Bodywork

***Disclaimer: This blog is not meant to be used as legal or medical advice.  It is written as my person perspective on how medical professionals could blend western medicine with other modalities***
Greetings, listeners, and welcome to another episode of The Integrated Pharmacist Podcast.  This week, I'm discussing bodywork.  This is the complementary/alternative modality that has garnered the most acceptance and usage.  It includes physical manipulation such as massage therapy and reflexology, movement therapy such as qigong, yoga and ti chi, and energy work such as reiki and therapeutic touch.  Although it is a diverse set of modalities, I'd like to touch upon one in each of these three categories.
Physical manipulation comes naturally to many people as a mode of self care and home care.  After a long day on your feet, it feels good to get a nice foot rub.  When our muscles develop knots, human touch makes the pain more bearable.  Positive physical touch can be calming, relaxing, and enjoyable.  There are different styles of massage that emphasize specific techniques, parts of the body, depth of tissue manipulation, and the patient's experience.  Some styles of massage have potential to promote health by assisting lymph flow, inducing relaxation, softening scar tissue, and decreasing specific nociception.  This potentially means that massage could help fight infection, lower blood pressure, reduce stress damage to internal organs, balance blood sugar, and raise pain tolerance.

Physical manipulation also includes reflexology which is foot massage with the intent to modulate health throughout the body.  For example, applying pressure on the outer edge of the foot is meant to positively affect the spine.  I found a telling example involving the modality of reflexology compared to general foot massage.  In this study, 385 women battling stage three or four breast cancer were split into 3 arms: reflexology, lay foot manipulation, and conventional care.  The reflexology arm received foot treatments that targeted 9 specific points on the foot associated with breast cancer.  The therapist also used a specific technique used in reflexology of the thumb to evoke pressure on those points.  This technique is called thumb-walking.  In comparison, the lay manipulation used a vaguely similar massage, but with no thumb-walking, and avoidance of the 9 specific breast cancer points.  If you'll remember from last week's episode, one of the trials I referenced could have been improved had they went back to the patients to ask which treatment arm they thought they were in.  Well, this trial included this measure.  Furthermore, the study designers had reflexology-naive subjects learn the lay manipulation technique as if it were reflexology.  This afforded another level of blinding to the patients.  Each patient in the reflexology and lay manipulation arms received a 30 minute treatment once a week for 4 weeks.  The results of the trial demonstrate a mild improvement in a few areas such as dyspnea in favor of reflexology.  However, I would point out that the placebo treatment was technically another form of massage, and both of these arms saw similar improvement over the control group!  What I get from this trial is that general foot massage can provide some relief to suffering patients.
Although reflexology itself didn't pan out, I believe this demonstrates the therapeutic affect of human touch.  I think it fits well within western medicine.  If a patient has access to human touch, it's bound to have a positive affect on their quality of life.  I would absolutely encourage family and friends of patients to not only visit with their loved one, but have physical contact with them.  Massage can enhance that therapeutic affect; however, this typically comes at a significant price and it is not covered by most insurance.  However, I think it would be beneficial for medical facilities to include a staff massage therapist for patients who may be suffering from long-term disease or harsh medication therapies.
Movement therapy is a little different.  This is the practice of moving the body as health.  It includes

yoga, taichi, qigong, as well as others.  Physical therapy might fall under this category as well as the last since they typically help their patients through movement, training, and therapeutic touch.  Yoga is an ancient Indian art of meditation that involves movement.  Taichi is a gentle form of martial arts that concentrates on directing energy.  Qigong is a Chinese exercise that is similar to taichi, but it involves a different set of movements and focus.  Each of these have a spiritual or energetic element to them, because there is a focus on feeling an ethereal energy.  From the outside perspective, it looks like there is a lot of imagination involved in manipulating this energy.  However, they are also forms of physical movement that allows the participant to go to their limits without exceeding them.  It can be a significant workout no matter what your level of physical ability is.  Yoga is often thought to be only for the most flexible of people, but there are forms of yoga that do not require exact positioning.  These forms practice going to your personal "edge" - the place just before it really hurts.  The same goes for taichi and qigong.  There are many different styles of these movement arts, and by attending different instructors, your experiences will vary.
I found a meta-analysis regarding taichi and a trial involving qigong.  Obviously, the patients were aware of whether they were participating in movement therapy or not.  The practitioners involved were not blinded.  As you can see, these are not the strongest trial attributes.  And in both instances, there was only a mild evidence that the modality was effective.  For example, the taichi analysis looked at patients with type 2 diabetes status.  Measuring fasting blood glucose and hemaglobin A1c, there was improvement in all treatments arms.  The studies that included a waiting group as the control showed significant difference.  However, studies that included other physical activities demonstrated equal benefit to the control.  This was true of the qigong study as well.  Compared to regular exercise, there was no added benefit for decreasing hypertension.  Even though these pieces of evidence are not the results the practitioners of these modalities may have wished for, they still showed that these modalities were at least as effective as regular exercise.
With how gentle these movement therapies can be, I would argue that there is an opportunity to provide health benefits to people who have difficulty moving.  Health benefits including controlling blood sugar, lowering blood pressure, and strengthening the heart muscles.  I would encourage patients who struggle with exercise and reducing weight to find these movement therapies and at least try it.  If they find it works for them, that's a win!  This easily fits into western medicine as a form of exercise.  For all the disease states that include exercise as a non-pharmacological intervention, these modalities are a perfect fit.

Finally, there are the energy manipulation modalities including reiki, acupressure, polarity therapy and therapeutic touch.  Now, I will clarify, this kind of therapeutic touch refers to a method of energy manipulation that is not physical contact.  It is not the same as massage or physical therapy.  This kind of therapeutic touch and reiki both purport to adjust the energies around the body.  They are said to adjust the patient's chakras by influencing the flow of life force around the body.  This would presumably have a positive affect on the aura of the patient which will allow healing to take place within the body.  People use all these modalities to improve mood, reduce pain, and ease autonomic nervous system complications.
Surprisingly, I found a relatively well designed clinical trial for therapeutic touch that demonstrates efficacy.  The trial performed in Tehran, Iran took 90 female cancer patients undergoing harsh chemotherapy split into 3 groups.  The control group received regular care, the experimental group received 30 minutes of therapeutic touch, and the placebo group received 30 minutes of sham-therapeutic touch.  The trial tracked pain and fatigue and therapy was administered for 5 consecutive days.  Although the placebo group experienced statistically significant benefit over the control, the experimental group demonstrated even more improvement in both pain and fatigue.  There were some limitations with this trial.  First, the subjects were all presumably Iranian women who had cancer.  This makes it difficult to extrapolate data to other groups.  Also, this was only a single-blinded study.  The primary investigator conducted the 30 minute treatments for both the therapeutic touch and sham arms of the trial.  This could potentially introduce bias, because the investigator might do things (even subconsciously) that signal to the patients what her desired outcomes are.  However, the findings are still of some value, and further investigation is warranted.
As far as recommendations go, therapeutic touch can be taught relatively quickly.  Therefore, the cost burden is really not as significant as some other practices.  I think if a willing patient is open to the idea of energy manipulation, they should give it a try.
For more information about massage therapy, you can visit the American Massage Therapy Association at www.amtamassage.com.  Typically, you will not find a reputable massage therapist charge less than about $1 a minute, and a decent one will charge around $90 to $100 for an hour.  Foot massage and reflexology typically do not last more than 30 minutes and charge less than $1 per minute.  If you'd like to learn more about qigong, find conferences, and earn certification, visit the National Qigong Association at www.nqa.org.  A typical qigong class can cost between $60 and $125 depending on instructor, style, and location.  And finally, to find out how to become a therapeutic touch healer or request a healing session, you can visit the Therapeutic Touch International Association at therapeutictouch.org.  You can request distance healing for free, but an in-person healing session will last about an hour at approximately $40 to $90 a visit.  To become a therapeutic touch practitioner, each training costs around $200 - $500, and it costs $1200 - $1500 all together to be a certified therapeutic healer with a $25 yearly membership fee.
If you like this podcast and would like to hear more about holistic medicine, I recommend listening to the Loud-Mouth Pharmacist podcast by Dr. Neal Smoller as well as the Pharmacists Out of the Box Podcast with Drs. Heather Hardin and Bryn Tenney.
I would like to thank everyone who has taken the time to listen to this podcast.  If you enjoy what you hear, please subscribe, rate and review, and tell a friend.  To read the transcript and review the references for the trials I mentioned, you can visit my blogger page at integratedpharmacist.blogspot.com.  If you'd like to reach me directly, you can email me at integratedpharmacist@gmail.com.  Thanks again and tune in next week for more of the Integrated Pharmacist Podcast.

References:
Wyatt G, Sikorskii A, Rahbar MH, Victorson D, You M. Health-related quality-of-life outcomes: a reflexology trial with patients with advanced-stage breast cancer. Oncol Nurs Forum. 2012;39(6):568–577. doi:10.1188/12.ONF.568-577
Xia TW, Yang Y, Li WH, Tang ZH, Li ZR, Qiao LJ. Different training durations and styles of tai chi for glucose control in patients with type 2 diabetes: a systematic review and meta-analysis of controlled trials. BMC Complement Altern Med. 2019;19(1):63. Published 2019 Mar 14. doi:10.1186/s12906-019-2475-y
Cheung BMY, Lo JLF, Fong DYT, et al.  Randomised controlled trial of qigong in the treatment of mild essential hypertension.  Journal of Human Hypertension 19, 697-704 (2005).
Aghabati N, Mohammadi E, Pour Esmaiel Z. The effect of therapeutic touch on pain and fatigue of cancer patients undergoing chemotherapy. Evid Based Complement Alternat Med. 2010;7(3):375–381. doi:10.1093/ecam/nen006