Manipulative Alternative Medicine

By: Jessica Gatewood

I. Abstract

The goal of this paper is to give a brief overview on the world of alternative medicines, while taking a closer look into the types of manipulative methods that are offered by many certified or license professionals. As the paper moves from different methods and techniques, the origin, history, benefits, and limitations are examined. Manipulative alternative methods are some of the most practiced methods in the modern or conventional health care systems. Manipulative techniques are methods in which the practitioner physically manipulates the musculoskeletal system of the patient. Many other forms of alternative methods are viewed in a skeptical light. The literature disproves many of those methods whereas manipulative methods actually have some benefit to the individual by reducing the stress on nerve pathways in the body. Not all individuals receive the same outcome as others; some may experience aversive effects from manipulative methods.
Keywords: alternative medicine; manipulative alternative medicine; osteopathy; chiropractic; Feldenkrais method; Trager approach; The Alexander technique; acupressure; massage therapy, rolfing, reflexology

II. Introduction

In traditional Western culture it is custom to treat illness with traditional medicines that target the biological mechanisms in the body. According to the National Center for Complementary and Alternative Medicine, many ancient Eastern cultures alternative methods were used that are often times referred to as contemporary alternative medicines (CAM). Some of these healing methods were devised over 2,000 years ago in ancient Chinese cultures. Alternative medicines are a group of products and procedures rather than one individual procedure. The CAM procedure is focused primarily on the relationship and involvement between the use of CAM and the use of conventional medicine as well. This concept benefits the patient by receiving treatment as a “whole person” (Sointu, 2006). (

III. Origination

In this section we will cover some of the most common types of manipulative alternative medicinal processes as well as experience some first hand benefits and limitations of using the techniques. Alternative medicines originated in ancient cultures like China, and India where Ayurvedic medicine originated. These practices “depend upon living upon living in harmony with” (Goldberg, 1997, p. 5) the forces of nature. In the mid-nineteenth century the discovery of microbes developed the germ theory, which led to the development of the “birth of contemporary medicine” (Goldberg, 1997, p. 6). The discovery of microbes led to the understanding of how viruses, bacteria, and fungi cause illnesses and infection.
Even though alternative methods may vary, they all incorporate the same philosophies. Traditional Chinese Medicine, Ayurvedic medicine, and Naturopathic medicine all focus on “empowering the individual to accept responsibility” (Goldberg, 1997, p. 14) for task recovering and health maintenance. One of the biggest emphases on lifestyle is the nutrition, and living and balanced lifestyle. Without getting enough exercise, sleep, and emotional stability the individual may not have a healthy frame of mind (Goldberg, 1997). All forms of alternative medicine procedures influence the importance of the musculoskeletal system are part of the source of illness due to blocked energy pathways. The overall goal of alternative medicine if to treat the individual as a whole system of working parts instead of treating the symptoms. (Goldberg, 1997)
The five categories of alternative medicine focus on soothing the nerve pathways in different areas of the body. These categories include Whole Medical Systems, Mind-Body Alternative Medicine, Biologically-based Alternative Medicine, Manipulative and Body-based Alternative Medicines, and Energy Therapies. Whole Medical Systems focus on the entire body as a complete functional system. Some examples are Ayurvedic medicine, Homeopathy, Naturopathic medicine, and Traditional Chinese Medicine. There are many other common forms of Whole Medical Systems. Mind-Body Alternative Medicine processes focus on altering the mind’s capacity that affects the bodily functions. Sometimes this can be acquired by hypnotherapy, biofeedback, yoga, etc. Biologically-based practices focus on the natural products in life that can heal the mind and body. The most common types of Biologically-based alternative methods are vitamins, and herbs. Energy Therapies focus on controlling the energy field that the body experiences; this is controlled by two types, biofield therapies and bioelectromagnetic-based therapies.
In this section we will focus more closely on Manipulative and Body-based Alternative Medicines. These processes focus on manipulating the body and/or it’s movements in one or more areas of the body to alleviate stress or illness in those areas. There are several techniques in this category that will be discussed in further detail.

IV. History of Manipulative Alternative Medicines

Manipulative medicine does not have one specific origin. Many of the procedures date back to 400 B.C.E. to the Mediterranean area. Unfortunately, many of the earlier procedures and methods were not documented in this area. It was not until evidence was discovered in Greece that manipulative medicines really began to be studied. Hippocrates, who is referred to as the father of medicine, was the first individual to explain and describe the benefits to spinal manipulation methods. His research on scoliosis and the effects gravity plays to alleviate the pain is one of Hippocrates most famous works. (Pettman, 2007).
As any other scientific field, other individuals who expanded on their knowledge discovered the research methods and techniques that had made manipulative practices what they are today. A Roman surgeon, Claudius Galen, was one of the first to document his research on manipulation of the spinal regions to improve the tension and pain for walking and standing. According to Pettman (2007), Galen also documented many “illustrations of his manipulative techniques” that are still used in the modern world of manipulative medicines. These illustrations are often still seen in medical textbooks as references to his methods.
A medical professional from Baghdad, Avicenna, helped spread the idea of spinal manipulation throughout Latin countries. Avicenna translated Hippocrates book, The Book of Healing, to Latin, which lead to the spread through Europe and the western civilizations. This publication reached great thinkers like Leonardo Da Vinci who later expanded their knowledge to the modern western cultures and their fused sense of medicine. (Pettman, 2007)
One of the most influential people in the study of manipulative alternative medicine is Andrew Still who is known as the father of osteopathic medicines. He was privileged with a good education from his father who was also a physician and Methodist Minister. He gained his knowledge of medicine from apprentice work and attended very little classes. In the 1800s a physician could be apprenticed instead of attending a medical school in which they would attend seminar classes. Once Still experienced the life changing traumatic event of losing all three of his children during the plague in Europe, he started to disbelieve in standardized medicine and turned towards osteopathic medicine. (Pettman, 2007)
Through personal experiences of severe headaches Still learned about the pressure and displacement of spinal vertebrae. With pressure on both sides of his neck, his headaches were relieved. He began to research and discover the areas in the spinal area that directly relate to pain that causes other ailments. Manipulation to the spinal area and the nerves surrounding the area cannot only alleviate pain but can also decrease the risk of illness and cure diseases like scarlet fever, whooping cough, and croup. (Pettman, 2007)
Many other medical physicians made discoveries like Still accomplished and added further knowledge and insight on the field of alternative medicine. Once manipulative methods and practices reached the modern western civilization like America, individuals were still very uneducated and unprepared to actually practice medicine in any specialty. Harvard President Charles Eliot was the first person with power to change the education curriculum of the American medical schools. Instead of attending two four-month semesters of medical training, the medical students of Harvard were now being tested on a higher level of skill. These individuals were finally being held accountable for the time they have spent learning the practice of medicine. This movement caused graduates to travel to Europe for any extensive education in the field of medicine. When these individuals returned home from school they would practice their newfound methods and the ideology of alternative medicines began to spread.
(Pettman, 2007)

V. Types of Manipulative Medicines

Manipulative medicines are focused on the manipulating the musculoskeletal system to enhance the health and function of the body. In hopes to cure illnesses, villagers began using manipulative therapies and referring to them as “bone-setting”. These bone-setting techniques altered the placement of bones that would alleviate pain and cure some illnesses. The individuals who chose to practice these methods were often times looked down upon and medical professionals who strictly believed in standardized medicine began to disapprove of their work (Martin, 1994). This was the start of a clinical paradigm in the 19th century. (Pettman, 2007)

Not only was Andrew Still a very influential person in the world of manipulative medicine, many others contributed to the knowledge and developed many different methods of practice that we still use in today’s practices. One of these influential people being D. D. Palmer founded chiropractic medicine During the 20th century manipulative medicines or bone-setting became the topic of medical conversations again and began a whole new eye opening phenomena to the field of medicine. (Pettman, 2007)

A. Chiropractic Medicine

One of the most popular methods of complementary alternative medicines (CAM) is known as chiropractic medicine. It surfaced in the last 1890’s by a grocer from Davenport, Iowa named D. D. Palmer who was also known as a magnetic healer. The concept of chiropractic medicine is that one or more vertebrae in the spine are misplaced and cause pressure on nerves in the spinal column; this is referred to as subluxations. Through chiropractic treatments the vertebrae can be manipulated and moved back in to alignment to relieve the pressure on the nerves in the spinal column. When there is pressure on the nerves in the spinal column the individual can suffer from not only discomfort and pain but from illness as well. (Carroll, 2009)
Over the years chiropractic medicine has been a largely growing field. Chiropractic medicine transpired from 4 different fields of practice. One of the most influential of the four was bone-setting. Bone-setters were people who made adjustments to individuals who may be experiencing discomfort or may have suffered from subluxations that had been done incorrectly (Kaptchuk & Eisenberg, 1998). Some other areas of professions that helped influence chiropractic therapies were magnetic healing, orthodox medicine, and public health reform. In 1976 the lawsuit won on behalf of the chiropractors against the American Medical Association (AMA), allowed traditional medicine and chiropractic medicine to be practiced in the same environments and in hospitals (Carroll, 2009). In 1997 it has been reported that about 30 million children had made visits to chiropractic practitioners in the United States (Humphreys, 2010). Parents using this method of treatment for pediatric medicine is often time referred as pediatric manual therapy (Ped MT).
Although many individuals find chiropractic medicine beneficial in treating the pain in their back but other areas as well, many individuals suffer from receiving chiropractic treatments. According to Kaptchuk & Eisenberg (1998), there have been “138 cases of serious complications due to chiropractic” therapies. Some of these complications include spinal cord compression, fractures in the vertebrae, lock-in syndrome, and many other possible complications exist. Some medical professionals and researchers opt for an informed consent form to be filled out before they undergo any chiropractic therapeutic practices due to the risk of further complicating the individual’s health. (Katchuk & Eisenberg, 1998)
Overall the consensus of using chiropractic medicine seems to be divided. Many people think that it helps their tension or stress in pressure points disappear after an adjustment, and other people may experience aversive effects from the adjustment. There are only a small percentage of patients that experience these effects. However the severity of these aversive effects are considered with much weight. (Ernst & Canter, 2006)

Visit this link to see an interview of a patient experiencing pain, and receiving an adjustment from a trained and licensed professional.

B. Osteopathic Manipulative Therapy (OMT)

Osteopathy originated in the last thirty years of the nineteenth century in the United States from a result of the research of Andrew Taylor Still. Still founded the first school for osteopathy in Kirksville, Missouri in 1892. By the time Still died in December of 1917 there were over five thousand licensed osteopaths in the United States. Now there are over fifteen medical colleges that offer osteopathic curriculum. In the United States osteopathy is practiced along side with conventional methods, obstetrical practices, and surgical which allows the individual to gain a strong comprehensive knowledge base of health care. This curriculum gives the individual the same license as an M.D. but since they practice osteopathy they obtain a D.O. (Doctors of Osteopathy). (Goldberg, 1997)
According to Goldberg (1997), “Osteopathy is a form of physical medicine that helps restore the structural balance of the musculoskeletal system”. It combines many different techniques and therapies to heal the problematic areas in the body. Some of these procedures include postural therapies, physical therapy, and joint manipulation. Since there are many areas to target, this demonstrates how osteopathy focuses on the body as a whole system.
The idea of osteopathy is that if there is an area of the body that is affected by an infection, or a nerve pathway is blocked then all other functions of that area are affected as well. For example, if the upper spinal cord is blocked or damaged then the limbs close by (arms), lungs, and any internal organs can be affects as well. The benefits of receiving osteopathic treatment are learning supplemental functions and processes to prevent any future problems with the affected area or any other future area. With any type of therapy there is a variable level of effectiveness that depends on a number of different factors. In osteopathy the level of effectiveness depends on the level of organic disease, musculoskeletal involvement, nutritional involvement, and the ability of the individuals body to heal effectively. (Goldberg, 1997)
According to William Farber, D.O., of Milwaukee, Wisconsin states that research shows that “osteopathy has been effective for treating issues that have not been resolved through surgery”. It also aids in relief for individuals with joint conditions, spinal conditions, arthritis, allergies, cardiac diseases, breathing dysfunctions, chronic fatigue syndrome, hiatal hernias, high blood pressure, headaches, sciatica, and any other nerve disorders that deal with inflammation. For all of the previous ailments increasing the blood circulations helps boost the immune system, which in turn helps restore good health to affective organs. (Goldberg, 1993).
Dr. Farber gives the story of a patient who suffered from a locked knee due to a previous injury of a cartilage tear. Dr. Farber insisted on having a MRI (magnetic resonance imaging) scan done which confirmed the tear and was referred to Dr. Farber to an orthopedic specialist who administered cortisone injections and conducted physical therapy. After a couple months the patient experienced no relief and returned to Dr. Farber who administered myofascial release of the muscles and connective tissue around the knee. Dr. Farber says, “the results were immediate, with the locking and pain relieved”, and after “a second treatment, the problem was completely resolved (Goldberg, 1997).” Myofascial release is a type of soft tissue therapy that is done to massage and release the drainage that may be built up and blocked in the affected area. Relaxing the contracted muscles, the stretch reflex, and increasing the circulation accomplish the release of venous and lymphatic drainage.
Another success story comes from Terry Moule, D.O., who treated Sebastian Coe for a lower back and hip problem that became a threat to his Olympic career. He was the current world record holder for the 1,500 meters and was training for the 1980 Olympics in Moscow. After going through numerous medical treatments and conventional osteopathic treatments, and then within a couple of weeks of being treated by Dr. Moule, Coe felt no pain and was running at a higher rate than before. The treatment that Dr. Moule used was neuromuscular technique that is a similar to the method used by Dr. Farber in the previous story. Both methods seek to massage and stimulate the soft tissue muscles that are affected close to the skeletal muscles. Sebastian Coe went on to the Moscow Olympics and won two gold medals.
Although there are many cases of successful treatments of osteopathy, there are rare cases of aversive effects in 1 in 500,000 individuals who receive neck manipulations. The effects can consist of cervical artery dissection, or even stroke following cervical manipulations in 1 in 5.85 million individuals. (Kapral & Bondy, 2001) Since there is very little research has been done on the implications, there must be more research done in order to understand the likelihood of something aversive occurring after receiving osteopathy. This research often corresponds with chiropractic works and can often times be misinterpreted and mistaken for one another.
The consistency between the way osteopathy is practiced in the regions and different countries in the world may also contribute to helping find what may help alleviate some of the problems that occur during these treatments.

C. The Alexander Technique

Sometimes the most reinforcing and effective way of learning and discovering new theories is by personal experience. In this case, Frederick Matthis Alexander was one of the first people to discover how posture affects an individual’s daily activities. Alexander was a turn-of-the-century Shakespearean actor who discovered he would began to lose his voice when he would get on stage. This was not a continuous occurrence, but a more intermittent, so he began to study himself and practice in the mirror before he would go onstage. He discovered this his posture would become tense, and his breathing pattern was irregular and tense as well. From this experience he developed the technique to alter his habitual muscular response when breathing before and while singing. There are over twenty-five hundred people in the world who are trained to administer and teach the Alexander Technique is recognized by the Inner London Education Authority in Europe.
The Alexander Technique focuses on the relationship between the individual’s neck, back, and head. A healthy and proper relationship between these three areas will create proper movement and functioning for the individual. Poor posture or inhibited use of movement in the body can lead to on contribute to curvatures in the spine, rheumatism, arthritis and many gastrointestinal and breathing disorders. (Goldberg, 1997)
Some benefits to learning how to use the Alexander Technique and become accustomed to the method is extinguishing bad habits that are harmful to your health. There are many techniques to be learned to help increase your posture that will relieve stress in the long run. These techniques can also increase your self-awareness by decreasing the amount of tension built up in your muscles that can create un-alertness.
A case of a herniated disc in the lower lumbar vertebrae cause many problems for a female in her mid twenties. When she was younger she first injured her back in a horseback riding incident in which she never sought medical attention. Eleven years later during a blizzard, she was shoveling the snow and she felt pain in her lower back in the same area as the previous injury. Over the course of the next few years she continuously injured herself until one serious of episodes she began to lose the feeling in one of her legs. This raised concern and she sought medical attention. After she participated in posture techniques under the Alexander method she realized her injuries and pain was caused by tension in her back that was never reduced or relieved. Learning how to postulate yourself is a hard task if you are already used to your old habits. However re-learning some of these techniques could reduce tension that count be the root of many problems.
There is also research done on the effectiveness of the Alexander Technique. Overall these studies show outcomes similar to the study done by Stallibrass & Chalmers, (2002). This study showed that the patients who receive the Alexander Technique treatments did experience some relief from pain if administered correctly, but must continue with treatments or the pain will return. Since the Alexander Technique is concerned with posture there are injuries that can occur over time if you thinking logically about the skeletal system. For example if you do not sit with good posture (upright in a chair, back against the back of the chair, and both feet on the floor) the individual will experience back pain from being hunched over. A therapeutic technique that manipulates posture seems very skeptical in my opinion, however, if you think about the importance of learning different techniques to help alleviate pain it seems to make logical sense.

D. The Feldenkrais Method

Moshe Feldenkrais, creator of the Feldenkrais Method via Wikimedia Commons
Moshe Feldenkrais, creator of the Feldenkrais Method via Wikimedia Commons

Who would of thought that nuclear radiation research would have lead to a development of a “self-image” therapy in which movement is reflects the nervous system. A physicist Moshe Feldenkrais that participated in research in nuclear radiation and antisubmarine technology for the British Admiralty in France and Europe experienced a sports-related injury. During this stay on a submarine he stayed actively involved in physical activity. Due to the amount of activity he was enduring Feldenkrais reactivated the injury. Since he was aboard he submarine he was determined to alleviate the pain through self-manipulation and self-awareness of how his injuries are occurring. This is where his studies began that are part of the Feldenkrais method. Instead of turning to surgery Feldenrkrais applied his previous knowledge of mind and body experiences and found a process in teaching himself to walk without pain. (Reese, 2004)Like the Alexander Technique, Feldenkais believed in the body working as a whole. According to Goldberg (1997), the body is a “complex system of intelligence and function in which all movement reflects” (Goldberg, 1997, p. 101) the individual’s self-image and nervous system. The important of breath was also recognized as a form of movement; poor movement and function of the muscles surrounding the lungs can lead to irregular and improper breathing. In these findings Feldenkrais developed two methods, Awareness through Movement, and Functional Integration. In the Awareness through Movement method the individual learns new patterns to replace the old undesirable patterns. As the individual begins learning the new patterns they become more aware of the old patterns they need to replace. In the Functional Integration method the individuals learn new movements through a sense of touch. The practitioner tried to convey a sense of positive and improved self-image and movement. This method is customized to the individual and is targeted on his or her own needs.
Overall this method is different from other movement therapies because it does not attempt to permanently alter the structure of the body. Feldenkrais’ ideas enforce experimentation, innovation, and a sense of exploration so that individual can find their own style of movement that benefits their own style. Some benefits of The Feldenkrais Method is that it helps create more movement for those who are limited from stress, accidents, back pain, or any other physically enabling illness. Many athletes use The Feldenkrais Method to enhance movement in areas they have suffered injuries. (Goldberg, 1997)
A Guild Certified Feldenkrais Practitioner, Diane Valentine had a personal experience with fused vertebrae in her neck. Once she moved into her thirties she was in so much pain she consulted an orthopedic surgeon who told her he could not help her. She later found a yoga class who had an instructor who suffered from arthritis like she did, and had success with her yoga techniques called asanas. (
Years later Diane was in a car accident in which she injured her elbow and could not relieve the pain with any therapeutic technique she tried. A student in her yoga class had advised her to try the Feldenkrais Functional Integration. Diane alleviated all the pain in her elbow in one session and it never returned. Diane was so fascinated with the instant relief that she started taking the four-year Feldenkrais professional instructional training classes that would allow her to be an practitioner and administer the techniques herself. Diane had a strong bases of yoga which made Feldenkrais easy to acquire. Knowing both methods made each stronger and most successful. After going through Feldenkrais sessions people who are also going through yoga dn trying to accomplish asanas find it easier to accomplish the positions. Yoga is known as the mental aspect of relaxation and flexibility, whereas Feldenkrais is the flexibility and movement of the body. However, both are focused on connecting the body, mind and spirit with each other. (

E. Rolfing

This next method was influenced by a childhood experience and later developed using an influence from Hatha yoga. Ida Pauline Rolf P.D., a biochemist from New York experienced a respiratory condition when she was a child and was treated successfully trough osteopathy. Her respiratory condition involved a dislocated rib from a kick of a horse that had to be repositioned. The strong influence of Hatha Yoga influences Rolf’s principle that the body must be balanced in order to correspond with the law of gravity. Rolf developed this method in the 1950s which was then known as Postural Release, then later referred to as Structural Integration of the Human Body, and known commonly known as the Rolfing method of Structural Integration (Stirling, 2006). In 1970 she founded the Rolf Institute for Structural Integration and has since trained over eight hundred people. (Goldberg, 1997)
According to Goldberg (1997), rolfing “is based on the idea that human function is improved when the segments of the body, such as the head, neck, legs, pelvis, feet, and torso, are all in alignment”. After years of bad posture an individual’s muscle structure begins to become impaired and can lead to a reduction in mental clarity. In the future this can also take a toll on the psychological state and lead to emotional stress of the individual as well. The muscular structure that is directly affected by the years of bad posture is the fascial tissues. These are tissues that consist of a thin layer, semifluid like layer that surrounds the layers of muscles that encompasses the muscles, bone, blood vessels, nerves, and the organs. These muscles also play an important role in maintaining correct movement and posture. (Goldberg, 1997) The treatment method of Rolfing involves applying pressure like massaging procedures. Many practitioners use their fingers, knuckles, and elbows to release the tension and build up in the fascial tissue. Removing all the tension from the fascia allows you to balance the body again. Once you begin balancing the planes of your body you can put your whole body back into balance. (Goldberg, 1997)
Research done at the University of Maryland shows that Rolfing may assist in reducing chronic stress, enhance neurological functioning, promote changes in body structure or posture, and a reduction of curvature of the spine. Ida Rolf’s research and findings contributed to the role of gravity and how it related to the function of movement, and the bodies posture. (Goldberg, 1997)
Since Rolfing includes the deep manipulation of tissues often times people with blood disorders, broken bones, ulcers, or may be pregnant should not receive treatments. This diseases or disorders may cause aversive effects on the patient because of its stimulation. However there is no actually scientific data to support these effects but Rolfing should be used in precautionary measures. Another concern is for patients who have receive abdominal surgeries or have any diseases concerning organs in the stomach regions. It has been reported that a ureteral stent was dislocated after receiving a Rolfing treatment (Kerr, 1997).

F. Reflexology

Reflexology migrated to the United States from Europe by William Fitzgerald, M.D., who was a laryngologist at St. Francis Hospital in Connecticut. In Europe it was referred to as zone therapy. A physiotherapist, Eunice Ingham expanded on Fitzgerald’s work and created the basis for reflexology. Ingham created the maps we use today that relate the reflexes on our feet to the corresponding organs.
Reflexology focuses on the areas in the feet and hands that are directly related to the organs or other parts of the body; these can be glands, limbs, or reflexes. Many people use reflexology as a coping mechanism to relieve stress, improve blood circulation, unblock nerve pathways to energize and balance your body, and stimulate deep tissue relaxation. Reflexologists are trained to apply pressure to the reflex points that are directly related to organs and/or glands that are affected. There are 7,200 nerve endings in each foot in which lactic acid and calcium deposits can build up and cause muscular stiffness. It is a principle focus of reflexology to target these problem areas and stimulate the pressure points. (Goldberg, 1997)
Research done by Terrence Oleson, Ph.D., and Bill Flocco, founder of the American Academy of Reflecology, found that reflexology procedures benefit females who experience discomfort and pain from premenstrual syndrome (PMS). These methods also help with treating hypertension, pain, and anxiety. It is a healthy and simple way to induce relaxation and a soothing frame of mind. (Goldberg, 1997)
Many researchers and experimenters have problems with the effectiveness of reflexology. There is no actually scientific evidence that shows the correlation between the zones that alleviate symptoms in other areas of the body. If the patient gives a self-report of less pain, it may be occurring due to the placebo effect. It is unknown which attributes to alleviation in pain, which leads people to lump Reflexology into the alternative medicines that do not always work. Some patients may also experience a small amount of pain when receiving these treatments if there is a tremendous amount of pressure in the zones of focus. (Barrett, 2004)

G. The Trager Approach

Since 1927 there have been over seven thousand people trained to administer the Trager technique, and over nine hundred current practitioners. Like many of the other founders of techniques previous, Milton Trager, had a personal experience with an injury; he then spent 50 years fine tuning his method, and later developed the Trager Approach. He established the Trager Institute along with Betty Fuller in 1980. Like Feldenkrais Approach and the Alexander Approach, the Trager approach focuses on the systematic movement of muscles in the body as well.
Like the Feldenkrais method, the Trager approach focuses on teaching new patterns to replace habitual undesirable ones. There are two different types of methods the patient can experience. One is to lay on a table, or a mat on the floor, and let the practitioner physically move your body to teach you the correct behaviors in which your body should elicit. The other method is to have a practitioner teach the new desired movements of the body through a free-form, dance like activity. The principle of this method is about producing pleasurable sensations by using the motions of muscles and joints. These pleasurable sensations begin in the muscle and travel to the nerve endings, to the central nervous system, and make their way to the individual’s mind. This is a repetitious cycle but it promotes a sense of deep relaxation. (Goldberg, 1997)
Many people find relief from severe neuromuscular discomfort that may be a result from age, a prior disease, or previous injury. The field has also seen benefit from the Trager approach “in disorders like polio, muscular dystrophy, and multiple sclerosis” (Goldberg, 1997, p. 106). It may seem unfathomable to experience any limitations to practicing a rhythmic, playful movement procedure that will help you move and function easier. In exercising the individual’s mind by continuing the central nervous system, the individual also gains an increase in energy as well.
The Trager Approach is considered to be a less invasive technique to acquire new movements, however there are some precautionary measures to take. If the patient has experiences an injury in a joint from physical activity, it is not likely that they will be successful in the free-form movement technique. Some other precautions to take are patients who may be elderly or frail and do not have the ability to complete the dance-like exercises. Patients who have recently received surgery on joints, or may have blood disorders should not attempt the physical activity technique due to soreness in their joints and or the likelihood of re-injuring. The manipulation during the free-form technique and even the manual correctional method can create blood clots in patients who have a history of blood disorders. The Trager Approach is overall less invasive than some of the other manipulative alternative methods we have covered, but it should still be used after consulting a medical professional.
(Trager & Hammond, 1987)

H. Acupressure

Acupressure is one of the oldest procedures around. Although it is very closely related to acupuncture, it does not use needles. This phenomenon began around five thousand years ago in the ancient Chinese cultures when they discovered where the points on the body are that relieve illness, disease, stress, and any other ailments. Acupressure is the older of the two methods but has been pushed under the rug due to developing technologies for stimulating these pressure points without having to manually do it.
Meridians are channels that run through that body energy flows. In both acupressure and acupuncture, they both strive to increase the amount of energy flow to increase the chi or qi that flows through these meridians. Some organs function on different energy meridians and draw from different sources of chi. Acupressure methods are concerned with relieving the pressure in the points the may be experiencing tension before they can develop toxins or create illnesses.
There are many different acupressure techniques that can be used, but one that may come most useful to many people is self-acupressure. This can be taught to, and used by anyone. Two of the most popular forms are self-acupressure are Acu-Yoga and Do-In. Acu-Yoga is just what it sounds; it mixes acupressure methods, breathing methods, as well as yoga methods. For example using your fingers to apply pressure in the same points on your body, and using yogic postures and stretches to achieve a sense of relaxation and tranquility. Do-In procedures still use stretching methods and breathing methods, but focus on pleasurable stimulating the body through the meridians in the body.
Shiatsu is one of the popular Japanese methods of acupressure. It is a form of self-acupressure and focuses on administering rhythmic sequences on specific points for a given amount of time (3-10 seconds) and it awakens the energy medians. Jin Shin Jyutsu is another common method that was developed in Japan by Jiro Murai. He is known as the man who remapped the meridians that the chi flows throughout the body. In this procedure the practitioner holds the pressure point for a couple of minutes and then releases trying to remove the pain from the immediate area and/or the area directly related with it. For example, Susie has a very bad headache and cannot get it to go away. She has always heard that squeezing the skin in between your thumb and your index finger will make the severity of your headache decrease, so she tried it. Although it was not one hundred percent successful, she did take her mind off of her headache and she was no thinking about her headache as much.
There are a few implications in using acupressure and or acupuncture that has been discovered in the literature over the years. The main criticism is that there is no scientific evidence to the relief of pressure in these pathways or if the alleviation is merely a placebo effect (Madsen, Gotzcshe, & Hrobjartsson, 2009). Another adverse effects that may occur from the insertion of needles is nerve damage from the lack of education or just improperly inserting. This is rare in cases that are administered by licensed and educated professionals (White et al., 2001). Brain damage can also occur when a needle is improperly inserted at the base of the skull, and can often times cause stroke in patients as well. Pneumothorax can be seen in patients who may have a needle inserted too deep into their lung (Yekeler, 2007). Pneumothorax is the insertion of air or gas between the lung and the chest wall (Tschopp, 2006). If a needle in inserted into the protective membrane surrounding the heart, the heart could permanently have a defect.
Acupuncture and Acupressure should also be used under precautionary measures by a medical professionals by women who are pregnant due to the likelihood of harming the uterus. (Yekeler, 2007)

VI. Massage Therapies

It can often times be very difficult to distinguish between what category massage therapies should belong to, mind-body alternative medicines, or manipulative and body-based alternative medicines. Most of the time they can overlap each other and benefit the individual in dual areas like the muscular system and the connection between the mind and the body. Massage therapies are one of the oldest alternative methods to be studied originating in the eastern Asian countries. During the 1850s, two American physicians studying in Sweden during the Renaissance immigrated the therapies to the United States. The introduction of massage therapy into the western world helped treat health related issues, or so people have been led to believe. In the early 1900s massage therapy was no longer in the spotlight of the medical professional world, and modern medicine began to take its reign. (, 2006)
There are many different types of massage therapies that target different areas or different muscular systems in our bodies that relieve stressors and tension. According to Goldberg (1997), “massage can benefit such conditions as muscle spasm and pain, spinal curvatures (lordosis, scoliosis), soreness related to injury ad stress, headaches, whiplash, temporomandibular joint syndrome (TMJ), and tension-related respiratory disorders such as bronchial asthma or emphysema”. Some methods of massage help break up the wastes that are built up and stored in the muscle, and get it to start to work itself out of the individual’s body. This process can lead people to believe that massage therapies are a good way to naturally help and keep the body restored and able to fight off illnesses. Massage therapies are also useful in treating patients with pain discomfort that could be caused by a number of different instances.
Along with the major benefits stated previously there are many other positive aspects to therapeutic massage methods like decreasing scar tissue by breaking up the fibrosis and adhesions that develop after injuries. It can also reduce swelling from injuries and or illnesses, and increase the amount of lymphatic circulation in the body. One major benefit that is not mentioned often is that it strengthens the muscles in your body that work as a system that moves waste through your body to excrete them. This helps eliminate future infections and/or illnesses. (Goldberg, 1997)
Like all other alternative methods, massage therapy has its rare cases of negative effects on patients. Since massage therapy is a popular technique even as a luxury in today’s western civilizations, these cases of adverse effects seem very minimal as a whole in society. Since this is simply a manipulative method, if the patient is ill or experiencing any pain that they are unaware of, there may be some potential risks. In a case reported by Ernst (2003), a 39 year old female was experiencing abdominal pain and sought massage therapy. After being admitted to the hospital due to her increased abdominal pain, medical professionals found a hematoma in her abdomen from the massage therapist. There are several different cases that target different areas of the body, but the literature overall states that massage therapy can be harmful if not practiced by licensed and educated professionals. (Ernst, 2003)

VII. Various Research on Manipulative Therapies

Conducting sufficient research that can be replicated with another sample size is what expands the knowledge in any field of study. In manipulative alternative medicine, the more knowledge that we have gained over the centuries, and the more methods and techniques we have gained is through research and experiments. The most important thing about the research is how it reflects on the population and whether it targets on one specific type of population or if it can work for anyone who is experiencing the symptoms that may be alleviated by receiving treatment. In the following sections there is some examples of research in the literature on specific methods of manipulative alternative methods. Overall more research needs to be completed to be able to conclude how successful and or adverse these methods are.

VIII. Acupressure/Acupuncture Research

In the 1970s there was a researcher in California at the University of California and San Francisco, Kenneth Pelletier, who was conducting research that explored people who could control their autonomic functions using their mind body experiences. During an interview between Bonnie Horrigan and Pelletier himself he revealed his research findings. The cases Pelletier was looking into with great detail was pain perception, brain waves, blood pressure, and heart rate. After receiving funding from a donor, John Fetzer who established the Fetzer institute, Pelletier completed his study with 3 participants. The participants were from various fields of expertise, and were unrelated in anyway. The participants were a karate expert, a drug smuggler, and a Dutch mediator, Jack Schwarz, who had be previously studied by Dr. Elmer Green. (Horrigan, 2002)
During this study the karate expert was the first participant to be observed in which their findings were published in Playboy. The karate expert took a sharpened bicycle spoke and pushed it through his forearm. Once the spoke was through his forearm he would hang a heavyweight from the spoke and he would focus his chi using his karate methods. Pelletier and his laboratory assistants would record his heart rate using an electroencephpalographic (EEG). Since these findings were published Pelletier had an inmate reach out to him from prison in San Quentin. After negotiations with the Department of Corrections the inmate was allowed to attend the laboratory for research with Pelletier and his assistants. (Horrigan, 2002)
The inmate’s trails demonstrated various methods of puncturing the body. He gave a his brief history of his drug smuggling life style and how he taught himself to control his blood pressure to control his bleeding, and also control his pain tolerance. He was injured numerous times from gunshot wounds and had to learn how to control his autonomic functions so he would not be discovered. In his experiment he inserted three sharpened bicycle spoke through one side of his cheek, through his mouth and out the other cheek. He also taught Pelletier about eating light bulbs and breathing fire as well. (Horrigan, 2002)
The third participant, Jack Schwarz, was contacted by Pelletier and his assistants to participant in their experiment because of his expertise. Within a week of attending the trials he used a large-diameter knitting needle and inserted it through his bicep. After reviewing all three participants trials, it raised many questions for researchers. Was this really a usual phenomenon, or are these three individuals rare a respond differently to these stimuli? (Horrigan, 2002)
To resolve these implications Pelletier conducted tests on all three participants to judge their responses to pain by using standardized pain response tests. To measure their responses to blood clotting, they measured the standard bleeding time, and measured the standard clotting time for each participant. Pelletier also measure the neurotic state of the participants and found that when Jack meditated he could rid his body of pain, keep himself from bleeding, and keep his heart rate down. If he were to attempt to insert a needle through his bicep without meditating he would be in a lot of pain and would probably bleed. (Horrigan, 2002)
Pelletier’s research was widely criticized by other scientists in the field, and also rejectd from journals in the beginning. Once the journals received the documentations and video of the trails, the relationship between tolerances of pain, decreased bleeding, and decreased heart rate became apparent. This was not just a phenomenon that only some people could experience, but if someone is in the right state of mind, a meditative state of mind, they can participant in activities such as these or something like acupuncture. (Horrigan, 2002)

IX. Feldenkrais Research

There have been many different studies done to explore the benefits of the Feldenkrais method and the potential it has to alleviate pain, increase flexibility, reduce anxiety, and even control of functions.
According the research done by Smith, Kolt, & McConville (2001) “pain management combines cognitive, behavioral, and psychological techniques”. To accomplish this management technique it requires cooperation between the patient and the counselor. To achieve the behavioral aspect it is important for a counselor to help a patient find new coping skills to deal with the pain as well as give individual counseling to the patient. Group counseling can be helpful in a situation that may deal with a group of people who are injured like in a war situation. In the study done by Smith et al. (2002) the goal was to examine the effects of the Feldenkrais method has on a multidimensional construct, and to examine the effect the method has on the state of anxiety in a clinical setting. The two hypotheses that were tested were “evaluate dimensions of pain following a Feldenkrais Awareness Through Movemenment (ATM) session in people experiencing chronic low back pain (CLBP)”, and was there “a significant reduction in state anxiety following a Feldenkrais ATM session in people experiencing CLBP. (Smith et al., 2002)
The study involved 26 participants that were randomly assigned from the community health center and a rehabilitation hospital who reported experiencing CLBP by definition of the American Medical Association’s (1988) definition. To rate the pain the participants were experiencing they used the Short-Form McGill Pain Questionnaire that was developed by Melzack in 1987. This questionnaire has three different components so that it can be scored on descriptive sensory, affective, and to evaluate the dimensions of pain. To test the state of anxiety Smith et al. (2002) used the State Trait Anxiety Inventory (STAI) Form Y that was developed by Spielberger et al. in 1983. This test consists of scales that evaluate the feelings of apprehension, tension, and nervousness, and worry. (Smith et al., 2002)
The participants were assigned to one of two groups, Group 1 that received the Feldenkrais ATM, and Group 2 the control group. Group 1 was instructed to sit on the floor and follow the audiotape that walked the participants through breathing methods that would help them relax. The researchers thought it might be best to not do movements on the floor that may involve the pelvis, legs, or increase lower back pain they already have trouble with. Following this 30-minute session the participants filled out the questionnaires. The participants in the control group first completed the questionnaires, and then participated in a 30-minute audiotape session. (Smith et al., 2002)
The results of this study showed that Group 1, that received the Feldenkrais ATM did not reduce the sensory or evaluative dimensions for pain but was effective for the reduction in affective dimension, for people who are experiencing CLBP.
(Smith et al., 2002)

X. Rolfing Research

Some interesting research has be done on soft tissue manipulation (Rolfing method) and how it corresponds with shifts in the pelvic inclination angle and parasympathetic tone. In previous research it was discovered that the pelvic tilt could be associated with autonomic stress. It has been shown that soft tissue manipulations to the pelvic area can stimulate the parasympathetic nervous system (PNS) as well as the sympathetic nervous system (SNS). (Cottingham, Porges, & Richmond, 1988)
In Cottingham et al. (1988) the purpose was to evaluate the effects of receiving the Rolfing method for participants who exhibited an anteriorly tilted pelvis, and to also evaluate the effects the Rolfing procedure has on the parasympathetic nervous system (PNS) following the 24 hours after the session. Two examine the responses of the nervous systems Cottingham et al. (1988) observed the cardiac PNS tone by listening to the vagal tone that Porges was known for. This vagal tone is the “accurate technique of quantifying the respiratory sinus arrhythmia amplitude through the application of time-serious statistical techniques” (Cottingham et al., 1988)
In this experiment Cottingham et al. (1988) used 32 healthy male participants between the ages of 21 and 35 and were selected based on their existing condition of an anteriorly tilted pelvis in the sagittal plane. Half of the participants were randomly assigned to Group 1 and half were randomly assigned to Group 2 where both groups receive 10-sessions of the Rolfing method prior to the study, four of which were soft tissue pelvis manipulating. There was also a control group for each study to show that there was no change in the PNS or the SNS after the 24 hour time period of the trial.
The researchers used a Vagal Tone Monitor to measure the increase in parasympathetic activity. This consisted of a “microcomputer-based device that calculated vagal tone and heart rate on-line” (Cottingham et al., 1988). Electrodes were places on the wrists of patients that measured the electrocardiographic activity by an ECG amplifier. To measure the angle of pelvic inclination the researchers used a device called an inclinometer that contained a universal protractor and a bar-clamp caliper. (Cottingham et al., 1988)
The results of the study supported both hypotheses tested by Cottingham et al. (1988). The soft tissue manipulation did affect the angular tilt of the pelvic region as well as affect the parasympathetic nervous system and the sympathetic nervous system. The control group that did not receive any manipulative treatments showed no decrease in angular position of the pelvis between pretest and the 24-hour posttest. However, the experimental group demonstrated a decrease in angular position after the Rolfing method sessions, and displayed a decreased heart rate in relation to the PNS. In conclusion of this research experiment, the results support the idea that the Rolfing method could be used in treating a number of clinical cases of lower back pain. (Cottingham et al., 1988)
Osteopathic Research
At the University of North Texas Health Sciences Center in Fort Worth, Texas there was a study done that used a larger sample size to reflect back to the population rather than the typical smaller studies the field was used to seeing. In 2003, Licciardone, King, Hensel, & Williams completed a study to examine the effects that osteopathic manipulative treatment (OMT) and ultrasound physical therapy (UPT) would have on decrease the amount of lower back pain an individual experiences on a daily basis. All methods and treatment protocol to this study was approved by the International Review Board (IRB). (Licciardone et al., 2003)
There were 488 participants in this study, all of which completed an extensive interviewed over the telephone where they were asked many questions about the experiences with OMT in the past three months, and in the past year. There were a number of criteria that each participant could qualify for the study, and a checklist of things in which would disqualify. The biggest issue was pregnancy because the effects of the UPT and the fetus were unknown. A brief medical history was also acquired via telephone due to reasons that could not allow success in the study. For example, if an individual suffered from cancer, they may not find any relieve from OMT and the disease is deeply rooted in the body. (Licciardone et al., 2003)
Of the 488 participants, they were split into four different groups. Each group received a different combination of treatment. Group A received both OMT and UPT, Group B received OMT but received the bogus UPT, Group C received the bogus OMT but the active UPT, and Group D received both the bogus OMT and UPT procedures. This created a 2x2, between-between design for functional analysis. For each group there are four treatment “subgroups” that contain 6 participants in each group. There is a therapist for each of these groups who collects data but is blind to their treatment procedures. (Licciardone et al., 2003)
In the active OMT phases of treatment the therapist were flexible to the participants. Over a period of time the researchers developed a sense of knowledge that OMT would be more successful if it was individualized rather than standard for each person. This would allow for each person to target his or her specific lower back pain area. There were 14 approved techniques the therapists had to choose from to individualize each participant’s treatment plan. These techniques are outlined in the Glossary of Osteopathic Terminology. During this phase of treatment the participants are rated on a scale of 0-2 according to the severity of their dysfunction. This evaluation is done from a seated position, prone position, and left and right lateral recumbent positions. (Licciardone et al., 2003)
In the active UPT phase the same therapists that administered the OMT to the participants will administer the UPT. This method is the same type of ultrasound equipment used in many physical medicine programs. The apparatus is set to an intensity of 1.2W/cm2, and using a frequency of 1MHz for ten-minute sessions. This will allow the area of focus to be heated to 4 degrees Celsius. The idea behind heating the soft muscle tissue is to relax the muscle and ameliorate symptoms of pain and decrease any signs of inflammation. If the participants felt any discomfort during this procedure they were advised to let the therapist know and they did not have to continue. (Licciardone et al., 2003)
The sham or bogus OMT phase was developed by the North Texas Chronic Low Back Pain Trail itself. This was designed to involved minimal involvement between the therapist and the participant. There was contact between the therapist and the participant but they were not receiving the correct treatment in order to alleviate any symptoms they were having. These participants were evaluated in the same positions as the participants who received the active OMT. (Licciardone et al., 2003)
The sham UPT received sub therapeutic ultrasound that was set to an intensity of 0.1W/cm2, and a frequency of 1MHz. The difference in this case is that the head of the applicator will be applied to the participants skin and moved in all aspects of the previous active UPT trials. This creates the illusion of receiving the active UPT and could produce psychological effects of feeling heat in the low back pain area of focus. (Licciardone et al., 2003)
The results of this study are still in progress and have no been released to the press. However from previous research OMT has shown to be very helpful in treating low back pain and often time alleviating any and all symptoms the patient may experience. This study is one of the first that has been done that examines the effects of OMT and UPT corresponding together. When the participants are through with their sessions of OMT and UPT they will be asked to fill out questionnaires to rate the pain level and their satisfaction level. This is where more data will come from other than the data recorded by the therapists in the sessions.
(Licciardone et al., 2003)

XI. Conclusions

This chapter has given a brief overview of alternative medicines in general, where they originated, what they are, and what types actually exist. In today’s modern society there are many people who do not believe in alternative medicines and view it as an ancient part of the world. Some types of alternative medicine are now considered as luxury and exercise, such as massage therapy and yoga. Many of the different techniques intertwine with each other but have many significant benefits to the individual if completed right. It is all about the mind; if you let the theory into your mind, you may just gain more knowledge and strength.
Manipulative medicines are procedures and techniques that require movement and manipulation to the musculoskeletal system of an individual’s body. Often times this is a result of injury and or illness. These procedures alleviate the symptoms of pain, inflammation, and even often times prevent any further illness from occurring. The most common types of manipulative procedure is massage therapy and chiropractic. Typically an individuals first visit to a chiropractor is after an injury, but in my person experience once you have your first visit and realize after years of bad posture and many injuries, you need several adjustments to get your spine back into alignment.
All of these manipulative methods give your body the energy to recuperate and fight of the toxins that break your body down.


__Barrett, Stephen__. "Reflexology: A close look". Quackwatch. (2004-09-25). Retrieved 2007-10-12.
Cottingham, John T., Stephen W. Porges, and Kent Richmond. "Shifts in Pelvic Inclination Angle and Parasympathetic Tone Produced by Rolfing Soft Tissue Manipulation." Physical Therapy 68.9 (1988): 1364-370. Print.
Ernst, E. (2003). The safety of massage therapy. Rheumatology (Oxford, England), 42(9), 1101-1106. Retrieved from MEDLINE with Full Text database.
Ernst, E., and P. H. Canter. "A Systematic Review of Systematic Reviews of Spinal Manipulation." J R Social Medicine 99 (2006): 192-96. Print.
Horrigan, Bonnie. "Kenneth R. Pelletier, Ph.D., MD, Mindbody Medicine." Alternative Therapies 8.6 (2002): 90-99. Print.
Kapral, M., & Bondy, S. (2001). Cervical manipulation and risk of stroke. CMAJ: Canadian Medical Association Journal = Journal De L'association Medicale Canadienne, 165(7), 907-908. Retrieved from MEDLINE with Full Text database.
Kaptchuk, Ted J. Eisenberg, David M. "Chiropractic, Origins, Controversies, and Contributions." Archives of Internal Medicine 158.20 (1998): 2215-224.
Kerr, H.D.. Ureteral stent displacement associated with deep massage. WMJ 1997;96(12):57-58.
Licciardone, John C., Hollis H. King, Kendi L. Hensel, and Daniel G. Williams. "Osteopathic Health Outcomes In Chronic Low Back Pain: The Osteopathic Trail." Osteopathic and Primary Care 2.5 (2008). Print.
Madsen, M. V., Gotzsche, P. C., Hrobjartsson, A. (2009). "Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups". BMJ 338: a3115. doi:10.1136/bmj.a3115. PMID 19174438
"Massage Therapy: An Introduction." National Center for Complementary and Alternative Medicine [NCCAM] - Home Page. U.S. Department of Health and Human Services, Sept.-Oct. 2006. Web. 23 Nov. 2010. <>.
Martin, Steven C. "Chiropractic and the Social Context of Medical Technology." Isis 85.2 (1994): 207-27. Journal Storage. Web. 14 Nov. 2010. <>.
Pettman, E. (2007). A history of manipulative therapy. The Journal Of Manual & Manipulative Therapy, 15(3), 165-174. Retrieved from MEDLINE with Full Text database.
Reese, Mark. "About Moshe." Home. Feldenkrais Southern California Movement Institute, 2004. Web. 30 Nov. 2010. <>.
"Rolfing Structural Integration." InteliHealth:. Aetna IntelliHealth Inc., 7 Sept. 1999. Web. 30 Nov. 2010. <>.
Smith, Alison L., Gregory S. Kolt, and Janet C. McConville. "The Effects of Feldenkrais Method on Pain and Anxiety in People Experiencing Chronic Low Back Pain." Journal of Phsyiotherapy 29.1 (2001). Print.
Stallibrass, C. P. Sissons, C. Chalmers (July 2002). "Randomised Controlled Trial of the Alexander Technique for Idiopathic Parkinson's Disease" (PDF). Clinical Rehabilitation 16 (7): 695–708. doi:10.1191/0269215502cr544oa. PMID 12428818. Retrieved 2007-05-01.
Stirling, Isabel. Zen Pioneer: The Life & Works of Ruth Fuller Sasaki (2006) Shoemaker & Hoard. ISBN 978-1-59376-110-3 pg. 8
Trager, Milton M.D., with Hammond, Cathy. Movement as a Way to Agelessness: A Guide to Trager Mentastics, Barrytown, NY., Station Hill Press, 1987,1995, ISBN 0-88268-167-2.
Tschopp, J-M. "Management of Spontaneous Pneumothorax: State of the Art." European Respiratory Journal 28.3 (2006): 637-50. Print.
White, A., Hayhoe, S., Hart, A., Ernst, E.. (2001). "Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists". //British Medical Journal// 323 (7311): 485–6. doi:10.1136/bmj.323.7311.485. PMID 11532840. PMC __48133__
"What Is Complementary and Alternative Medicine? [NCCAM CAM Basics]." National Center for Complementary and Alternative Medicine [NCCAM] - Home Page. U.S. Department of Health and Human Services, Apr. 2010. Web. 20 Oct. 2010. <>.
Yekeler, E., Tunaci, M., Tunaci, A., Dursun, M., Acunas, G.. "Frequency of Sternal Variations and Anomalies Evaluated by MDCT". American Journal of Roentgenology 186 (4): 956–60. doi:10.2214/AJR.04.1779. PMID 16554563. Retrieved 2007-11-24.