Essentials of Complementary and Alternative Medicine (June 1999)

O
THER
 I
NDICATIONS
Massage has demonstrated effects on a number of other conditions that physicians and other health care practitioners may want to consider. These include use in the 
intensive care unit for stress and pain management (
22
); prevention of perineal trauma during childbirth (
23
); pressure ulcers (
24
); low back pain (
25
); muscle 
soreness from exercise (
26
), (
27
), (
28
), (
29
); cancer pain (
30
); and to improve maternal–infant bonding (
31
).
These are some areas of improved function noted following massage therapy. In addition to each clinical condition being marked by unique changes, there was also a 
set of common findings. Across most of the studies, decreases were noted in anxiety, depression, and stress hormones (cortisol and catecholamines). Increased 
parasympathetic activity may be the underlying mechanism for these changes. The pressure stimulation associated with touch increases vagal activity, which in turn 
lowers physiological arousal and stress hormones (cortisol levels). The amount of pressure is critical because light stroking is generally aversive, much like a tickle 
stimulus. Decreased cortisol levels lead to enhanced immune function. Parasympathetic activity is also associated with increased alertness and better performance on 
cognitive tasks. Given that most diseases are exacerbated by stress and given that massage therapy alleviates stress, receiving massages should probably be ranked 

with diet and exercise on any list of health priorities, as it was in India around 1800 
BC
.
Major Contraindications
Some massage therapists have warned of contraindications for massage (
1
). There is little research examining particular contraindications. These contraindications 
include the following:
1. Infectious or contagious skin conditions. There is concern that massage may spread the infection from the infected area to other parts of the body as well as 
to the therapist.
2. High fever. Massage therapy may further increase body temperature.
3. Scar tissue, open wounds, and burn areas. Massaging is contraindicated with new wounds because the healing tissue is fragile. This might be qualified by 
the recency of the scar tissue because burn areas can benefit from massaging with cocoa butter to reduce itching.
4. Varicose veins or phlebitis. There is the possibility that a dislodged blood clot might result in pulmonary embolus, but no systematic research or case reports 
have examined this.
5. Tumors and infected lymph nodes. Massage therapy may cause metastases by loosening cells from tumors. It is advisable not to directly massage a tumor, 
although it is unlikely that massage would cause cells to break off any more than they would from daily exercise. However, most cancer treatments contribute to 
skin sensitivity, and patients receiving chemotherapy often feel too sick to be touched.
6. Low platelet count. Rigorous massage may cause bruising.
ORGANIZATION AND TRAINING
Currently, there is considerable variability from school to school regarding training standards and from state to state regarding licensing standards. Training 
requirements vary—from providing specialized training as a certification program for already-licensed professionals (e.g., nurses) to extensive programs designed to 
be professional degrees. Some states have extensive licensing requirements, whereas other state legislatures have been lobbied by professional groups to prevent 
the licensure of massage therapists. National organizations do not agree on standards: some suggest licensing is a minimal standard and others suggest not requiring 
licensure. Although massage therapy has been practiced since before recorded time, the standards and professional activities of the field are in their infancy and 
need further development. See 
Chapter 2
 for states that license massage therapists.
PROSPECTS FOR THE FUTURE
Massage therapy appears to have common positive effects on many clinical conditions. These effects seem to involve facilitating parasympathetic activity, leading to 
more organized physiology, lower stress hormones, and enhanced immune function. In addition, increased parasympathetic activity enables greater alertness and 
improved cognitive performance. Finally, measures of several clinical conditions appear to be affected; for example, reduced glucose levels in diabetes and improved 
pulmonary function in asthma. These changes may also result from increased parasympathetic activity and reduced stress hormones.
Further research is needed not only for replication purposes, but also for investigation of associated disease processes. In addition, research is needed on those 
conditions massage therapists have cautiously labeled contraindications. Finally, cost-benefit analyses are needed to help justify further support for research and 
efforts to convince insurance companies and health maintenance organizations that massage therapy should be covered. An example of the cost-effectiveness of 
massage therapy taken from our research is that $4.7 billion in medical costs could be saved yearly if all prematurely born infants were massaged. That figure was 
derived from 470,000 infants born prematurely each year being massaged and discharged 6 days early (as they were in a study [
32
] at a hospital cost savings of 
$10,000 per infant). Further, the massage program could be offered by senior citizen volunteers, who would also benefit both health- and cost-wise. In the study in 
which we used senior citizen volunteers as the massage therapists for the infants, the senior citizen therapists had lower stress hormones and fewer trips to the 
doctor's office following 1 month of massaging infants (
20
). Similar cost-effectiveness figures are likely to emerge for other conditions because they too benefit 
significantly from the stress reduction effects of massage therapy.
The token level of research funding currently provided by the massage therapy professional societies and the federal government will not support adequately 
designed research protocols. Until respectable funding levels are achieved for the field of massage therapy, it will remain alternative. Tremendous potential exists for 
massage therapy, however, and realization of this potential will contribute to improved health and reduced costs for many.
C
HAPTER
 R
EFERENCES
1.
Hollis N. Massage for therapists. Oxford: Blackwell, 1987.
2.
Beck M. The theory and practice of therapeutic massage. New York: Milady, 1988.
3.
Chaitow LJ. Soft tissue manipulation. Wellingborough: Thorsons, 1988.
4.
Field T. Touch in early development. Hillsdale, NJ: Lawrence Erlbaum Associates, 1995.
5.
Lidell L. The book of massage: the complete step by step guide to eastern, western techniques. London: Ebury, 1984.
6.
Maxwell-Hudson C. A complete book of massage. London: Doiling-Kindersley, 1988.
7.
Ironson G, Field T, Scafidi F, et al. Massage therapy is associated with enhancement of the immune systems cytotoxic capacity. Int J Neurosci 1996;84:205–218.
8.
Field T, Ironson G, Pickens J, et al. Massage therapy reduces anxiety and enhances EEG pattern of alertness and math computations. Int J Neurosci 1996;86:197–205.
9.
Field T, Morrow C, Valdeon C, et al. Massage reduces anxiety in child and adolescent psychiatric patients. J Am Acad Child Adolesc Psychiatry 1992;31:124–131.
10.
Field T, Henteleff T, Hernandez-Reif M, et al. Children with asthma have improved pulmonary function after massage therapy. J Pediatr 1998;132:854–858.
11.
Field T, Hernandez-Reif M, LaGreca A, et al. Glucose levels decreased after giving massage therapy to children with diabetes mellitus. Spectrum 1997;10:23–25.
12.
Field T, Schanberg SM, Scafidi F, et al. Tactile/kinesthetic stimulation effects on preterm neonates. Pediatrics 1986;77:654–658.
13.
Older J. Touching is healing. New York: Stein and Day, 1982:86
14.
Field T, Hernandez-Reif M, Taylor S, et al. Labor pain is reduced by massage therapy. J Psychosom Obstet Gynecol 1997;18:286–291
15.
Field T, Peck M, Krugman S, et al. Massage therapy effects on burn patients. J Burn Care Rehabilitation 1998;19:241–244
16.
Sunshine W, Field T, Schanberg S, et al. Massage therapy and transcutaneous electrical stimulation effects on fibromyalgia. J Clin Rheumatol 1996; 2:18–22
17.
Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150:971–978
18.
Field T, Schanberg S, Kuhn C, et al. Bulimic adolescents benefit from massage therapy. Adolescence 1998. In press
19.
Field T, Sunshine W, Hernandez-Reif M, et al. Chronic fatigue syndrome: massage therapy effects on depression and somatic symptoms in chronic fatigue syndrome. J Chronic Fat Syn 
1997;3:43–51
20.
Field T, Hernandez-Reif M, Quintino O, et al. Elder retired volunteers benefit from giving massage therapy to infants. J Appl Gerontol 1998;17:229–239
21.
Jones N, Field T, Davalos M. Massage attenuates right frontal EEG assymetry in one-month-old infants of depressed mothers. Infant Beh Devel 1998 (in press)
22.
Dunn C, Sleep J, Collett D. Sensing an improvement: an experimental study to evaluate the use of aromatherapy, massage, and periods of rest in an intensive care unit. J Adv Nurs 
1995;21:34–40
23.
Labrecque M, Marcoux S, Pinault JJ, et al. Prevention of perineal trauma by perineal massage during pregnancy: a pilot study. Birth 1994;21:20–25
24.
Olson B. Effects of massage for prevention of pressure ulcers. Decubitus 1989;2:32–37
25.
Pope MH, Phillips RB, Haugh LD, et al. A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute 
low back pain. Spine 1994;19:2571–2577
26.
Rodenburg JB, Steenbeek D, Schiereck P, et al. Warm-up, stretching and massage diminish harmful effects of eccentric exercise. Int J Sports Med 1994;15:414–419
27.
Smith LL, Keating MN, Holbert D, et al. The effects of athletic massage on delayed onset muscle soreness, creatine kinase, and neutrophil count: a preliminary report. J Orthop Sports Phys 
Ther 1994;19:93–99
28.
Viitasalo JT, Niemela K, Kaappola R, et al. Warm underwater water-jet massage improves recovery from intense physical exercise. Eur J Appl Physiol 1995;71:431–438
29.
Weber MD, Servedio FJ, Woodall WR. The effects of three modalities on delayed onset muscle soreness. J Orthop Sports Phys Ther 1994;20:236–242
30.
Weinrich SP, Weinrich MC. The effect of massage on pain in cancer patients. Appl Nurs Res 1990;3:140–145
31.
White-Traut RC, Nelson MN. Maternally administered tactile, auditory, visual, and vestibular stimulation: relationship to later interactions between mothers and premature infants. Res Nurs 
Health 1988;11:31–39
32.
Field T, Schanberg S, Cafidi F, et al. Tactile/kinesthetic stimulation effects on preterm neonates. Pediatrics 1986;77:654–658.

CHAPTER 23. Q
IGONG
Essentials of Complementary and Alternative Medicine
CHAPTER 23. Q
IGONG
Ching-Tse Lee and Ting Lei
Background
 
Definition
 
History and Development
Principal Concepts
 
Assumption about Nature and Mankind
 
Pathogenesis and Etiology
 
Diagnosis
 
Therapy
Provider–Patient Interaction
 
Patient-Assessment Procedures
 
Differential Diagnosis
Therapy and Outcomes
 
Treatment Patterns
 
Treatment Options
 
Description of Treatments/Interventions with Case Examples
 
Treatment Evaluation
Use of the System for Treatment
 
Major Indications Based on Approach
Organization
 
Training
 
Quality Assurance
 
Reimbursement Status
 
Relation with Conventional Medicine
Prospects for the Future
Chapter References
“With Regard to Chi Circulation: If it is deep, it is stored; if it is stored, it is extended; if it is extended, it can move downward; if it moves downward, it can be fixed; if it 
is fixed, it can be consolidated; if it is consolidated, it can sprout.”
—From an ancient script carved on a jade ornament more than 2000 years ago
BACKGROUND
Definition
Qigong is a major branch of Traditional Chinese medicine (TCM). It is a generic term used to denote methods used to cultivate, regulate, and harness  chi (vital 
energy) for general self-preservation and health, healing, self-defense, longevity, and, particularly, spiritual development.  Chi means vital energy and gong means 
function, or work; thus, qigong literally means the function of chi. The theoretical background of qigong is deeply rooted in classical Chinese cosmology, which views 
the human being as a microcosmic energy system synergistically embedded in the macrocosm (e.g., the ecological environment). These micro- and macrocosms 
constitute a unified energy field, and energy is constantly interchanged between them based on the operational principle of homeostasis. From TCM's point of view, 
how to maintain chi homeostasis is the modus vivendi for health, and how to attain it at a higher level is the  modus operandi of healing.
As far as healing is concerned, beneficial effects can be achieved by the following:
1. Applying the extrinsic chi (the vital energy transmitted from other people) and/or infusing healers'  intrinsic chi (the vital energy generated by the practitioner) to 
restore the patient's energy to a healthy state.
2. Performing movement-oriented qigong to direct and speed up intrinsic  chi flow through the ailed areas.
3. Mobilizing the power of the mind (intention/imagination/visualization) to move internal  chi through the blocked areas.
4. Practicing meditation to allow the energy to perform its natural health and healing function.
Dynamic and meditative qigong exercises that generate and preserve energy also strengthen the body, mind, and spirit and prevent diseases (
1
). For health or 
healing, qigong is holistic by engaging mind, body, and spirit in  chi cultivation. As such, qigong exercises are neither merely body movements nor relaxation 
responses per se. Rather, an altered state of consciousness and an action consciousness may be aroused while performing meditative-oriented and 
movement-oriented qigong exercises, respectively. Given the human organism as a homeostatic system, these two forms of consciousness provide feedback for 
self-regulation (
2
). Furthermore, qigong operating on the spiritual dimension entails transcendental consciousness that engages the practitioner to interact with the 
environment at a higher level, which may facilitate the healing process (
3
).
History and Development
An archaeological finding of a porcelain vase with a drawing of a human figure holding a seemingly meditative qigong posture shows that qigong was performed 
approximately 5000 years ago. The word  chi first appeared in inscriptions carved on bones and tortoise shells that have been dated back three millennia. Although we 
now realize the effects of ecological factors on health and illness, the basic understanding of the etiology of human illness during this period was shamanic in nature.
The theoretic foundations of currently practiced TCM are primarily based on  The Yellow Emperor's Classic of Internal Medicine, which made sketchy references to 
qigong healing (
4
). The excavation of the tomb (Mawangtui, Chinese for a feudal king's graveyard) of an officer from the first century 
BC
 provided the missing link of 
this important branch of Chinese healing arts. Among the excavated materials most pertinent to health and healing are scrolls of 44 drawings of qigong postures, with 
short commentaries and a collection of medical texts that preceded similar material found in  The Yellow Emperor's Classic of Internal Medicine (
5
). The chi and 
meridian theories recorded in these texts are basically the same as those of contemporary TCM. Detailed analyses of these materials indicate that qigong was an 
integral part of the healing arts at that time. The drawings found in this tomb are the most comprehensive documents of the ancient qigong exercises ever recovered.
These ancient exercises can be divided into three categories. The first group, designed for health promotion, included some animal forms, such as the bear, bird, and 
monkey. The second group depicted breathing exercises to use extrinsic energy for health and healing purposes. The third group included movement forms 
specifically designed for healing. Patients performed these exercises to guide and facilitate  chi circulation in various parts of the body, thereby eliminating pains and 
ameliorating disease.
The development of the qigong healing arts in TCM history followed two major paths. The first path refers to the tradition of self-healing style of qigong (SHQ, or 
internal gigong), including movement-oriented qigong, meditation-oriented qigong, and breathing exercise-oriented qigong. The second path, which refers to healing 
provided by qigong practitioners (external qigong), arrived during the modern era. The development of these two branches of qigong is described briefly in the 
following subsections.
S
ELF
-H
EALING
 S
TYLE OF
 Q
IGONG

Movement-Oriented Qigong
This form of qigong first appeared as simple body movements performed by individuals to facilitate energy circulation and healing. It gradually evolved into dancelike 
sequences of qigong movements, such as Tai chi chuan (
6
), wild goose (
7
), and soaring crane qigong (
8
). These gentle, supple, and slow movements channel energy 
through the blocked and stagnated areas, thus eliminating discomfort in the affected areas and restoring the normal physiological functions.
Meditation-Oriented Qigong
In contrast to movement-oriented qigong, meditation-oriented qigong stresses inner serenity, control of one's own microcosmic energy, and a connection with the 
macrocosmic energy system. This modality is performed in a sitting, standing, or sleeping position. Body movement is kept to a minimum so that it does not disrupt the 
working of the mind. The major emphasis of this modality is to restore the homeostasis of the energy system through harmonizing  yin and yang energy, clearing the 
obstruction in energy circulation, and obtaining an optimal amount of energy through meditation. The theoretical foundation of this practice can be traced back to 
I-Ching and Lao-tzu (
9
), both of which referred to chi. Meditative qigong is implied in some of the passages of these works. Following the path of Lao-tzu, Chuan-tzu 
expanded the delineation of  chi to include the chi generated by breathing. In so doing, references were made to breathing qigong exercises as well as to meditation, 
relaxation techniques, and massage.
The curative effects of meditation qigong became known in modern China after Chiang (
10
) published a book describing his own experiences with meditation. Chiang 
claimed to have completely cured himself of tuberculosis and of the related internal hemorrhage with meditation. He experienced energy circulation in both the 
governing meridian and conception meridian, which are located in the midline of the front and the back of the body—the so-called microcosmic orbit circulation.
Breathing-Oriented Qigong
Because fresh air has long been considered a source of vital energy, breathing exercises were designed to increase energy levels, strengthen various vital organs, 
and expel the sick chi. Breathing exercises were practiced by ancient sages. For the purpose of strengthening and invigorating energy, one should practice daily 
breathing exercises, preferably in the morning hours. For healing purposes, the overnight stagnated  chi should be intentionally exhaled in a prolonged manner to 
expel the sick chi, and then the morning fresh air should be wholeheartedly inhaled and stored in the body. This should be done several times a day and for as long 
as it takes to store sufficient energy in the body. Then, and only then, can the individual attempt to use his or her  intention to move the stored energy to attack the 
illness.
The practice of breathing-oriented qigong clearly marks the birth of mind–body medicine. Master Huang-zhen of the Tang dynasty (
11
) was credited as the inventor of 
this method. During the same time period, Sung integrated breathing exercises with vocalization and created what is now known as the six-word method, which entails 
the production of the following six sounds— shu, kir, su, tzua, fou, and shie—a combination that is thought to ameliorate disease of the liver, heart, lung, kidney, 
spleen, and triple burner, respectively.  Triple burner is a TCM term describing the three sections of the body: the upper burner (chest), the middle burner (stomach 
area), and the lower burner (lower abdomen). This method, and a modified version of it, are still being practiced today (
12
).
PRINCIPAL CONCEPTS
Assumption about Nature and Mankind
The theoretic foundation of qigong is representative of TCM. It postulates that human beings, aside from having a concrete and observable physical body, also 
possess a subtle microcosmic energy system that synergistically connects with the macrocosmic system. Chi constantly flows through the meridian system in a 
balanced mode. Within a human being's subtle energy system, a myriad of  chi unceasingly flows through the body via a complex matrix of networks called meridians, 
which are set in a predetermined circadian sequence and homeostatic pattern (
13
, 
14
 and 
15
). Chi functions to protect the individual from pathogens; nourish the 
body through the conversion of nutrient substances; activate physiological activities, including all internal and external movements; retain all body substances; and 
eliminate biological waste products. Disturbances of this energetic system may lead to deviation from homeostasis, which results in physiological and mental 
dysfunction, deterioration of health, and eventually disease.
If the disturbed condition persists, illness may ensue. According to the model just described,  chi disturbance is the beginning of the unfolding of an illness (
Fig. 23.1
). 
The appearance of physical signs of discomfort marks the second stage of disease development. Qigong diagnosis of energy disturbances allows the condition to be 
corrected at the beginning of disease development, thus preventing the unfolding of the disorder. Because the detection of energy imbalance requires training and 
awareness of chi, diagnostic methods have been developed to allow the healer to make inferences from the energy system's conditions. TCM physicians have 
developed methods, such as acupuncture, moxibustion, and complex herbal prescriptions, to restore the subtle energy system for healing and health purposes. These 
approaches are described in 
Chapter 12
, “Traditional Chinese Medicine.” They are designed to treat the illness at the second stage of its development, that is, at the 
appearance of signs and symptoms. In general, this is the stage at which conventional medicine is most effective in treating disease. The advances of medical 
science in understanding pathophysiological and biochemical mechanisms, inventing fine-grained technology for diagnosis, and developing pharmaceutical agents 
account for the efficacy of the Western approach at this stage.
F
IGURE
 23.1. Development of disease and points of intervention.