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Practicing shiatsu in Australia: A workforce survey
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Contents lists available at ScienceDirect
Advances in Integrative Medicine journal homepage: www.elsevier.com/locate/aimed
Practicing shiatsu in Australia: A workforce survey Emma Strappsa,* , Jennifer Huntera,b,c, Dorothy Douglasa , Paul Spencea a
Shiatsu Therapy Association of Australia, Bendigo, Victoria, Australia National Insititute of Complementary Medicine Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia c Menzies Centre for Health Policy, University of Sydney, New South Wales, Australia b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 March 2019 Received in revised form 1 July 2019 Accepted 27 July 2019 Available online xxx
Background: Shiatsu is an under-represented modality within complementary medicine (CM) research. No previous data has been collected on the shiatsu workforce in Australia. Objectives: This study aimed to characterise shiatsu practitioners in Australia and their clinical practice with the view of informing clinical research. Methods: In 2016, a 32-question on-line cross-sectional survey was advertised to shiatsu practitioners on the Shiatsu Therapy Association of Australia’s (STAA) mailing list and through other professional associations. Descriptive statistics were used to analyse the data. Results: Of the 121 respondents 70.3% (n = 85) were female, the median age was 48 years and 74.4% (n = 90) were STAA members. The median number of years in practice was ten. Most were self-employed (93.3%, n = 112/120) working less than 20 h per week (82.1%, n = 92/120) in a variety of settings, most commonly solo practice (76%, n = 91/120) followed by group practices alongside other shiatsu practitioners, allied health or medical doctors (53.3%, n = 64/120). Practitioners reported typically spending over an hour of contact time with a broad range of clients who often had multiple healthcare needs, including those incurring a high burden of disease such as chronic pain and mental health. The top four symptoms/conditions that practitioners reported improved outcomes were pain/musculoskeletal (40.6%, n = 128/315), mental health/wellbeing (26.0%, n = 82/315), fatigue (10.2%, n = 31/315) and gastrointestinal (6.3%, n = 20/315). On average, a positive effect was reportedly observed following four treatments at 1–2 week intervals. Almost two thirds (63.2%, n = 67/106) of practitioners reported regularly referring their clients to other health professionals. Conclusions: Results from the first national workforce survey of shiatsu practitioners in Australia suggest Shiatsu practitioners are engaging in the shared care of their clients’ health and wellbeing, including referrals or recommendations to other healthcare practitioners. Practitioner characteristics generally align with those reported for the broader field of CM in Australia and shiatsu practitioners in Western Europe. Reported positive outcomes for chronic diseases and common yet difficult-to-treat symptoms signal areas for future clinical research. © 2019 Elsevier Ltd. All rights reserved.
Keywords: Shiatsu Complementary medicine Workforce Survey Massage Acupressure Whole system Holistic healthcare
What is already known about the topic
What this paper adds
There have been several workforce surveys undertaken and reported on CM modalities, including ‘massage therapy’, in Australia in the last 10 years with statistical information on personal characteristics, employment characteristics and types of clinical expertise or special interest.
However none have focused specifically on shiatsu therapy and little is known about this relatively small workforce in relation to the broader manual touch therapy field working in Australia.
* Corresponding author at: Shiatsu Therapy Association of Australia, P.O. Box 727, Bendigo, Victoria, 3552, Australia. E-mail addresses: [email protected] (E. Strapps), [email protected] (J. Hunter), [email protected] (D. Douglas), [email protected] (P. Spence).
1. Introduction The practice of shiatsu has, to date, received little academic attention in Australia and internationally. In response to a perceived need for data specific to the Australian shiatsu workforce, in 2016, the Shiatsu Therapy Association of Australia (STAA) initiated a workforce survey aimed to establish baseline information about practitioner demographics, workplace conditions and client demographics. It also aimed to identify commonly presented symptoms or conditions
https://doi.org/10.1016/j.aimed.2019.07.003 2212-9588/© 2019 Elsevier Ltd. All rights reserved.
Please cite this article in press as: E. Strapps, et al., Practicing shiatsu in Australia: A workforce survey, Adv Integr Med (2019), https://doi.org/ 10.1016/j.aimed.2019.07.003
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that practitioners ‘observed’ as responding positively to shiatsu for the purpose of further investigation. Shiatsu [1,2] has been practiced in Australia for more than 45 years when Japanese sisters, Michiyo and Hiroko Urakawa started their practice in Melbourne in 1973 [3]. The profession is selfregulated, however, STAA was established in 1987 to uphold professional standards of training and practice [4]. In 1990 training in Australia became standardised and endorsed by the Australian Government within the Health Training Package as the Diploma of Shiatsu and Oriental Therapies (DSOT), currently HLT52215 [5]. The qualification competencies are based on the shiatsu technique of sustained and relaxed use of the weight of the body for treating tsubo, or acupressure points, and meridian systems as they are identified and interpreted via a number of shiatsu styles [1,2,6,7]. Theory encompasses philosophy and principles of shiatsu assessment and treatment [6,7,8,9], Traditional Chinese Medicine (TCM) theories [1,10,11,12,13] and Western anatomy and physiology [5]. Additional Oriental therapy techniques include tonification and sedation [1,14], corrective exercises [1,15], cupping [1], moxibustion [1,16] and recommendations to clients about selfcare, for example; suggestions for changes in diet and lifestyle, stretches and/or breathing techniques [17,18,19]. This training provides a foundation for the application of shiatsu therapy as a complex intervention, including client health history and assessment, treatment protocols and self-care recommendations and utilisation of additional Eastern therapies based interventions. 2. Methods 2.1. Study design A cross-sectional national survey of shiatsu practitioners working in Australia was conducted from 6 June to 17th July 2016.
membership database of past and present members (n = 309) was sent an email invitation with an electronic link and a request to forward the link to other shiatsu practitioners known to them. Shiatsu practitioner members of other relevant associations including; Australian Association of Massage Therapists (currently Massage and Myotherapy Australia), Association of Massage Therapists and Australian Traditional Medicine Society were also invited via their association’s newsletter or email with an electronic link. 2.4. Analysis Returned data was exported from SurveyMonkey1 [20] into Microsoft1 Excel1 [21] and IBM1 SPSS1 Statistics v25.0 [22]. Descriptive statistics were predominantly used with inferential explorative statistics determined a priori. The numbers of responses to each question were used as denominators for reporting percentages. Management of answers to open-ended questions about symptoms and conditions was by manual grouping, followed by a preliminary coding framework, review and agreement upon the final coding approach and analysis. 2.5. Human research ethics The survey was conducted in accordance with the National Statement on Ethical Conduct in Human Research (2007) guidelines [23] and approved by the STAA National Council. The boards of the collaborating practitioner Associations provided approval before advertising the survey to their members. All anonymous data is held securely according to the 2007 Human Research Ethical Conduct (HREC) protocol. 3. Results 3.1. Response and completion rates
2.2. Survey instrument A 32-item questionnaire was designed and developed, in consultation with STAA National Council, over 6 months (see Appendix 1: Survey Questions). The questionnaire was delivered online via SurveyMonkey1 [20], in paper format by return post to the STAA office, or via email. Three STAA members returned paper surveys. All survey data was de-identified prior to statistical analysis.
Eligible survey participants included 211 STAA members, 74% of which were female. A total of 121 surveys were returned, 118 via SurveyMonkey and 3 via email. Of these, 115 (95.0%) were complete. The survey response rate for eligible STAA members was 43% (n = 90). There was no statistically significant difference in gender between responder and non-responder STAA members (χ2 (1) = 0.851, p = 0.4). Response rates from other professional associations could not be calculated.
2.3. Sample and recruitment
3.2. Practitioner demographics
Eligible participants were shiatsu practitioners with a DSOT qualification or equivalent and living in Australia. The entire STAA
Table 1 summarises characteristics of the 121 respondents. The median age was 48 years (range: 25–71), 44% were older than 50
Table 1 Shiatsu practitioner characteristics (n = 119). Age (median)
Female
85 (71.4%)
Average years in clinical practice
48 years
(range: 25 – 71 years)
Male
34 (28.6%)
12
(SD 9.2)
Location Shiatsu training Shiatsu practice
ACT 0 1 (0.8%)
NSW 28 (23.5%) 31 (26.1%)
NT 3 (2.5%) 2 (1.6%)
SA 0 1 (0.8%)
QLD 5 (4.2%) 11 (9.2%)
TAS 0 3 (2.5%)
WA 0 0
Association Membershipc
AACMA 3 (2.5%)
ANF 6 (5.0%)
MMA 5 (4.2%)
STAA 90 (75.6%)
TMS 12 (10.1%)
Yoga Australia 12 (10.1%)
VIC 76 (63.8%) 68 (57.1%)
OTHER 7 (5.8%)a 1 (0.8%)b
OTHER 20 (16.8%)
ACT: Australian Capital Territory, NSW: New South Wales, NT: Northern Territory, SA: South Australia, TAS: Tasmania, WA: Western Australia, VIC: Victoria. a United Kingdom (n = 3), Canada (n = 1), Italy (n = 1), United States (n = 1). b All of Australia (n = 1). c More than one response allowed - AACMA: Australian Acupuncture and Chinese Medicine Association, ANF: Australian Nursing Federation, MMA: Massage and Myotherapy Australia, STAA: Shiatsu Therapy Association of Australia, TMS: Traditional Medicine Society, ‘other’ included: AAHTC: Australian Association of holistic and Transpersonal Counsellors, AHA: Australian Homeopathic Association, IICT: International Institute for Complementary Therapies, ISA: Independent Sporting Association, APS: Australian Psychological Society, Shiatsu Society (United Kingdom).
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and 2% younger than 30. The majority were female (70%, n = 85). The median number of years in practice was 10 (range: less than 1 year to 33 years). Training locations of respondents were mainly in Victoria (66.4%, n = 79/119), followed by New South Wales (21.8%, n = 26/ 119). Of the seven practitioners trained overseas, one studied in Japan. Victoria and New South Wales were where the majority continue to practice. Over one third of the 119 respondents practice in multiple suburb locations within a state (40%, n = 47) and one respondent stated they work across Australia. Most respondents (87%, n = 90/104) were STAA members and 54% (n = 56/104) were members of at least two of the 12 practitioner associations listed in Table 1. The Shiatsu Society in the United Kingdom was amongst ‘other’ professional Associations. 3.3. Workplace and employment Respondents practice in a variety of environments and employment conditions (Table 2), Most practitioners spent some time working in a solo practice setting (76%, n = 91/120), either in a solo clinical space, at home, in a mobile practice that could include home visits and corporate environments. A substantial proportion also work in a group setting alongside other practitioners or therapists (35.8%, n = 43/120). A further 21 practitioners (17.5%) only work in a group setting. In ten instances, shiatsu practitioners work alongside medical doctors in primary or secondary care settings. Other community settings included ‘specialised services for survivors of sexual assault or torture’, a ‘community hub’ and a ‘community house’. Two practitioners provided shiatsu in a teaching environment. Most respondents identified as ‘self-employed or subcontractor’ (93%, n = 112/120). Of the four who were employed, one had a formal contract with their employer. Those subcontracted or employed were either somewhat satisfied (72%, n = 13/18) or very satisfied with their employment arrangement (11%, n = 2/18). None reported being dissatisfied. Part-time employment was most common, with 84% (n = 98/ 117) of practitioners working 20 h or less per week. The maximum number of hours worked per week was 48 while the median was ten. This included time with clients (usually paid) and time spent on business administration, professional development and marketing (usually unpaid). The median reported time spent with a client was 75 min per session, ranging from 14 to 240 min.
Table 2 Workplace settings. N = 120
%
Solo Home or solo clinic room Mobile practice Corporate massage Hotel
91 83 40 8 1
75.8 69.2 33.3 6.7 0.8
Group Shiatsu practitioners only Shiatsu, other CM and/or allied health Including medical doctors Community organisation, hospital outpatient Hospital inpatient Day spa, bathhouse
64 8 52 9 8 1 8
53.3 6.7 43.3 7.5 6.7 0.8 6.7
Other Corporate events, festivals, markets Teaching / student clinic
7 4 2
6.7 3.3 1.7
CM – Complementary medicine practitioners.
3
3.4. Client demographics A series of broad categorical questions about client’s characteristics were asked. Around half (52%, n = 55/106) reported most of their clients were female, 46% (n = 49/106) consulted approximately equal numbers of males and females, and one reported their clients were mostly male. The most common reported client age group was 40–60 years old (78%, n = 83/106), followed by adults under 40 (59%, n = 63/106), adults over 60 (22%, n = 23/106), then children and teenagers (10%, n = 11/106). 3.5. Clinical areas of expertise or special interest A list of common conditions and demographic groups was provided with the option to nominate more than one area of clinical interest or expertise along with an open-ended answer (Table 3). Multiple conditions were identified by 98 (86.7%) of the 113 respondents. Five practitioners stated they considered themselves generalists with no particular area of expertise or interest. Conditions most commonly selected were stress/ relaxation/mental health (73.5%, n = 83/113), pain/musculoskeletal/rehabilitation (55.8%, n = 63/113), management of chronic health conditions (45.1%, n = 51/113) and women’s health (42.5%, n = 48/113). 3.6. Positive outcomes practitioners ‘observe’ following shiatsu Of the 121 respondents, 106 (87.5%) answered an open-ended question (See Appendix 1, Question 17) asking them to list up to three presenting symptoms or conditions where they commonly observe shiatsu therapy yielding positive results. The four symptoms or conditions most listed were: pain/musculoskeletal (40.6%, n = 128/315), followed by mental health/wellbeing (26.0%, Table 3 Clinical interest and commonly observed outcomes from shiatsu. Clinical Interests n = 113
n
%
Women’s health Men’s health Senior citizens Paediatrics Teenagers / youth
48 13 20 11 16
42.5 11.5 17.7 9.7 14.2
Chronic health conditions general cancer care disability care Pain, Musculoskeletal, Rehabilitation Stress, relaxation, mental health
51 41 21 12 63 83
45.1 36.3 18.6 10.6 55.8 73.5
Observed Positive Outcomes n = 315 outcomes, n = 106 respondents
n
%
Pain, Musculoskeletal back neck shoulder headache a Stress, Relaxation Mental health Insomnia, Improved sleep Energy, Fatigue Gastrointestinal Women’s health Other b
128 35 44 24 35 49 47 11 32 20 10 18
40.6 11.1 13.9 7.6 11.1 15.6 14.9 3.5 10.2 6.3 3.2 5.7
a Includes “headache & fatigue” (n = 6) that were coded as Energy, Fatigue; and “stress - headaches” (n = 2) that were coded as Stress, Relaxation. b Other: respiratory symptoms (n = 4); cancer (n = 2); fluid retention (n = 2).
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Table 4 Global summary statistics including all Conditions/Symptoms (1, 2, and 3).
Number of Treatments for a Positive Change Treatment Frequency (Weeks) Time to Observe Positive Change (Weeks)
Mean
Median
Std. Dev.
Min
Max
N
2.5 1.8 6.3
2.0 1.5 4.0
1.7 1.0 5.7
1.0 1.0 1.0
12.0 6.0 52.0
288 290 254
4. Discussion
n = 82/315), fatigue (10.2%, n = 31/315) and gastrointestinal (6.3%, n = 20/315) (Table 4). Where possible, practitioner responses were coded into categories and subcategories. However, this was not always straightforward as there were instances where information spanning more than one of the categories were listed. For example, commonly, terms such as relaxation, tension or stress were used when referring to physical relief (e.g. “stress - neck and shoulder tension”), mental/emotional relief (e.g. “stress/anxiety”), both (e.g. “relax in body and mind”) or it was not specified and a single word was listed (e.g. “stress”, “relaxation”, “tension”). As such, the decision was made to keep this as a separate category that included all instances where these concepts were mentioned. Insomnia/improved sleep was another example where the category was kept separate, as it was recognised that the causes of insomnia may be physical (e.g. obstructive apnoea), emotional (e.g. anxiety/depression) or behavioural (e.g. poor sleep habits, shift work). Therefore, whilst the most common symptom or condition listed was the pain/musculoskeletal category (40.6%, n = 128/315), this in part reflected the broader definition for this category. Following this question, respondents were asked to provide estimates of the number of shiatsu treatments typically required before a positive change is observed, the typical time interval between treatments, and the length of time typically required before a positive change is observed. Overall, respondents estimated the mean number of treatments required was 2.5 (median = 2), treatment frequency mean was 1.8 weeks (median = 1.5) and mean time to observe changes was 6.3 weeks (median = 4) (Table 4).
Significantly, this is the first national workforce survey of shiatsu practitioners in Australia. Results of the survey suggest shiatsu practitioners are engaged in the shared care of clients with service provision to a broad demographic with multiple healthcare needs, including those incurring a high burden of disease such as pain management and mental health [24]. The results provide baseline information about the shiatsu workforce in Australia, areas for development of training and employment pathways, and preliminary indications for the role of shiatsu in providing supportive care in both primary and secondary healthcare settings. Shiatsu practitioner demographics mostly aligned with other Australian CM practitioners reported by Leach (2013) [25] and Steel et al. (2018) [26]. Similarly, the reported demographics of shiatsu clients aligned with existing data about people using CM in Australia [25,26] and clients from Long’s European study [27]. However, a notable difference between shiatsu practitioners and other CM practitioners in Australia is the higher proportion of shiatsu practitioners working less than 20 h per week. The reasons for this are unclear and warrant further exploration regarding the implications for the workforce and future STAA career pathway planning. There was some evidence of shiatsu being provided in integrative medicine settings. Around half of the respondents reported working in multidisciplinary settings alongside other types of healthcare practitioners, with some working in hospital settings or alongside medical practitioners in primary care settings. Like other CM practitioners [26], it was not uncommon for shiatsu practitioners to hold more than one professional association membership including non-CM health professional memberships. This suggests some practitioners may be integrating shiatsu with other healthcare modalities. Other indicators of integrative practice included inter-professional referrals to and from shiatsu practitioners with a range of CM, allied health and medical/dental practitioners. How these referrals were made was not elicited. It is not known if these referrals were informal recommendations or accompanied by a handover, such as a referral letter. Importantly, given that many shiatsu clients will likely have medical conditions, this finding provides some reassurance that practitioners aim to practice within their scope and while many
3.7. Referrals to and from other healthcare practitioners Respondents reporting clients most often find them by word of mouth was 93% (n = 99/106). Also common were Internet advertising 46.2% (n = 49/106), the STAA website 20% (n = 21/ 106) and referrals from other healthcare practitioners 55.6% (n = 59/106). Practitioners also reported ‘occasionally’ (63.2%, n = 67/106) or ‘regularly’ (32.1%, n = 34/106) referring clients to a broad range of healthcare practitioners. Only 4.7% (n = 5/106) reported ‘never’ referring their clients. (Table 5) Table 5 Referrals to and from other healthcare practitioners. Practitioner type
Shiatsu practitioner Chinese medicine Natural therapist * Allied health Psychologist Medical practitioner Dentist Exercise instructor Other **
Shiatsu practitioners who receive referrals (n = 106)
Shiatsu practitioners who refer (n = 101)
n
%
N
%
30 20 27 19 10 13 0 0 0
28.3 18.9 25.5 17.9 9.4 12.3
0 73 47 51 49 58 10 54 9
0.0 72.3 46.5 50.5 48.5 57.4 9.9 53.5 8.9
More than one response allowed * Natural therapist includes naturopaths (n = 42), homeopaths (n = 14), and nutritionists or dieticians (n = 10) ** Other: Kinesiologist, Feldenkrais practitioner, Podiatrist, Meditation facilitator, Bush Flower remedies.
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practitioners often worked in solo-practice, there was evidence of inter-professional collaboration with other healthcare practitioners. Whilst patient experiences were not evaluated, the reported relatively long contact times with clients correlates with a growing body of evidence suggesting the healing process and experience of the client benefits from the time spent developing the clientpractitioner relationship [28–30] and is further highlighted by the following excerpt from a qualitative study in the UK that explored issues around length of consultation time in the primary care setting: “The systematic review consistently showed that doctors with longer consultation times prescribe less and offer more advice on lifestyle and other health promoting activities. Longer consultations have been significantly associated with better recognition and handling of psychosocial problems and with better patient enablement” [31]. Similarly, whilst the clinical outcomes of clients receiving shiatsu were also not evaluated, the areas of reported clinical interests and expertise closely aligned with the Western European survey of shiatsu practitioners [27], a wide range of Australian CM practitioners [26], and clinical research evaluating the effectiveness of shiatsu, oriental meridian massage and acupressure [32–35]. Not surprisingly, the most commonly reported areas of clinical expertise or special interest generally aligned with conditions and symptoms reported by practitioners as benefitting from shiatsu. Combined, the findings indicate potential topics for future clinical research. Conditions difficult to treat such as pain, stress, mental health, fatigue and functional gastrointestinal symptoms and those highlighted by the medical sector as ‘major concern’ for Australia’s burden of disease are especially indicated [24]. However, whilst national clinical priorities are important, focusing research on single conditions or symptoms runs the risk of missing simultaneous improvements in multiple clinical outcomes, along with positive health attributes such as wellness, disease prevention, self-efficacy and resilience [28–30]. Shiatsu therapy is a complex intervention that utilises a holistic, individualised approach [1,2,32–35]. The challenge of coding many of the open-ended responses from practitioners regarding commonly observed positive clinical outcomes into a single disease category or symptom, suggests that many shiatsu therapy outcomes are more holistic. Clinical researchers and evaluators of shiatsu research should therefore take heed of the recognised challenges with using the standard randomised control trial study design to evaluate complex interventions [34,36–39] for example, appropriate methodologies could included mixed methodology and outcome measures that are individualised, holistic and/or capture client experiences [38–40]. Other considerations for future clinical research include the reported long contact time with clients and an average of four treatment sessions at one to two-week intervals before a positive outcome was typically observed. This highlights the importance of piloting study designs to ensure the ‘dose’ (i.e. session time, frequency and duration) of the trial is sufficient to capture positive changes. Along with measuring direct clinical outcomes, future shiatsu research would also benefit from assessing other important outcomes including patient experiences, broader health service utilisation and economic cost analysis [36]. Finally, despite the proactive role that shiatsu practitioners are playing in the interdisciplinary healthcare of Australians, the relatively small size of the profession compared to other CM professions raises concerns about the future of shiatsu as a recognised, specialist manual therapy in Australia [41,42]. Further, at the time of this survey, there were only two DSOT courses on offer in Australia, both located in Melbourne, Victoria. This represents a dramatic decline over the past decade and is expected to narrow future practitioner distribution. The Australian
5
Government’s recent decision to remove shiatsu from taxsubsidised private health insurance rebates will likely contribute to this predicted decline in the practice of shiatsu. Interestingly, rebates will remain for massage, which currently comprises the largest CM workforce in Australia [25,26]. It remains unclear how these changes to funding policies and educational opportunities will impact the practice of shiatsu in Australia. Indeed, this signals a role for STAA in engaging with the broader massage therapy community to support the use of safe, high-quality traditional shiatsu massage techniques in Australia while maintaining the integrity of shiatsu as a specialist modality. The main limitations of this study reflect the sampling frame and response rates that in turn limit the generalisability of the results. While response rates from STAA members were adequate and likely representative, the number of non-STAA member participants helped improve external validity. However, the total number of shiatsu practitioners in Australia, and therefore the true representativeness of the sample, is unknown. Additionally, there was low or no representation from some states and territories. Caution with interpreting the practitioners’ responses about observed outcomes from shiatsu is also warranted due to the obvious problems with practitioner confirmation bias. Notwithstanding these limitations, the results remain informative and are the first of their kind for Australia. 5. Conclusion This cross-sectional, national survey provides vital information on the profile of shiatsu practitioners and their clinical practice in Australia. Shiatsu practitioners appear to be contributing to the health and wellbeing of a wide range of clients with various clinical conditions and symptoms including those highlighted by the medical sector as ‘major concern’ for Australia’s disease burden. The paucity of clinical and workforce research in Australia signals the need to evaluate the efficacy and cost-effectiveness of shiatsu and its potential value to clients and health services. Relevant topics for clinical research include pain, stress, fatigue, multimorbidity, preventive care, and wellbeing. Patient experiences, holistic outcomes and economic outcomes warrant evaluation. Workforce research could explore why people choose to study shiatsu, their training opportunities and employment pathways, how shiatsu practitioners collaborate with other healthcare practitioners and their role in providing coordinated, integrative medicine services in Australia. Author Contributions Emma Strapps and Jennifer Hunter designed the research project and lead the analysis of the results. Emma Strapps and Dorothy Douglas were responsible for overall project management. Paul Spence provided statistical analysis support. All authors contributed to writing the manuscript and approved the final version. Funding Research assistance provided by Emma Strapps was partially funded by STAA via its research support stream. In kind support was provided by STAA and member volunteer contributions. Ethical statement 1) This material has not been published in whole or in part elsewhere; 2) The manuscript is not currently being considered for publication in another journal;
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3) All authors have been personally and actively involved in substantive work leading to the manuscript, and will hold themselves jointly and individually responsible for its content.
Declaration of Competing Interest All authors are STAA Research Committee volunteers. Emma Strapps is a shiatsu practitioner and Director of Research and Development for STAA. Dorothy Douglas is a shiatsu practitioner and President of STAA. Paul Spence is a qualified shiatsu practitioner. Jennifer Hunter is a qualified shiatsu practitioner, integrative medicine primary care clinician and academic researcher with NICM Health Research Institute, Western Sydney University and the Menzies Centre for Health Policy, University of Sydney. As a medical research institute, NICM receives research grants and donations from foundations, universities, government agencies, individuals and industry. Sponsors and donors provide untied funding for work to advance the vision and mission of NICM. The project that is the subject of this article was not undertaken as part of a contractual relationship with any donor or sponsor. Acknowledgements We acknowledge support from the STAA National Council and the STAA Research Committee. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.aimed.2019. 07.003. References [1] C. Beresford-Cooke, Shiatsu; Theory and Practice, 2 ed., Elsevier Science Ltd., UK, 2003. [2] P. Lundberg, The Book of Shiatsu, Gaia Books Ltd., UK, 1992. [3] S. Dexter, Hiroko Urakawa Pointers Journal, Spring, Australia, 2007, pp. 12–14 2007. [4] Shiatsu Therapy Association of Australia (2017) https://www.staa.org.au/ About (Accessed 19 September 2018). [5] https://training.gov.au/Training/Details/HLT52215 (Accessed 19 September 2018). [6] S. Masunaga, W. Ohashi, Zen Shiatsu: How to Harmonise Yin and Yang for Better Health, Japan Publications, Japan, 1989. [7] T. Namikoshi, The Complete Book of Shiatsu Therapy, Japan Publications, Japan, 1994. [8] HLT52215 SHU006 Provide shiatsu therapy treatments. https://training.gov. au/Training/Details/HLTSHU006 (Accessed 4 May 2019). [9] HLT52215 SHU005 Perform oriental therapies health assessments. https:// training.gov.au/Training/Details/HLTSHU005 (Accessed 4 May 2019). [10] HLT52215 SHU007 Provide oriental therapies treatments. https://training.gov. au/Training/Details/HLTSHU007 (Accessed 4 May 2019). [11] M. Ellis, The ‘Life Gate’: Thoughts on Heat, Pointers Spring, Australia, 2017, pp. 19–23 (Accessed 4 May 2019). [12] M. Ellis, The Fluid Nature of Qi, Pointers Spring, Australia, 2018, pp. 4–8. [13] M. Ellis, Flesh and Blood: the Three Treasures in the Exterior, Pointers Spring, Australia, 2015, pp. 6–12. [14] B. Palmer, Muscles Have Feelings Too, Pointers Spring, Australia, 2015, pp. 13–16. [15] Zen Imagery, Exercises: Meridian Exercises for Wholesome Living, Masunaga S, Japan Publications, 1989.
[16] M. Webster, An Evolving Case Study on Low Back Pain, Pointers Spring, Australia, 2014, pp. 13–17. [17] W. Wilson, Assessing and Treating Digestive and Breathing Problems, Pointers Spring, Australia, 2017, pp. 24–26. [18] G. Yardley, Chronic Neck Pain: Case Study, Pointers Spring, Australia, 2015, pp. 34–36. [19] Hashimoto K (M.D.) & Oshawa G. (1981) Sotai: Natural Exercise Macrobiotic Foundation, U.S. [20] SurveyMonkey Inc., San Mateo, California, USA, www.surveymonkey.com. [21] Microsoft Excel, Microsoft Co., Washington, United States. https://www. microsoft.com/en-au. [22] IBM SPSS Statistics for Windows, Version 25.0. (Released 2017). IBM Corp. Armonk, NY: IBM Corp. https://www.ibm.com.SPSS/Versions. [23] National Statement on Ethical Conduct in Human Research 2007 (updated 2018) reference number E72, ISBN: 1864962755 https://nhmrc.gov.au/aboutus/publications/national-statement-ethical-conduct-human-research-2007updated-2018 (Accessed 22/1/16 and 25/2/19). [24] Australian Institute of Health and Welfare, Australia’s Health 2018: in Brief. Cat. no: AUS 222 p. 56 https://www.aihw.gov.au/reports/australias-health/ australias-health-2018/contents/table-of-contents (Accessed 2 September 2018), (2018) . [25] M. Leach, Profile of the complementary and alternative medicine workforce across Australia, New Zealand, Canada, United States and United Kingdom, Complement. Ther. Med. J. 21 (2013) 364–378. [26] A. Steel, et al., The Australian complementary medicine workforce: a profile of 1,306 practitioners from the PRACI study, J. Altern. Complement. Med. 24 (4) (2018). [27] A.F. Long, The Effects and Experience of Shiatsu: A Cross-European Study, Leeds: University of Leeds, School of Healthcare, 2007. [28] J. Hunter, K. Corcoran, S. Leeder, K. Phelps, Integrative medicine outcomes: what should we measure? Complement. Ther. Clin. Pract. 19 (1) (2013) 20–26 2013. [29] J. Hunter, J. Marshall, K. Corcoran, S. Leeder, K. Phelps, A positive concept of health – interviews with patients and practitioners in an integrative medicine clinic, Complement. Ther. Clin. Pract. 19 (4) (2013) 197–203 2013. [30] Koithan, et al., The process of whole person healing: “unstuckness” and beyond, J. Altern. Complement. Med. 13 (6) (2007) 659–668. [31] G. Freeman, et al., Evolving general practice consultation in Britain: issues of length and context, BMJ (2002), doi:http://dx.doi.org/10.1136/ bmj.324.7342.880. [32] N. Robinson, A. Lorenc, X. Liao, The evidence for Shiatsu: a systematic review of Shiatsu and acupressure, BMC Complement. Altern. Med. 11 (88) (2011). [33] V. Villani, et al., Single blind, randomized, pilot study combining shiatsu and amitriptyline in refractor primary headaches, Neurol. Sci. 38 (6) (2017) 999– 1007, doi:http://dx.doi.org/10.1007/s10072-017-2888-7. [34] Browne, et al., Relieving pressure – an evaluation of Shiatsu treatments for cancer & palliative care patients in an NHS setting, Eur. J. Integr. Med. 21 (2018) 27–33, doi:http://dx.doi.org/10.1016/j.eujim.2018.06.002. [35] S. Tsiormpatzis, Safety and risks of shiatsu: protocol for a systematic review, Eur. J. Integr. Med. (2019), doi:http://dx.doi.org/10.1016/j.eujim.2019.03.006. [36] D. Pach, et al., Effectiveness and cost-effectiveness of Tuina for chronic neck pain: a randomized controlled trial comparing Tuina with a no-intervention waiting list, J. Altern. Complement. Med. 24 (Mar (3)) (2018) 231–237, doi: http://dx.doi.org/10.1089/acm.2017.0209 2018. [37] S. Yuan, et al., Effects of shiatsu in the management of Fibromyalgia symptoms: a controlled pilot study, J. Manipulative Physiol. Ther. 36 (7) (2013) 436–443, doi:http://dx.doi.org/10.1016/j.jmpt.2013.05.019. [38] Boutron, et al., Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration, Ann. Intern. Med. 148 (4) (2008) 295–309. [39] N. Munk, K. Boulanger, Adaptation of the CARE guidelines for therapeutic massage and bodywork publications: efforts to improve the impact of case reports, Int. J. Ther (2014) Massage Bodyw v.7(3) PMID: 25184013. [40] C. Paterson, N. Britten, Acupuncture as a complex intervention: a holistic model, J. Altern. Complement. Med. 10 (5) (2004) 791–801, doi:http://dx.doi. org/10.1089/acm.2004.10.791 (Accessed 6 February 2019). [41] Complementary Health Industry Reference Committee Industry Skills Forecast (2017) https://www.skillsiq.com.au/site/DefaultSite/filesystem/documents/ Industry-Skills-Forecasts-June2017/Complementary%20Health%20IRC% 20Industry%20Skills%20Forecast_April2017%20Refresh.pdf (Accessed 23 November 2018). [42] Australian Bureau of Statistics. Complementary Therapies http://www.abs. gov.au/AUSSTATS/[email protected]/Lookup/4102.0Chapter5202008 (Accessed 16 September 2018).
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Contents lists available at ScienceDirect
Advances in Integrative Medicine journal homepage: www.elsevier.com/locate/aimed
Practicing shiatsu in Australia: A workforce survey Emma Strappsa,* , Jennifer Huntera,b,c, Dorothy Douglasa , Paul Spencea a
Shiatsu Therapy Association of Australia, Bendigo, Victoria, Australia National Insititute of Complementary Medicine Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia c Menzies Centre for Health Policy, University of Sydney, New South Wales, Australia b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 March 2019 Received in revised form 1 July 2019 Accepted 27 July 2019 Available online xxx
Background: Shiatsu is an under-represented modality within complementary medicine (CM) research. No previous data has been collected on the shiatsu workforce in Australia. Objectives: This study aimed to characterise shiatsu practitioners in Australia and their clinical practice with the view of informing clinical research. Methods: In 2016, a 32-question on-line cross-sectional survey was advertised to shiatsu practitioners on the Shiatsu Therapy Association of Australia’s (STAA) mailing list and through other professional associations. Descriptive statistics were used to analyse the data. Results: Of the 121 respondents 70.3% (n = 85) were female, the median age was 48 years and 74.4% (n = 90) were STAA members. The median number of years in practice was ten. Most were self-employed (93.3%, n = 112/120) working less than 20 h per week (82.1%, n = 92/120) in a variety of settings, most commonly solo practice (76%, n = 91/120) followed by group practices alongside other shiatsu practitioners, allied health or medical doctors (53.3%, n = 64/120). Practitioners reported typically spending over an hour of contact time with a broad range of clients who often had multiple healthcare needs, including those incurring a high burden of disease such as chronic pain and mental health. The top four symptoms/conditions that practitioners reported improved outcomes were pain/musculoskeletal (40.6%, n = 128/315), mental health/wellbeing (26.0%, n = 82/315), fatigue (10.2%, n = 31/315) and gastrointestinal (6.3%, n = 20/315). On average, a positive effect was reportedly observed following four treatments at 1–2 week intervals. Almost two thirds (63.2%, n = 67/106) of practitioners reported regularly referring their clients to other health professionals. Conclusions: Results from the first national workforce survey of shiatsu practitioners in Australia suggest Shiatsu practitioners are engaging in the shared care of their clients’ health and wellbeing, including referrals or recommendations to other healthcare practitioners. Practitioner characteristics generally align with those reported for the broader field of CM in Australia and shiatsu practitioners in Western Europe. Reported positive outcomes for chronic diseases and common yet difficult-to-treat symptoms signal areas for future clinical research. © 2019 Elsevier Ltd. All rights reserved.
Keywords: Shiatsu Complementary medicine Workforce Survey Massage Acupressure Whole system Holistic healthcare
What is already known about the topic
What this paper adds
There have been several workforce surveys undertaken and reported on CM modalities, including ‘massage therapy’, in Australia in the last 10 years with statistical information on personal characteristics, employment characteristics and types of clinical expertise or special interest.
However none have focused specifically on shiatsu therapy and little is known about this relatively small workforce in relation to the broader manual touch therapy field working in Australia.
* Corresponding author at: Shiatsu Therapy Association of Australia, P.O. Box 727, Bendigo, Victoria, 3552, Australia. E-mail addresses: [email protected] (E. Strapps), [email protected] (J. Hunter), [email protected] (D. Douglas), [email protected] (P. Spence).
1. Introduction The practice of shiatsu has, to date, received little academic attention in Australia and internationally. In response to a perceived need for data specific to the Australian shiatsu workforce, in 2016, the Shiatsu Therapy Association of Australia (STAA) initiated a workforce survey aimed to establish baseline information about practitioner demographics, workplace conditions and client demographics. It also aimed to identify commonly presented symptoms or conditions
https://doi.org/10.1016/j.aimed.2019.07.003 2212-9588/© 2019 Elsevier Ltd. All rights reserved.
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that practitioners ‘observed’ as responding positively to shiatsu for the purpose of further investigation. Shiatsu [1,2] has been practiced in Australia for more than 45 years when Japanese sisters, Michiyo and Hiroko Urakawa started their practice in Melbourne in 1973 [3]. The profession is selfregulated, however, STAA was established in 1987 to uphold professional standards of training and practice [4]. In 1990 training in Australia became standardised and endorsed by the Australian Government within the Health Training Package as the Diploma of Shiatsu and Oriental Therapies (DSOT), currently HLT52215 [5]. The qualification competencies are based on the shiatsu technique of sustained and relaxed use of the weight of the body for treating tsubo, or acupressure points, and meridian systems as they are identified and interpreted via a number of shiatsu styles [1,2,6,7]. Theory encompasses philosophy and principles of shiatsu assessment and treatment [6,7,8,9], Traditional Chinese Medicine (TCM) theories [1,10,11,12,13] and Western anatomy and physiology [5]. Additional Oriental therapy techniques include tonification and sedation [1,14], corrective exercises [1,15], cupping [1], moxibustion [1,16] and recommendations to clients about selfcare, for example; suggestions for changes in diet and lifestyle, stretches and/or breathing techniques [17,18,19]. This training provides a foundation for the application of shiatsu therapy as a complex intervention, including client health history and assessment, treatment protocols and self-care recommendations and utilisation of additional Eastern therapies based interventions. 2. Methods 2.1. Study design A cross-sectional national survey of shiatsu practitioners working in Australia was conducted from 6 June to 17th July 2016.
membership database of past and present members (n = 309) was sent an email invitation with an electronic link and a request to forward the link to other shiatsu practitioners known to them. Shiatsu practitioner members of other relevant associations including; Australian Association of Massage Therapists (currently Massage and Myotherapy Australia), Association of Massage Therapists and Australian Traditional Medicine Society were also invited via their association’s newsletter or email with an electronic link. 2.4. Analysis Returned data was exported from SurveyMonkey1 [20] into Microsoft1 Excel1 [21] and IBM1 SPSS1 Statistics v25.0 [22]. Descriptive statistics were predominantly used with inferential explorative statistics determined a priori. The numbers of responses to each question were used as denominators for reporting percentages. Management of answers to open-ended questions about symptoms and conditions was by manual grouping, followed by a preliminary coding framework, review and agreement upon the final coding approach and analysis. 2.5. Human research ethics The survey was conducted in accordance with the National Statement on Ethical Conduct in Human Research (2007) guidelines [23] and approved by the STAA National Council. The boards of the collaborating practitioner Associations provided approval before advertising the survey to their members. All anonymous data is held securely according to the 2007 Human Research Ethical Conduct (HREC) protocol. 3. Results 3.1. Response and completion rates
2.2. Survey instrument A 32-item questionnaire was designed and developed, in consultation with STAA National Council, over 6 months (see Appendix 1: Survey Questions). The questionnaire was delivered online via SurveyMonkey1 [20], in paper format by return post to the STAA office, or via email. Three STAA members returned paper surveys. All survey data was de-identified prior to statistical analysis.
Eligible survey participants included 211 STAA members, 74% of which were female. A total of 121 surveys were returned, 118 via SurveyMonkey and 3 via email. Of these, 115 (95.0%) were complete. The survey response rate for eligible STAA members was 43% (n = 90). There was no statistically significant difference in gender between responder and non-responder STAA members (χ2 (1) = 0.851, p = 0.4). Response rates from other professional associations could not be calculated.
2.3. Sample and recruitment
3.2. Practitioner demographics
Eligible participants were shiatsu practitioners with a DSOT qualification or equivalent and living in Australia. The entire STAA
Table 1 summarises characteristics of the 121 respondents. The median age was 48 years (range: 25–71), 44% were older than 50
Table 1 Shiatsu practitioner characteristics (n = 119). Age (median)
Female
85 (71.4%)
Average years in clinical practice
48 years
(range: 25 – 71 years)
Male
34 (28.6%)
12
(SD 9.2)
Location Shiatsu training Shiatsu practice
ACT 0 1 (0.8%)
NSW 28 (23.5%) 31 (26.1%)
NT 3 (2.5%) 2 (1.6%)
SA 0 1 (0.8%)
QLD 5 (4.2%) 11 (9.2%)
TAS 0 3 (2.5%)
WA 0 0
Association Membershipc
AACMA 3 (2.5%)
ANF 6 (5.0%)
MMA 5 (4.2%)
STAA 90 (75.6%)
TMS 12 (10.1%)
Yoga Australia 12 (10.1%)
VIC 76 (63.8%) 68 (57.1%)
OTHER 7 (5.8%)a 1 (0.8%)b
OTHER 20 (16.8%)
ACT: Australian Capital Territory, NSW: New South Wales, NT: Northern Territory, SA: South Australia, TAS: Tasmania, WA: Western Australia, VIC: Victoria. a United Kingdom (n = 3), Canada (n = 1), Italy (n = 1), United States (n = 1). b All of Australia (n = 1). c More than one response allowed - AACMA: Australian Acupuncture and Chinese Medicine Association, ANF: Australian Nursing Federation, MMA: Massage and Myotherapy Australia, STAA: Shiatsu Therapy Association of Australia, TMS: Traditional Medicine Society, ‘other’ included: AAHTC: Australian Association of holistic and Transpersonal Counsellors, AHA: Australian Homeopathic Association, IICT: International Institute for Complementary Therapies, ISA: Independent Sporting Association, APS: Australian Psychological Society, Shiatsu Society (United Kingdom).
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and 2% younger than 30. The majority were female (70%, n = 85). The median number of years in practice was 10 (range: less than 1 year to 33 years). Training locations of respondents were mainly in Victoria (66.4%, n = 79/119), followed by New South Wales (21.8%, n = 26/ 119). Of the seven practitioners trained overseas, one studied in Japan. Victoria and New South Wales were where the majority continue to practice. Over one third of the 119 respondents practice in multiple suburb locations within a state (40%, n = 47) and one respondent stated they work across Australia. Most respondents (87%, n = 90/104) were STAA members and 54% (n = 56/104) were members of at least two of the 12 practitioner associations listed in Table 1. The Shiatsu Society in the United Kingdom was amongst ‘other’ professional Associations. 3.3. Workplace and employment Respondents practice in a variety of environments and employment conditions (Table 2), Most practitioners spent some time working in a solo practice setting (76%, n = 91/120), either in a solo clinical space, at home, in a mobile practice that could include home visits and corporate environments. A substantial proportion also work in a group setting alongside other practitioners or therapists (35.8%, n = 43/120). A further 21 practitioners (17.5%) only work in a group setting. In ten instances, shiatsu practitioners work alongside medical doctors in primary or secondary care settings. Other community settings included ‘specialised services for survivors of sexual assault or torture’, a ‘community hub’ and a ‘community house’. Two practitioners provided shiatsu in a teaching environment. Most respondents identified as ‘self-employed or subcontractor’ (93%, n = 112/120). Of the four who were employed, one had a formal contract with their employer. Those subcontracted or employed were either somewhat satisfied (72%, n = 13/18) or very satisfied with their employment arrangement (11%, n = 2/18). None reported being dissatisfied. Part-time employment was most common, with 84% (n = 98/ 117) of practitioners working 20 h or less per week. The maximum number of hours worked per week was 48 while the median was ten. This included time with clients (usually paid) and time spent on business administration, professional development and marketing (usually unpaid). The median reported time spent with a client was 75 min per session, ranging from 14 to 240 min.
Table 2 Workplace settings. N = 120
%
Solo Home or solo clinic room Mobile practice Corporate massage Hotel
91 83 40 8 1
75.8 69.2 33.3 6.7 0.8
Group Shiatsu practitioners only Shiatsu, other CM and/or allied health Including medical doctors Community organisation, hospital outpatient Hospital inpatient Day spa, bathhouse
64 8 52 9 8 1 8
53.3 6.7 43.3 7.5 6.7 0.8 6.7
Other Corporate events, festivals, markets Teaching / student clinic
7 4 2
6.7 3.3 1.7
CM – Complementary medicine practitioners.
3
3.4. Client demographics A series of broad categorical questions about client’s characteristics were asked. Around half (52%, n = 55/106) reported most of their clients were female, 46% (n = 49/106) consulted approximately equal numbers of males and females, and one reported their clients were mostly male. The most common reported client age group was 40–60 years old (78%, n = 83/106), followed by adults under 40 (59%, n = 63/106), adults over 60 (22%, n = 23/106), then children and teenagers (10%, n = 11/106). 3.5. Clinical areas of expertise or special interest A list of common conditions and demographic groups was provided with the option to nominate more than one area of clinical interest or expertise along with an open-ended answer (Table 3). Multiple conditions were identified by 98 (86.7%) of the 113 respondents. Five practitioners stated they considered themselves generalists with no particular area of expertise or interest. Conditions most commonly selected were stress/ relaxation/mental health (73.5%, n = 83/113), pain/musculoskeletal/rehabilitation (55.8%, n = 63/113), management of chronic health conditions (45.1%, n = 51/113) and women’s health (42.5%, n = 48/113). 3.6. Positive outcomes practitioners ‘observe’ following shiatsu Of the 121 respondents, 106 (87.5%) answered an open-ended question (See Appendix 1, Question 17) asking them to list up to three presenting symptoms or conditions where they commonly observe shiatsu therapy yielding positive results. The four symptoms or conditions most listed were: pain/musculoskeletal (40.6%, n = 128/315), followed by mental health/wellbeing (26.0%, Table 3 Clinical interest and commonly observed outcomes from shiatsu. Clinical Interests n = 113
n
%
Women’s health Men’s health Senior citizens Paediatrics Teenagers / youth
48 13 20 11 16
42.5 11.5 17.7 9.7 14.2
Chronic health conditions general cancer care disability care Pain, Musculoskeletal, Rehabilitation Stress, relaxation, mental health
51 41 21 12 63 83
45.1 36.3 18.6 10.6 55.8 73.5
Observed Positive Outcomes n = 315 outcomes, n = 106 respondents
n
%
Pain, Musculoskeletal back neck shoulder headache a Stress, Relaxation Mental health Insomnia, Improved sleep Energy, Fatigue Gastrointestinal Women’s health Other b
128 35 44 24 35 49 47 11 32 20 10 18
40.6 11.1 13.9 7.6 11.1 15.6 14.9 3.5 10.2 6.3 3.2 5.7
a Includes “headache & fatigue” (n = 6) that were coded as Energy, Fatigue; and “stress - headaches” (n = 2) that were coded as Stress, Relaxation. b Other: respiratory symptoms (n = 4); cancer (n = 2); fluid retention (n = 2).
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Table 4 Global summary statistics including all Conditions/Symptoms (1, 2, and 3).
Number of Treatments for a Positive Change Treatment Frequency (Weeks) Time to Observe Positive Change (Weeks)
Mean
Median
Std. Dev.
Min
Max
N
2.5 1.8 6.3
2.0 1.5 4.0
1.7 1.0 5.7
1.0 1.0 1.0
12.0 6.0 52.0
288 290 254
4. Discussion
n = 82/315), fatigue (10.2%, n = 31/315) and gastrointestinal (6.3%, n = 20/315) (Table 4). Where possible, practitioner responses were coded into categories and subcategories. However, this was not always straightforward as there were instances where information spanning more than one of the categories were listed. For example, commonly, terms such as relaxation, tension or stress were used when referring to physical relief (e.g. “stress - neck and shoulder tension”), mental/emotional relief (e.g. “stress/anxiety”), both (e.g. “relax in body and mind”) or it was not specified and a single word was listed (e.g. “stress”, “relaxation”, “tension”). As such, the decision was made to keep this as a separate category that included all instances where these concepts were mentioned. Insomnia/improved sleep was another example where the category was kept separate, as it was recognised that the causes of insomnia may be physical (e.g. obstructive apnoea), emotional (e.g. anxiety/depression) or behavioural (e.g. poor sleep habits, shift work). Therefore, whilst the most common symptom or condition listed was the pain/musculoskeletal category (40.6%, n = 128/315), this in part reflected the broader definition for this category. Following this question, respondents were asked to provide estimates of the number of shiatsu treatments typically required before a positive change is observed, the typical time interval between treatments, and the length of time typically required before a positive change is observed. Overall, respondents estimated the mean number of treatments required was 2.5 (median = 2), treatment frequency mean was 1.8 weeks (median = 1.5) and mean time to observe changes was 6.3 weeks (median = 4) (Table 4).
Significantly, this is the first national workforce survey of shiatsu practitioners in Australia. Results of the survey suggest shiatsu practitioners are engaged in the shared care of clients with service provision to a broad demographic with multiple healthcare needs, including those incurring a high burden of disease such as pain management and mental health [24]. The results provide baseline information about the shiatsu workforce in Australia, areas for development of training and employment pathways, and preliminary indications for the role of shiatsu in providing supportive care in both primary and secondary healthcare settings. Shiatsu practitioner demographics mostly aligned with other Australian CM practitioners reported by Leach (2013) [25] and Steel et al. (2018) [26]. Similarly, the reported demographics of shiatsu clients aligned with existing data about people using CM in Australia [25,26] and clients from Long’s European study [27]. However, a notable difference between shiatsu practitioners and other CM practitioners in Australia is the higher proportion of shiatsu practitioners working less than 20 h per week. The reasons for this are unclear and warrant further exploration regarding the implications for the workforce and future STAA career pathway planning. There was some evidence of shiatsu being provided in integrative medicine settings. Around half of the respondents reported working in multidisciplinary settings alongside other types of healthcare practitioners, with some working in hospital settings or alongside medical practitioners in primary care settings. Like other CM practitioners [26], it was not uncommon for shiatsu practitioners to hold more than one professional association membership including non-CM health professional memberships. This suggests some practitioners may be integrating shiatsu with other healthcare modalities. Other indicators of integrative practice included inter-professional referrals to and from shiatsu practitioners with a range of CM, allied health and medical/dental practitioners. How these referrals were made was not elicited. It is not known if these referrals were informal recommendations or accompanied by a handover, such as a referral letter. Importantly, given that many shiatsu clients will likely have medical conditions, this finding provides some reassurance that practitioners aim to practice within their scope and while many
3.7. Referrals to and from other healthcare practitioners Respondents reporting clients most often find them by word of mouth was 93% (n = 99/106). Also common were Internet advertising 46.2% (n = 49/106), the STAA website 20% (n = 21/ 106) and referrals from other healthcare practitioners 55.6% (n = 59/106). Practitioners also reported ‘occasionally’ (63.2%, n = 67/106) or ‘regularly’ (32.1%, n = 34/106) referring clients to a broad range of healthcare practitioners. Only 4.7% (n = 5/106) reported ‘never’ referring their clients. (Table 5) Table 5 Referrals to and from other healthcare practitioners. Practitioner type
Shiatsu practitioner Chinese medicine Natural therapist * Allied health Psychologist Medical practitioner Dentist Exercise instructor Other **
Shiatsu practitioners who receive referrals (n = 106)
Shiatsu practitioners who refer (n = 101)
n
%
N
%
30 20 27 19 10 13 0 0 0
28.3 18.9 25.5 17.9 9.4 12.3
0 73 47 51 49 58 10 54 9
0.0 72.3 46.5 50.5 48.5 57.4 9.9 53.5 8.9
More than one response allowed * Natural therapist includes naturopaths (n = 42), homeopaths (n = 14), and nutritionists or dieticians (n = 10) ** Other: Kinesiologist, Feldenkrais practitioner, Podiatrist, Meditation facilitator, Bush Flower remedies.
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practitioners often worked in solo-practice, there was evidence of inter-professional collaboration with other healthcare practitioners. Whilst patient experiences were not evaluated, the reported relatively long contact times with clients correlates with a growing body of evidence suggesting the healing process and experience of the client benefits from the time spent developing the clientpractitioner relationship [28–30] and is further highlighted by the following excerpt from a qualitative study in the UK that explored issues around length of consultation time in the primary care setting: “The systematic review consistently showed that doctors with longer consultation times prescribe less and offer more advice on lifestyle and other health promoting activities. Longer consultations have been significantly associated with better recognition and handling of psychosocial problems and with better patient enablement” [31]. Similarly, whilst the clinical outcomes of clients receiving shiatsu were also not evaluated, the areas of reported clinical interests and expertise closely aligned with the Western European survey of shiatsu practitioners [27], a wide range of Australian CM practitioners [26], and clinical research evaluating the effectiveness of shiatsu, oriental meridian massage and acupressure [32–35]. Not surprisingly, the most commonly reported areas of clinical expertise or special interest generally aligned with conditions and symptoms reported by practitioners as benefitting from shiatsu. Combined, the findings indicate potential topics for future clinical research. Conditions difficult to treat such as pain, stress, mental health, fatigue and functional gastrointestinal symptoms and those highlighted by the medical sector as ‘major concern’ for Australia’s burden of disease are especially indicated [24]. However, whilst national clinical priorities are important, focusing research on single conditions or symptoms runs the risk of missing simultaneous improvements in multiple clinical outcomes, along with positive health attributes such as wellness, disease prevention, self-efficacy and resilience [28–30]. Shiatsu therapy is a complex intervention that utilises a holistic, individualised approach [1,2,32–35]. The challenge of coding many of the open-ended responses from practitioners regarding commonly observed positive clinical outcomes into a single disease category or symptom, suggests that many shiatsu therapy outcomes are more holistic. Clinical researchers and evaluators of shiatsu research should therefore take heed of the recognised challenges with using the standard randomised control trial study design to evaluate complex interventions [34,36–39] for example, appropriate methodologies could included mixed methodology and outcome measures that are individualised, holistic and/or capture client experiences [38–40]. Other considerations for future clinical research include the reported long contact time with clients and an average of four treatment sessions at one to two-week intervals before a positive outcome was typically observed. This highlights the importance of piloting study designs to ensure the ‘dose’ (i.e. session time, frequency and duration) of the trial is sufficient to capture positive changes. Along with measuring direct clinical outcomes, future shiatsu research would also benefit from assessing other important outcomes including patient experiences, broader health service utilisation and economic cost analysis [36]. Finally, despite the proactive role that shiatsu practitioners are playing in the interdisciplinary healthcare of Australians, the relatively small size of the profession compared to other CM professions raises concerns about the future of shiatsu as a recognised, specialist manual therapy in Australia [41,42]. Further, at the time of this survey, there were only two DSOT courses on offer in Australia, both located in Melbourne, Victoria. This represents a dramatic decline over the past decade and is expected to narrow future practitioner distribution. The Australian
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Government’s recent decision to remove shiatsu from taxsubsidised private health insurance rebates will likely contribute to this predicted decline in the practice of shiatsu. Interestingly, rebates will remain for massage, which currently comprises the largest CM workforce in Australia [25,26]. It remains unclear how these changes to funding policies and educational opportunities will impact the practice of shiatsu in Australia. Indeed, this signals a role for STAA in engaging with the broader massage therapy community to support the use of safe, high-quality traditional shiatsu massage techniques in Australia while maintaining the integrity of shiatsu as a specialist modality. The main limitations of this study reflect the sampling frame and response rates that in turn limit the generalisability of the results. While response rates from STAA members were adequate and likely representative, the number of non-STAA member participants helped improve external validity. However, the total number of shiatsu practitioners in Australia, and therefore the true representativeness of the sample, is unknown. Additionally, there was low or no representation from some states and territories. Caution with interpreting the practitioners’ responses about observed outcomes from shiatsu is also warranted due to the obvious problems with practitioner confirmation bias. Notwithstanding these limitations, the results remain informative and are the first of their kind for Australia. 5. Conclusion This cross-sectional, national survey provides vital information on the profile of shiatsu practitioners and their clinical practice in Australia. Shiatsu practitioners appear to be contributing to the health and wellbeing of a wide range of clients with various clinical conditions and symptoms including those highlighted by the medical sector as ‘major concern’ for Australia’s disease burden. The paucity of clinical and workforce research in Australia signals the need to evaluate the efficacy and cost-effectiveness of shiatsu and its potential value to clients and health services. Relevant topics for clinical research include pain, stress, fatigue, multimorbidity, preventive care, and wellbeing. Patient experiences, holistic outcomes and economic outcomes warrant evaluation. Workforce research could explore why people choose to study shiatsu, their training opportunities and employment pathways, how shiatsu practitioners collaborate with other healthcare practitioners and their role in providing coordinated, integrative medicine services in Australia. Author Contributions Emma Strapps and Jennifer Hunter designed the research project and lead the analysis of the results. Emma Strapps and Dorothy Douglas were responsible for overall project management. Paul Spence provided statistical analysis support. All authors contributed to writing the manuscript and approved the final version. Funding Research assistance provided by Emma Strapps was partially funded by STAA via its research support stream. In kind support was provided by STAA and member volunteer contributions. Ethical statement 1) This material has not been published in whole or in part elsewhere; 2) The manuscript is not currently being considered for publication in another journal;
Please cite this article in press as: E. Strapps, et al., Practicing shiatsu in Australia: A workforce survey, Adv Integr Med (2019), https://doi.org/ 10.1016/j.aimed.2019.07.003
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3) All authors have been personally and actively involved in substantive work leading to the manuscript, and will hold themselves jointly and individually responsible for its content.
Declaration of Competing Interest All authors are STAA Research Committee volunteers. Emma Strapps is a shiatsu practitioner and Director of Research and Development for STAA. Dorothy Douglas is a shiatsu practitioner and President of STAA. Paul Spence is a qualified shiatsu practitioner. Jennifer Hunter is a qualified shiatsu practitioner, integrative medicine primary care clinician and academic researcher with NICM Health Research Institute, Western Sydney University and the Menzies Centre for Health Policy, University of Sydney. As a medical research institute, NICM receives research grants and donations from foundations, universities, government agencies, individuals and industry. Sponsors and donors provide untied funding for work to advance the vision and mission of NICM. The project that is the subject of this article was not undertaken as part of a contractual relationship with any donor or sponsor. Acknowledgements We acknowledge support from the STAA National Council and the STAA Research Committee. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.aimed.2019. 07.003. References [1] C. Beresford-Cooke, Shiatsu; Theory and Practice, 2 ed., Elsevier Science Ltd., UK, 2003. [2] P. Lundberg, The Book of Shiatsu, Gaia Books Ltd., UK, 1992. [3] S. Dexter, Hiroko Urakawa Pointers Journal, Spring, Australia, 2007, pp. 12–14 2007. [4] Shiatsu Therapy Association of Australia (2017) https://www.staa.org.au/ About (Accessed 19 September 2018). [5] https://training.gov.au/Training/Details/HLT52215 (Accessed 19 September 2018). [6] S. Masunaga, W. Ohashi, Zen Shiatsu: How to Harmonise Yin and Yang for Better Health, Japan Publications, Japan, 1989. [7] T. Namikoshi, The Complete Book of Shiatsu Therapy, Japan Publications, Japan, 1994. [8] HLT52215 SHU006 Provide shiatsu therapy treatments. https://training.gov. au/Training/Details/HLTSHU006 (Accessed 4 May 2019). [9] HLT52215 SHU005 Perform oriental therapies health assessments. https:// training.gov.au/Training/Details/HLTSHU005 (Accessed 4 May 2019). [10] HLT52215 SHU007 Provide oriental therapies treatments. https://training.gov. au/Training/Details/HLTSHU007 (Accessed 4 May 2019). [11] M. Ellis, The ‘Life Gate’: Thoughts on Heat, Pointers Spring, Australia, 2017, pp. 19–23 (Accessed 4 May 2019). [12] M. Ellis, The Fluid Nature of Qi, Pointers Spring, Australia, 2018, pp. 4–8. [13] M. Ellis, Flesh and Blood: the Three Treasures in the Exterior, Pointers Spring, Australia, 2015, pp. 6–12. [14] B. Palmer, Muscles Have Feelings Too, Pointers Spring, Australia, 2015, pp. 13–16. [15] Zen Imagery, Exercises: Meridian Exercises for Wholesome Living, Masunaga S, Japan Publications, 1989.
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Please cite this article in press as: E. Strapps, et al., Practicing shiatsu in Australia: A workforce survey, Adv Integr Med (2019), https://doi.org/ 10.1016/j.aimed.2019.07.003