Massage Therapist Association runs a referral service through the toll-free number: 1-800-668-2022. In British Columbia the British Columbia Massage Therapist Association can be reached at: 1-888-413-4467 or through their web site.
Therapeutic touch is a method of hands-on healing in the body-energy category. It was developed in the 1970s by an American nurse, Dolores Krieger. Healing is based on the therapist's ability to channel the patient's energy toward the area of pain. It appears to relieve tension, pain or stress.
A therapeutic touch treatment lasts between 5 and 20 minutes. The practitioner works in a meditative state and uses his or her hands to assess the energy field of the recipient. Gentle passes with the hands few inches above the client's body helps to restore a normal flow of energy through the field. Very little actual touch is involved. The client remains clothed and may sit or lie down for the treatment. Research studies suggest that TT induces a rapid relaxation response, reduces pain, speeds healing, supports the immune system, and reduces stress.
Much of the TT literature will sound strange to students brought up in the scientific tradition of biology. It talks of energy flow, feelings and being in harmony with nature. Ideas like the healing properties of trees ("turn and stand with your spine in contact with the tree. Hold that position until the tree tells you move") may well be valid but they take a bit of getting used to. "Communication with animals during TT treatments quickly led to communication with trees and plants, rocks, rivers and lakes and to the Earth herself. Everything has consciousness. Everything has knowing. TT leads to a different understanding of the world."
Therapeutic Touch Network of Ontario
A general explanation of how TT works
Literature on the effectiveness of therapeutic touch and the healing of fractures
For your diversion, an enthusiastic site that includes a number of articles evaluating TT for animals (e.g., "A raccoon responds to therapeutic touch")
The skeptics have been particularly critical of TT; see, for example, the Quackwatch page
Ayurveda is considered the world's oldest complete medical system. Part of the Vedas, the divine texts of Hinduism, it dates back 3,500 to 4,000 years. Ayurveda means "the science of life"; its aim is not only to treat symptoms but to prevent illness and sustain life. Its roots are intertwined with those of yoga and meditation, both of which play a fundamental role in ayurvedic treatment.
Ayurveda holds that the universe is made up of five elements: air, fire, water, earth and ether; and three doshas: vata, pitta and kapha. The theory is that we can achieve health by balancing the three within ourselves. The doshas resemble the humours of ancient Greece, although the ayurvedic notion pre-dates that of the Greeks.
Doshas dictate everything about us, from the colour of our hair to the type of illnesses we suffer. They are even responsible for the foods we crave, our relationships and the things we like to do. We all contain elements of vata, pitta and kapha.
Roughly speaking, vata corresponds to air, pitta is fire and kapha is water. Vata is related to the body's energy, movement and the nervous system; pitta governs digestion, metabolism and temperature; kapha oversees phlegm, moisture and lymphatics. Exacerbation of a particular dosha, through eating the wrong foods or living inappropriately, will lead to illness.
Your dosha is determined mainly by taking your pulse and examining your tongue. The physician will examine the radial artery pulse at the root of the thumb, and, if healthy, it will seem strong and regular. Ayurvedic practitioners compare the unhealthy pulse to the movements of particular creatures. A vata pulse resembles the path of a snake, swift and thread-like; the pitta pulse is frog-like and erratic; the kapha pulse is at a deeper, swan-like pace.
A typical ayurvedic assessment would include an initial diagnosis. A health plan is tailored to the patient's dosha and especially involves dietary advice. Subsequent treatment might include herbal medicines, massage, steam bath, or treatments such as shirodhara (herbal oil dripped on to the head), vasti (enema using medicated oils) and abhangya (herbal body massage). These can apply to many complaints including skin diseases, rheumatoid arthritis, and depression.
Ayurvedic hospitals have now opened in the West; a three-year BA in ayurvedic studies has been launched at Thames Valley University in England. The course includes the fundamentals of anatomy, physiology, botany and the pharmacopoeia of Ayurveda, and practical training in detoxification, yoga and meditation.
Which Body Type Are You?
Vata: Elements: air and space
Vata people are restless with active minds. They tend to be lightly built, their skin may be dry and rough. Vatas are talkative, indecisive, erratic, solitary and may be emotionally insecure. They may suffer from stiff joints, rheumatic problems and constipation. They also have a tendency towards insomnia and depression. They make good artists and enjoy travelling, plays, stories and dancing.
Kapha: Elements: water and earth
Kapha people are big-boned, often overweight, with a pale, smooth complexion. A kapha needs a lot of sleep, has a rational mentality and speaks and moves slowly. They are calm, loyal people who are relaxed and emotionally secure. They may suffer from sinus problems, lethargy and nausea.
Pitta: Elements: fire and water
Pitta people are of average build and may have a ruddy complexion with moles, freckles or acne. They tend to go grey or bald early in life, and often have green or very piercing eyes. They are intense, purposeful, and precise, with a critical, sharp intelligence; can be argumentative. They make good leaders. At their worst they can be irritable and passionately angry. Pitta types enjoy sports, hunting and politics.
The Gerson Institute of Ayurvedic Medicine
A local centre in Ottawa is the Shree Ma Ayurveda centre
A systematic review of Ayurvedic treatments for diabetes. This reviewed 54 articles, including 7 RCTs and 7 cohort studies.
Updated September 10, 2018