massages. Cawley recommended larger samples and longitudinal measures in future research. Although this investigation adds important information to the body of knowledge about shiatsu massage and has incorporated several suggestions from earlier researchers, it must be noted that there are many limitations to this study. The most important limitation is the absence of a control group. Pain and anxiety were measured frequently throughout this study to control for maturation as well as for statistical regression, but these threats cannot be completely eliminated until a study is carried out with a control group experiencing the same type of pain as the treatment group. The repeated measures itself is a limitation because subjects may become very familiar with the instruments, especially when the time interval is only the one hour required for a treatment. Another limitation is the socioeconomic status of these subjects. Because shiatsu is not reimbursed by health insurance, Medicare, or Medicaid, the subjects in this study all paid a reduced price of $120 for four shiatsu treatments. For that reason, the findings of this study apply only to those individuals with lower back pain who can afford such intervention. Subjects in lower socioeconomic groups may not take advantage of this alternative therapy at this time due to the cost. In addition, this study was carried out in one small Midwestern town and in one shiatsu clinic. Replication with other groups in other settings would validate methods as well as findings. It must also be noted, however, that the findings of this study add another option for holistic nurses and other health professionals who are working with clients with lower back pain. These clients are often frustrated and trying alternative treatments on their own without assistance or advice from health care professionals (Eisenberg et al., 1998). Shiatsu massage, a noninvasive therapy, was not only a positive experience, it was very effective in reducing the pain and state anxiety in these subjects complaining of lower back pain. 68 JOURNAL OF HOLISTIC NURSING / March 2001 Downloaded from jhn.sagepub.com at PENNSYLVANIA STATE UNIV on March 4, 2016 Further research in this area will expand the types of illnesses and conditions that can be alleviated to some degree by shiatsu massage. In addition, it would be interesting to determine the differences, if any, between shiatsu massage and other types of massage as an alternative therapy for clients with specific chronic and acute health problems. Commissioned by the Shiatsu Society UK, this piece of work is not in itself research, rather it is an examination and assessment of all the research that has been done into Shiatsu and acupressure. Why has this been done? • It is an up-to-date gathering together of research into Shiatsu and acupressure, providing a much-needed overview of the field. • The review shows the extent and some of the potential scope of the possible applications of Shiatsu and acupressure. • It alludes to the challenges facing the researcher in the field of ‘energy medicine’. • It demonstrates the criteria needed for research, so that reading the review is equivalent to an education in how research can be done according to recognised standards and procedures. • The review is in itself an unbiased and rigorous work of scholarship, which assesses its own strengths and limitations according to accepted guidelines. It shows the clear intent of the Shiatsu community to look at its work impartially, which can only increase the respect in which it is held in wider scientific circles. It is clear that if Shiatsu is to achieve the degree of recognition and respect that is accorded to acupuncture, the Shiatsu community must acquire two linked resources – a body of research results; and a body of literature that not only describes and illuminates Shiatsu in its own vivid and poetic terms but also incorporates the science which lies behind both Shiatsu bodywork and the research into its effectiveness. The Importance of Research The way forward for Shiatsu is clear. After its initial enthusiastic adoption by the public in the '70's and '80's it has reached a plateau. The public has educated itself widely in the many forms of complementary medicine and now expects Shiatsu to justify its claims for effectiveness. Many research studies have been carried out on acupuncture, which has a longer written history and stronger public profile than Shiatsu, most of these studies in China, where the cultural and social situation favours research efforts of this nature, and they cost less. In the West, the situation is very different. The vast majority of clinical trials, which cost a great deal, are funded by pharmaceutical or biotechnology companies, even if they are sponsored by a governmental or public organization. These companies can easily fund the expensive process of controlled studies, as is required by the evidence-based medical movement; Shiatsu is not in that position. The number of patients enrolled in a study has a large bearing on the ability of the study to evaluate the effect of the intervention reliably. This is described as the ‘power’ of the trial. The larger the sample size or number of participants in the trial, the greater the statistical power. BUT more patients make for a more expensive trial. Hence the greater power of the studies funded by the pharmaceutical companies. And, of course, in a trial which