Shiatsu and Acupressure: Two Different and Distinct Techniques.

BACKGROUND: Although shiatsu has been taught in specialized schools in Japan since 1940, there is a limited amount of research for its practice. As a result, authors substitute shiatsu with acupressure to use available research on acupressure. It is the position of the authors that, while the two share common aspects, they are substantively different. This project was undertaken to describe technical differences and advocate for a clear distinction, especially in research studies and academic discussions.
METHODS: To understand whether it is appropriate to include acupressure studies in the evidence for shiatsu an analysis of the references included in a frequently cited systematic review was conducted to collect information about the protocols. In addition, a preliminary exploration of shiatsu practitioners' perceptions about the differences between shiatsu and acupressure is described. This exploration used videos of shiatsu and acupressure techniques and asked practitioners to comment on their perception of similarity. DISCUSSION: The results identified several key technical differences between the two, including type of pressure applied, the positioning of the thumb, and the way in which body weight is used. Researchers should separate shiatsu and acupressure in their designs and purposively choose one or the other. To facilitate such clarification, we have proposed a definition for shiatsu that may facilitate the differentiation between these two techniques.
CONCLUSION: The authors hope to stimulate discussion about the differences between shiatsu and acupressure, and to question the appropriateness of using acupressure studies as evidence of the efficacy of shiatsu. A true understanding of the efficacy of shiatsu cannot be determined until studies use a common definition of shiatsu and discontinue substituting acupressure research for evidence of shiatsu efficacy. When this happens, it is proposed that a clearer picture of the safety, efficacy, and mechanism of action of both shiatsu and acupressure will emerge.

INTRODUCTION

Shiatsu is a manual therapy of Japanese origin in which the practitioner applies pressure on certain points of the body in order to activate the body’s own healing capacities. Its name in Japanese means “finger pressure”.( Although shiatsu has been taught in specialized schools since 1940, and recognized in 1964 by the Ministry of Health of the Japanese National Government as a uniquely Japanese therapeutic treatment,( there is a relatively small body of evidence for its practice.( As a result, authors and practitioners seem to conflate shiatsu with acupressure to make use of the available research evidence on acupressure. In fact, a basic PubMed search for shiatsu as the sole search term returns primarily acupressure studies, with the first mention of shiatsu outside the first 100 citations. In an attempt to improve the search, the Medical Subject Heading (MeSH) database was searched for shiatsu. Once again, acupressure was returned as the related MeSH term—as shiatsu is considered to be a part of the ‘tree’ of acupressure.(

Similarities and Differences in the Literature

It should be noted that there are some similarities between shiatsu and acupressure. Both disciplines assess for imbalances in the body and use pressure to restore balance and health.( Some shiatsu styles—but by no means all—use, in part, Traditional Chinese Medicine meridians that coincide with acupressure.(

On a more technical level, both do not normally use oil or cream during the application of pressure, and some of the points pressed are the same. While there are some similarities, there are more substantive differences. First, shiatsu is a holistic discipline that approaches treatment by considering the whole body, whereas acupressure, in most cases, chooses to treat a few points only.( Second, the pressure used in shiatsu is always stationary and sustained.( In acupressure, the pressure applied is often circular or may use a pumping action in which the thumb repeatedly presses and releases pressure quickly.( Third, in shiatsu, the thumb is always in an extended position (see Figure 1), whereas, it is more common to use the thumb flexed at the metacar-pophalangeal joint in acupressure( (see Figure 2). Finally, shiatsu uses the whole weight of one’s body to apply pressure, whereas acupressure uses, in part, the strength of one’s arms or hands.(

Figure 1

“Always use the thumb extended. … Do not bend the thumb at the first joint”. Images and text from The Book of Shiatsu.( Reproduced with permission from Octopus Publishing Group Limited.

Figure 2

Thumbs flexed at the metacarpophalangeal joint. From: Effects of SP6 Acupressure on Labor Pain and Length of Delivery Time in Women During Labor by Lee, et al.( Reproduced with permission from Mary Ann Liebert, Inc. Publishers.

The neglect to clearly differentiate between shiatsu and acupressure is illustrated in a case report by Yeh et al.( The intervention is titled “acupressure (shiatsu)”. As one continues to read, the authors name the technique used as “collateral meridian acupressure therapy” and describe the procedure as “dynamic pressure toward a caudal direction at the posterior edge of the medial malleolus of [the] left foot at a frequency of 60 times per minute for 60 s., followed by a constant static force on the same point at cephalic direction for an additional 60 s.” (p. 485).

Although the second part of procedure, where a constant static force was applied, may be interpreted as part of a shiatsu treatment, the application of dynamic pressure is not. The movement as described goes against two of the basic principles of shiatsu: the use of the weight of the body to apply pressure, and sustained and static pressure. The movement is, however, a common element in acupressure.( It is not clear why the authors have included shiatsu in the title and abstract, as this is clearly a case report about acupressure. Their decision to do so contributes to confusion around these techniques.

One study that cites acupressure as a part of shiatsu( cites Robinson et al.( as the source of this statement. Robinson and colleagues further claim that evidence of efficacy of acupressure may indicate evidence of efficacy for shiatsu. Contradictory statements can be found within the same article: “Literature reviews indicated that the validity of acupressure efficiency supports shiatsu technique efficiency”, which is followed almost immediately by, “Sometimes, shiatsu is mistaken with “acupressure”, whereas it is technically different from the method”( (p. 178). And, there are others, including the authors of this article, who echo the statement by Teimoori et al.( that the two techniques are different.( These examples are but a few that illustrate the need to explore the differences between shiatsu and acupressure.

Need for Exploration of the Difference between Shiatsu and Acupressure

It is the position of the authors that, while shiatsu and acupressure share some common aspects, they are substantially different in their philosophy and technique. As a result, this article analysis and preliminary exploration of practitioners’ perceptions was undertaken in an attempt to describe the technical differences and advocate for a clear distinction to be made between them, especially in research studies and academic discussions.

In the literature, studies that equate both techniques oftentimes cite one review: “The Evidence for Shiatsu: A Systematic Review of Shiatsu and Acupressure”.( However, it is our position that shiatsu and acupressure are different. As such, to understand whether or not it is appropriate to include acupressure studies in the evidence for shiatsu, a thorough review of the references included in the systematic review was undertaken. Each article, as described below, was reviewed for information about the protocol used.

Building upon the analyses, a preliminary exploration of shiatsu practitioners’ perceptions of the differences of the two approaches is described. This exploration used videos that showed both shiatsu and acupressure techniques, and asked practitioners to comment on their perception of similarity. The purpose of this article is to stimulate discussion about the differences between shiatsu and acupressure, and to question the appropriateness of using the results of acupressure studies as evidence for the efficacy of shiatsu.

METHODS

Article Analysis

As there appears to be one review providing credence to the argument that acupressure research can be used in the absence of shiatsu research about efficacy, it is important to understand whether the studies included in the review sufficiently represent shiatsu as it is practiced.( We analyzed the description of the intervention provided in the studies reported in the review’s reference list.(

Methods for the Analysis

Of the 80 references in the systematic review, studies were included in our analysis that were written in English and included an explanation of the practical application of the study intervention. In addition, access to the full text was necessary to be included. Studies were excluded if they described self-shiatsu or acupressure, if the protocol was the same as a protocol already included, or if the intervention included the use of a device or lubricant.

Nine shiatsu studies were mentioned in the reference list. Of those, three were excluded because shiatsu was not the only technique used. The intervention consisted of shiatsu among other techniques such as acupuncture. Furthermore, there was no explanation of the shiatsu intervention. An additional four studies were excluded because they also did not explain the intervention. One study was about watsu, not shiatsu, and was also excluded. This left one study about shiatsu that was included in the analysis.

There were 71 acupressure references in the review. Of those, 24 were rejected because there was no description of the acupressure protocol. Three studies were not in English. Eleven studies used interventions that were either self-acupressure or used devices. Six studies were rejected because they repeated protocols that were included in other studies by the same authors or in systematic reviews. Three reported the use of a lubricant, such as oil or ice, so were excluded. Access to the full text of two studies was not possible. One study was not related to acupressure. Twenty studies were included in the analysis.

RESULTS

During the analysis, it was discovered that seven of the acupressure studies described the timing of the application of pressure only. As timing varies both in acupressure and shiatsu, these studies were removed in favour of focusing on other aspects of the protocol. Fourteen studies remained in the analysis (Figure 3).

Figure 3

Selection process that determined the 14 studies included in the analysis.

Information about the shiatsu and acupressure interventions described in the 14 studies were collected and compared. The results of this comparison are presented in Table 1.

Table 1

Results of the Comparison Between Shiatsu and Acupressure From the 14 Studies

	Shiatsu	Acupressure
Pressure	Pressure is always stationary or static. It is defined in the shiatsu literature as a passive, receptive aspect of shiatsu.(1,10,11,13–15) Pressure is always sustained.(10,11,16)	Pressure includes movement of the finger, elbow, etc. with circling, rubbing or kneading movements.(8,17–27)Pressure sometimes uses a quick pumping action, in which the thumb applies pressure and releases in a very quick motion.(6–8,21,22,28)
Use of Thumb	It is considered wrong in shiatsu to use the thumb flexed; the thumb is always used in the extended position (see Figure 1).(1,11)	The thumb is flexed at the metacarpophalangeal joint (see Figure 2).(6)
Movement of Hips	Movement of the hips is necessary to apply pressure with the weight of the body. The movement is ample to allow the practitioner to use only the weight of his/her body to apply pressure.(1,10,11,16,29)	No mention of this element has been found in the literature. From observing videos, one can see that the movement is more restricted.

Preliminary Exploration of Practitioners’ Perceptions

To explore further the differences between shiatsu and acupressure, a preliminary investigation was undertaken to explore practitioners’ perceptions of these two techniques. A basic questionnaire was created to capture practitioners’ responses, and excerpts from publically available videos were chosen by one of the researchers (FC) to demonstrate the techniques of interest.

Methods for the Preliminary Exploration

Shiatsu practitioners were identified via a Google search or through national shiatsu associations. One thousand two hundred and thirteen practitioners were invited via email to take part in the questionnaire. No attempt was made to limit participation to practitioners who practice shiatsu only, so respondents may have practiced different types of massage or bodywork.

Excerpts from public videos about shiatsu and acupressure were used to make four short videos in which both shiatsu and acupressure are shown. (The four videos have been uploaded to the website as Supplementary Materials.) The four short videos were emailed along with the survey to potential participants.

The questionnaire contained four sets of questions, one for each video. The questionnaire was translated into Spanish, French, and Italian, by three of the authors (FC, JPG, IA).

For Video 1, participants were asked, “Do you think treatment A and treatment B are the same? If yes, why? If no, why not?” Participants wrote in their responses in an open text box.

For Video 2, participants were asked the following, “Please pay attention to the thumbs. Do you think the use of the thumb in treatment A and treatment B is…”. The participants chose between very similar, slightly similar, neither similar nor different, quite different, and very different.

The question associated with Video 3 asked, “Please pay attention to the movement of the hips. Do you think that the use of the hips in treatment A and treatment B is…”. Again, participants chose between very similar, slightly similar, neither similar nor different, quite different, and very different.

Finally, participants were asked for Video 4, “Do you think treatment A and treatment B are…”; once again choosing between very similar, slightly similar, neither similar nor different, quite different, and very different.

Results from the Questionnaire

One hundred and one shiatsu practitioners completed the questionnaire. Responses were received from Australia, Belgium, Canada, Croatia, France, Ireland, Italy, the Netherlands, Norway, Slovenia, Spain, Switzerland, the USA and the UK. Five of the 101 respondents reported that they practiced acupressure in addition to shiatsu. Replies and data were anonymized before the results were analyzed. The results, in percentages, can be found in Table 2.

Table 2

Responses to the Questions About Videos 2–4

	Video 2Use o Thumb	Video 3Movement o Hips	Video 4Stationary Versus Pumping Pressure
Very similar	0.00%	5.9%	1.0%
Slightly similar	3.0%	18.8%	5.0%
Neither similar nor different	4.0%	7.9%	1.0%
Quite different	30.7%	25.7%	26.7%
Very different	62.4%	41.6%	66.4%
n-value	101	101	101

In response to the first question, 95% of respondents indicated that they thought the two techniques shown in Video 1 were different. For example, one respondent wrote:

The result might be the same, depending on what exactly is treated here. In treatment [A] the spot where the elbow rests may relax due to the continuous pressure and intention of the practitioner. In [treatment B] that same spot might be able to relax as well, as the practitioner [loosens] the tissue underneath. Although the results could be similar, one would have to consider the effects of both treatments on the client […] For me, [treatment A] is shiatsu, [treatment B] is more likely another technique.

Another respondent described the differences and spoke to their thoughts about mechanism of action, “… one is stationary pressure and the other is movement. Different styles of pressure stimulate different mechanoreceptors, which can affect the body’s response in different ways.”

Only 2% thought the techniques were the same; although one of these respondents wrote “I learned both so I use both”, making it unclear if they thought the techniques were the same or was just noting the similarity of the video to techniques they had previously learned. One respondent indicated it was difficult to decide. From their responses, two respondents seemed to have misunderstood the question.

When reviewing the second video, 93.1% of respondents indicated that the use of the thumb in the technique application was quite different or very different. Only 3% thought it was slightly similar or very similar and 4% thought it was neither similar nor different. For the third video, 67.3% of respondents indicated the use of the hips was quite different or very different. In this question, 24.7% thought it was slightly similar or very similar and 7.9% thought it was neither similar nor different. For the fourth video, 93.1% of respondents indicated the use of the thumbs/fingers was quite different or very different. In this question, 6.0% thought it was slightly similar or very similar and 1.0% thought it was neither similar nor different.

DISCUSSION

While some authors focus on of the differences between shiatsu and acupressure in theory and philosophy,( this exploration emphasized the differences in the technical aspects. From the analysis of the systematic review, there are many more differences than similarities in the techniques used in the two disciplines. The videos and the majority of responses to the questionnaire also highlight the differences.

The key technical differences, which have been described using both studies and textbooks, are summarized in Table 1.

It is the belief of the authors that the differences described above are interrelated. The thumb cannot be flexed in shiatsu, because the practitioner leans forward with the weight of the body. If the thumb was flexed, it could lead to injury. This teaching was noted by one of the respondents in the questionnaire: “… using the thumb the way [video 2] demonstrated can become tiring or damage one’s thumb”. Furthermore, pressure should be stationary when one uses exclusively the weight of the body, again to prevent injury to the practitioner.

With the key technical differences described, one should question the decision of some to use evidence about the efficacy of acupressure as a substitute for evidence regarding the efficacy of shiatsu. A true understanding of the efficacy of shiatsu cannot be determined until studies and reviews use a common definition of shiatsu and discontinue substituting one discipline for another. When this happens, it is proposed that a clearer picture of the safety, efficacy, and mechanism of action of shiatsu, and subsequently acupressure, will emerge. Future research should include detailed explanation of the way pressure was applied.

A Definition of Shiatsu

The following is proposed as a definition of shiatsu that can be used by researchers and reviewers to distinguish between shiatsu and acupressure, as well as other manual approaches. This definition was created such that it does not exclude any styles, whether based on the work of Tokujiro Namikoshi, Shizuto Masunaga or Katsusuke Serizawa, whose work is the basis of almost all shiatsu styles around the world.( In particular, Namikoshi-based shiatsu has been included, as it is the most widely practiced style in Japan.(

Shiatsu is a manual therapy applied by leaning forward in a relaxed manner with the weight of one’s body to an optimum point, and the correct use of fingers, palms, etc., in order to apply sustained, stationary pressure on different parts of the body for the purpose of correcting the imbalances of the body, and for maintaining and promoting health. It is a holistic therapy that aims to treat most of the body in each session.

CONCLUSION

Shiatsu and acupressure are often used in the literature interchangeably. However, there are several key technical differences between the two, including the type of pressure applied, the way in which the thumb is positioned, and the way in which body weight is used. At this time, the impact of these differences in application on efficacy of these techniques is not known. It is our position that researchers should separate shiatsu and acupressure in their designs and purposely choose one or the other to investigate. To facilitate such a clarification, we have proposed a definition for shiatsu that, if used by the community broadly, may facilitate the differentiation between these two techniques and support the investigation of the efficacy, safety, and mechanism of action of shiatsu. Until the body of literature expands to include more studies using true shiatsu interventions, researchers, practitioners, and other stakeholders should not substitute studies reporting the efficacy of acupressure as evidence of efficacy for shiatsu.

SUPPLEMENTARY MATERIALS

The videos used in this study have been done using YouTube’s fair use policy.( They have been used solely for non-commercial research purposes and with attribution provided below.

Video 1 — https://www.youtube.com/watch?v=gPIvLpuYPY4 shows stationary or static pressure and circling or rubbing pressure applied with the elbow. It compares scenes from the following videos: “Le massage shiatsu: documentaire COMPLET” (https://www.youtube.com/watch?v=D-cHpT_UUog() and “Tui Na Acupressure Massage & Chi release for sciatica” (https://www.youtube.com/watch?v=IBequSa-xyE()

Video 2 — https://www.youtube.com/watch?v=Xy7UW2NRoIM shows an extended thumb versus a thumb flexed at the metacarpophalangeal joint during technique application. It compares scenes from the following videos: “Vidéo Zen Shiatsu à Bordeaux” (https://www.youtube.com/watch?v=nys5esbC_Wo() and “Acupressure: Acupressure for the foot” (https://www.youtube.com/watch?v=W7NWr_Mcx3A()

Video 3 — https://www.youtube.com/watch?v=9k_Qdx2LbGA shows the movement of the hips using the weight of the body to apply pressure and when part of the weight of the body and the practitioner’s strength is used. It compares scenes from the following videos: “Acupressure massage (back)” (https://www.youtube.com/watch?v=TEeGKz1A0wo() and “Le massage shiatsu: Documentaire COMPLET” (https://www.youtube.com/watch?v=D-cHpT_UUog()

Video 4 — https://www.youtube.com/watch?v=cOomHz6wEEU shows the difference between pumping pressure (defined, for example, as pressure at a frequency of 60 times per minute for 60 s)( and sustained pressure. It compares scenes from the following videos: “Acupressure: Acupressure for the foot” (https://www.youtube.com/watch?v=W7NWr_Mcx3A() and “Shiatsu Workshop for Prone Position by Akitomo Kobayashi & Yuji Namikoshi 11” (https://www.youtube.com/watch?v=NqtoRUdl7NU()