this review, individualised acupressure refers to the selection of one or more acupressure (tsubo) points tailored to the individual recipient that is informed by a traditional Chinese medicine diagnosis. It may be delivered in the context of a shiatsu treatment (or alongside Research Protocol HTANALYSTS | NHMRC | EVIDENCE EVALUATION ON THE CLINICAL EFFECTIVENESS OF SHIATSU 11 other traditional Chinese medicine treatment). Most individualised acupressure is administered by the therapist, however, there may be instances when the therapist provides instructions for selfadministration or administration by a lay caregiver. Standardised (non-individualised) acupressure refers to one or more predetermined acupressure points for a specific condition, symptom or symptom cluster. While informed by the principles of traditional Chinese medicine, a traditional diagnosis of the recipient is not required for administration. The acupressure intervention may be administered by a qualified therapist, lay caregiver or self. Most self-administered acupressure is non-individualised, examples include the use of an acupressure band or large bead as a replacement for finger pressure. However, there may be some instances when a therapist uses this type of acupressure or provides instructions to their patient or lay caregiver for self-administration. Research Protocol HTANALYSTS | NHMRC | EVIDENCE EVALUATION ON THE CLINICAL EFFECTIVENESS OF SHIATSU 12 1.3 How the intervention might work Shiatsu The exact mechanisms for how shiatsu might work for different conditions has not been elucidated. However, some of the massage techniques included in shiatsu are similar to massage more generally. Consequently, shiatsu massage techniques may affect the body through similar mechanisms. The physical and psychological effects of massage more generally are thought to be explained (in part) by relaxation of the nervous system and musculature and through the release of neurotransmitters and hormones (19-21). Like all human interaction, touch is believed to induce an immediate calming effect, mediated by production of the hormone oxytocin (22, 23). Physiologically, massage may increase oxygenation to the muscles through inducing local biochemical changes that help blood and lymph flow, as well as affecting mood and pain perception through a subsequent effect on neural activity (20, 24-26). One study suggests that by supporting individuals to take control of their self-care, shiatsu practitioners encourage patients to make lifestyle changes (e.g. relaxing more, working less) which could impact their health (27). A limited number of exploratory studies of shiatsu applied to various anatomic regions on healthy adults have observed mixed results on autonomic nervous system functions including changes in heart rate, blood pressure and pupil diameter (20). In shiatsu, the role of connective tissue in delivering energy and information to the whole body is thought to be integral to correcting imbalances in the flow or energy of a recipients Ki (8). Here, the mechanical effect of stretching and applied pressure is believed to encourage hydration and flexibility of connective tissue that has become congested or brittle through inadequate circulation or after injury. Due to continuity and electromagnetic signalling properties between cells, the connective tissue is suggested to distribute and enhance communication throughout the body to promote self-healing (8). Shiatsu practitioners work directly with the energy flow along the meridian because bioelectric flow is believed to happen more readily along meridian lines due to differing electrical resistance (8). Acupressure The mechanisms underpinning any effects of acupressure are thought to be similar to acupuncture. The practice of acupuncture may produce benefits for conditions closely associated with the nervous system (28-30). Stimulation (or pressure) applied to points connected to or located near neural structures is thought to transmit information along pathways in the nervous system, inducing various changes including pain perception, and hormonal and neurochemical changes (28-30). Research Protocol HTANALYSTS | NHMRC | EVIDENCE EVALUATION ON THE CLINICAL EFFECTIVENESS OF SHIATSU 13 1.4 Why it is important to do this review In Australia, complementary therapies, including shiatsu, are most often used in conjunction with conventional medicine and other strategies for maintaining good health and wellness. For this reason, it is important to synthesise the evidence for the effectiveness of shiatsu, to enable consumers, health care providers and policy makers to make informed decisions about care. The 2015 Overview identified four systematic reviews that included two RCTs; however, the effect of shiatsu could not be independently evaluated from either RCT, as shiatsu was combined with other interventions in both studies. There was no independent evidence to suggest that shiatsu may have some beneficial health benefits compared with control or active comparators. Therefore, the overall efficacy, safety, quality or cost-effectiveness of shiatsu was not able to be assessed (4). The rationale for conducting this review is to update and enhance the evidence used to inform the 2015 Overview of shiatsu (4). That is, to identify studies