Edited by: Arch Mainous, University of Florida, United States
Reviewed by: Fatemeh Darsareh, Hormozgan University of Medical Sciences, Iran; Eron Grant Manusov, The University of Texas Rio Grande Valley, United States
This article was submitted to Family Medicine and Primary Care, a section of the journal Frontiers in Medicine
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External applications from anthroposophic medicine (EAAM) are touch-based applications such as rhythmical massages, embrocations, and compresses that serve as components of complementary treatment concepts for various diseases. The aim of this review is to gain an understanding of typical indications and outcomes and to systematically assess the effectiveness and safety of EAAM.
Medline/PubMed, CINAHL, the Cochrane Library, Embase, and PsycINFO were searched through May 2021 and supplemented by searches in specialized databases and personal requests to experts in the field. Studies and case reports on EAAM in patients, as well as healthy individuals, were included in the qualitative synthesis. Outcome parameters depending on each study were grouped as effect themes and assigned to study clusters using Thematic Analysis for a thematic overview of effect patterns.
Four RCTs, 7 cohort studies, 1 mixed-methods, 1 retrospective, 4 qualitative studies, 3 case series, and 25 case reports on EAAM were identified. The analysis indicated various effects of EAAM on physiological as well as psychological health indicators and patterns of effect development. Study quality was found to be high for only 2 studies, and moderate for 1 study, and all remaining 45 studies showed a moderate or high risk of bias or were not ratable with used rating tools.
The included studies present a wide range of potential indications for EAAM, while showing methodological drawbacks. To determine whether EAAM can be considered an effective treatment option, clinical studies exploring the effect of different EAAM modalities on defined patient groups are recommended for the future.
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Supporting individual patient needs at times goes beyond the limits of conventional medicine. Integrating methods from traditional, complementary, and integrative medicine into treatments may extend therapeutic options and add valuable knowledge on health promotion (
In general, external applications unfold their effects through several different mechanisms: the effect of physical treatment, the touch of the therapist, a calming environment, and the substance on the skin (
The effect of applications with altered temperatures on the organism can be explained by the principle of hormesis, a physiological regulatory reaction to activation by external stimuli or moderate stressors, such as heat or cold (
Through the complex system of nerve fibers on the skin, the sense of touch is of great importance for haptic and tactile perception and social interaction (
Anthroposophic medicine (AM) is an integrative medical system developed in Europe around 1900 by Rudolf Steiner and M. D. Ita Wegman. AM is based on the views of the spiritualist movement of Anthroposophy and is intended to be applied in combination with recognized science-based medical methods (
External applications from anthroposophic medicine are intended to stimulate autonomic self-regulation and salutogenic processes by physically influencing the distribution of warmth in the organism, and therefore, integrating the functions of
Types of external applications from anthroposophic medicine.
Application type | Origin | Practice description | Intention |
Rhythmical massage | Developed as an independent massage technique in anthroposophic medicine (AM), extending basic movements of classical massage. | Extends basic movements of classical massage by rhythmic, expanding and contracting, circular and lemniscate movements, and movements progressing from the depths to the periphery of the body. | Intended to influence the tissue, as well as the body, soul and spirit through the |
Rhythmical embrocation | Differentiation of specific elements of rhythmical massage. | Using only stroking, embrocation is mainly done in the form of rhythmically performed circles or spirals, perceived more locally on the skin rather than in the deeper tissue. | Intended to influence the body, soul, and spirit through the |
Pressel stream massage | Advanced form of rhythmical massage. | Alternately treating the lower and upper body and/or the left and right side of the body during a treatment sequence. Calves, thighs and the lower back are usually massaged in one session followed by the treatment of the upper back, arms and neck in the next. | Sequences are described to set a stimulating energy flow in motion ( |
Compresses | Application in different body regions using natural substances on the skin. Typical forms are warm wet compresses using |
Intended to support self-regulation ( |
While literature reviews are available for multimodal application and other treatment modalities of AM (
Given the research gap regarding EAAM, the overall aim of this mixed methods systematic review is to clarify existing applications and indications and to assess the effects and safety of EAAM. This aim has three specific outcomes: the analysis will describe typical indications for EAAM, typical outcomes will be summarized, and the effectiveness and safety will be systematically assessed.
The review was planned following the principles of a mixed methods systematic review (
For the description of eligibility criteria, refer to
Eligibility criteria.
Criteria | Inclusion |
Study types | Quantitative studies, e.g., randomized controlled trials (RCTs); quasi-experimental studies; qualitative studies; case studies and reports. |
Publication | Peer-reviewed publications, gray literature records, extensive abstracts. |
Language | English or German. |
Participants | No restrictions on the types of participants, symptoms, and indications. |
Interventions | Interventions involving direct interpersonal touch, including rhythmical massage, rhythmical embrocation, Pressel stream massage, compresses and wraps. |
Outcome measures | Any health indicators, such as somatic and psychological parameters. |
The literature search was built around search terms for “anthroposophic medicine” and “External Applications.” The following electronic databases were searched from their inception through 31 May 2021: Medline/PubMed, CINAHL, the Cochrane Library, Embase, and PsycINFO. The Anthromedics Merkurstab archive
Search strategy.
Source type | Source | Terms/Strategy |
Electronic data bases | Medline/PubMed | anthroposoph*[All Fields] AND (extern*[Title/Abstract] OR rhythmic*[Title/Abstract] OR massage[Title/Abstract] OR embrocation[Title/Abstract] OR wash*[Title/Abstract] OR compress[Title/Abstract] OR pack[Title/Abstract] OR poultice[Title/Abstract] OR wrap[Title/Abstract] OR essence[Title/Abstract] OR liniment[Title/Abstract] OR ointment[Title/Abstract] OR oil[Title/Abstract] OR tincture[Title/Abstract]) |
CINAHL | ||
Cochrane Library | anthroposoph* AND (extern* OR rhythmic* OR massage OR embrocation OR wash* OR compress OR pack OR poultice OR wrap OR essence OR liniment OR ointment OR oil OR tincture) | |
Embase | anthroposoph* AND (extern* OR rhythmic* OR massage OR embrocation OR wash* OR poultice OR wrap OR pack OR compress OR essence OR liniment OR ointment OR oil OR tincture) | |
PsycINFO | ||
Alternative electronic data bases | Anthromedics Merkurstab data base | |
CAMbase | anthroposoph* AND (extern* OR rhythm* OR massage OR embrocation OR wash* OR compress OR pack OR poultice OR wrap OR essence OR liniment OR ointment OR oil OR tinctur* OR äußer* OR äusser* OR aeußer* OR aeusser* OR Einreibung OR Wasch* OR Wickel OR Auflage OR Salbe OR Öl OR Oel) | |
CAM-Quest | CATEGORY: “Anthroposophische Medizin”: |
|
Open gray | anthroposophy; anthroposophic; Anthroposophie | |
ResearchGate | ||
Personal inquiry | Experts and institutions | E-mail inquiry to a total of 104 international experts and institutions of anthroposophic medicine and nursing |
Using a
Since studies of different methodologies were eligible for inclusion the assessment of study quality was undertaken in 3 steps. First, we sorted the studies by the level of evidence. For the detailed quality assessment, the recommended tool for risk of bias assessment of controlled trials in systematic reviews
All assessments were conducted by IM. Half of the QA-Tool assessments as well as half of the RoB assessments were also performed by JE independently. The remaining assessments were reviewed by JE. Conflicts of rating were discussed until a consensus was reached.
We first performed a Level of Evidence (LoE) assessment for all included studies, using an adapted version of the
For the quality assessment of the quantitative studies, we used the QA-Tool. The tool assesses study quality according to a strong, moderate, or weak rating quality along with the following domains: selection bias, study design, confounders, blinding, data collection methods, withdrawals and dropouts, intervention integrity, and analyses (
The RoB tool assesses the risk of bias in the domains of selection bias, performance bias, attrition bias, reporting bias, and detection bias using 8 criteria (
The literature search revealed a total of 665 records, resulting in 390 non-duplicate records of which 238 were excluded because they did not report on EAAM studies in English or German. Out of 144 full-texts assessed for eligibility, 99 articles were excluded because they were theoretical descriptions or instructions of EAAM (58 records), were double publications on the same study (25 records), reported epidemiological or ethnographic data (7 records), were not studied on EAAM (6 records), or were study protocols without results (3 records).
Finally, 45 studies were included, out of these 34 studies were on massage interventions and 11 were on compresses interventions. On massages, there were 3 RCTs, 5 cohort studies, 2 qualitative studies, and 24 case reports or series. On compresses, there were 1 RCT, 1 mixed methods study, 2 cohort studies, 1 retrospective study, 2 qualitative studies, and 4 case reports or series. The flowchart of the results of the literature search is depicted in
Flowchart of the results of the literature search.
Of the 45 studies, 18 were published in peer-reviewed journals (
The first included study was published in 2001, in fact as the second edition of a study originally published in 1992 (
The number of studies on EAAM in a given year reported in absolute terms. Studies exploring a mixed intervention of massages and other application types were counted as massage studies.
Characteristics of the study methodologies, samples, interventions, outcome assessments, and results are shown in
Summary of quantitative studies on massages.
Reference | Type of study | Participants: |
Intervention: Modality, substance, body region, number/time span | Main outcome assessment | Main results: Improvements of outcome parameters | Level of evidence, quality, risk of bias |
Kanitz et al. ( |
RCT, 3 groups, single-blinded | TSST followed by 1× treatment in individualized body regions, 3 groups: |
(A) Well-being: MDBF, Bf-S, assessment BT, AT |
BG and AT vs. BT |
LoE: II |
|
Seifert et al. ( |
RCT, 3 groups, single-blinded | TSST followed by 1× treatment in individualized body regions, 3 groups: |
Autonomic regulation: HRV parameters of ECG; |
BG: |
LoE: II |
|
Vagedes et al. ( |
RCT, 3 groups, not blinded | Treatment over 3 months, 3 groups: |
(A) Pain intensity during menstruation: NRS |
(A) BG: (1) vs. (3): |
LoE: II |
|
Hamre et al. ( |
Cohort study, 1 group, not blinded | RM, substance/region unspecified, 12× (median) within 84 days (median) | (A) Disease score |
12 months after start vs. BT: |
LoE: IV |
|
Wälchli et al. ( |
Cohort study, 1 group, not blinded | RM with individualized oils/ointments, in individualized body regions, 9× (average), 1–2× per week within 3 months | (A) Disease score |
AT vs. BT/after 6 months vs. BT: |
LoE: IV |
|
Wälchli et al. ( |
Cohort study, 1 group, not blinded | RM with individualized oils/ointments, in individualized body regions, 10× (average), 1–2 × per week within 3 months | (A) Surface temperature: IRI of dorsal region; assessment in waiting periods BT and AT |
AT vs. BT: |
LoE: IV |
|
Ostermann et al. ( |
Cohort study, 1 group, not blinded | RE with aroma oil with peat and lavender extracts, in individualized body regions, 3× within 24 days | (A) Mental state: Bf-S mood scale |
AT vs. BT: |
LoE: IV |
|
Vieira et al. ( |
Cohort study, 1 group, not blinded | Threefold External Therapy: Body sliding/organ rubbing/foot baths/compresses, substances unspecified, individualized treatment, 12 weekly sessions | (A) Cognitive function: MMSE |
AT vs. BT: |
LoE: IV |
Abstract, only abstract of study available; AE, adverse effects; AM, anthroposophic medicine; AT, after treatment; B-L, 24-item list of somatic complaints; Bf-S, Zerssens Adjective Mood Scale for assessment of mental state; BG, between groups; BT, before treatment;
Summary of quantitative studies on compresses.
Reference | Type of study | Participants: |
Intervention: Modality, substance, body region, number/time span | Main outcome assessment | Main results: Improvements of outcome parameters | Level of evidence, quality, risk of bias |
Ghadjar et al. ( |
RCT pilot, 2 groups, not blinded | 2 groups |
(A) Fatigue: MFI-20 Subscale |
BG: |
LoE: IV |
|
Stritter et al. ( |
Qualitative part of a mixed methods study: Case cross-over, 1 group, single-blinded (qualitative results: see |
4 different chest compresses over 4 weeks in 1 group: |
(A) Somatic complaints: B-L |
AT vs. BT per each treatment: |
LoE: IV |
|
Klich-Heartt ( |
Cohort study, 1 group, not blinded | Calf compress with lemon aroma oil, 1× | (A) Temperature: Clinical thermometer |
AT vs. BT: |
LoE: IV |
|
Therkleson ( |
Cohort study, 2 treatment groups, not blinded | Ginger compresses, 2 treatment groups, both 1-week daily ginger patch/compress applied to the midlumbar region: |
(A) Health assessment: Arthritis MHAQ/HAQ-II |
BG: ns, both groups reported together in percentages of patients, (A) Improvement in mean scores 1 week AT vs. BT: Pain: 48%, fatigue: 49%, GEO: 40%, functional status: 31%; improvement in all scores for all participants in all domains over following 24 weeks of self-treatment |
LoE: IV |
|
Simoes-Wüst et al. ( |
Retrospective descriptive study, 1 group, not blinded | Various compress types, patients treated with at least one compress during their hospital stay | State of health: 13 items; one-time assessment | Improvement in state of health attributed to the compresses: 70%, considerable recovery: 85%, considerable success of compresses: 76% | LoE: VI |
AT, after treatment; B-L, list of somatic complaints; BT, before treatment; distress thermometer, German version of the distress thermometer of the National Comprehensive Cancer Network; GEO, global effect of osteoarthritis; HAQ-II, Health Assessment Questionnaire II; LoE, level of evidence based on the evidence-based nursing care guidelines scheme [Ackley et al. (
Summary of qualitative studies on massages.
Reference | Type of study | Participants: |
Intervention: Modality, substance, body region, number/time span | Main outcome assessment | Main results: Improvements of outcome parameters |
Berger et al. ( |
Qualitative study, selection of the sample of Vagedes et al. ( |
RM, substance/region unspecified, 12×, weekly over 3 months | Semi-structured interviews, drawings ( |
Perception of RM as soft and overall beneficial, feeling different to conventional massage, influence on the whole body; improved pain management, calming, relaxing, increased self-awareness, cause for a process of transformation; reactions depend on the emotional state and readiness to resonate with the therapeutic process | |
Bertram et al. ( |
Qualitative study, phenomenology | RE (theoretical) | Semi-structured interviews | Psychosomatic reactions to RE rely on changes in physical parameters and changes in vegetative, mental and spiritual dimensions; |
Gray, study from gray literature; RE, rhythmical embrocation; RM, rhythmical massage.
Summary of qualitative studies on compresses.
Reference | Type of study | Participants: |
Intervention: Modality, substance, body region, number/time span | Main outcome assessment | Main results: Improvements of outcome parameters |
Stritter et al. ( |
Qualitative part of a mixed methods study: Case cross-over, 1 group, single-blinded |
4 different chest compresses over 4 weeks in 1 group: |
Interviews after each application, follow-up interview | Different onset of relaxation after all 4 applications and resting periods, different qualities of warmth through the ingredients ginger and mustard; |
|
Therkleson and Sherwood ( |
Qualitative study, phenomenology | Ginger kidney-compress, 1× | Semi-structured interview | 4 key themes: |
|
Therkleson ( |
Qualitative study, phenomenology | Ginger kidney-compress on 7 consecutive days | Daily diaries, drawings, personal/phone follow-up interviews | Unique qualities of heat, stimulation, anti-inflammation, and analgesia; |
Summary of case reports on massages.
Reference | Type of study | Participant: Age/gender, diagnosis | Intervention: Modality, substance, body region, number/time span | Main outcome assessment | Main results: Improvements of outcome parameters |
Gierse ( |
Prospective case study | 78/female, after surgical treatment of a humerus fracture | RM, substance/region/number unspecified | Observation, interviews, schematic progress documentation | Warming sensation, deepened breath, improvement of pain, hypoesthesia and mobility, improvement of mental state |
Göbels and Allmer ( |
Prospective case study | 39/female, mammary carcinoma, after bilateral mastectomy | RM, substance/region unspecified, 7× over 4 weeks | Observation, interviews, schematic progress documentation, guided diary for self-observation, SF-36; assessment each time | Positive effects on warmth regulation, body experience, emotional well-being, improved emotional well-being |
Klocker ( |
Prospective case study | Unspecified/male, burnout syndrome | RM, different regions, substance/number unspecified, in 2 cycles | Observation, interviews, schematic progress documentation | Muscle relaxation, warming sensation, harmonizing and deepening the breath, improved self-observation/self-awareness and self-reflection, improved drive |
Kögler ( |
Prospective case study | 47/female, lumbar syndrome | RM, substance unspecified, different regions, 14× in 2 cycles | Observation, interviews, schematic progress documentation | Reduction of pain intensity and frequency of pain attacks, muscle relaxation, warming sensation, harmonizing and deepening the breath, improved decisiveness |
Radünz ( |
Prospective case study | 41/male, obstructive sleep apnea | RM, substance/region unspecified, 10× | Observation, interviews, schematic progress documentation, SF-36; assessment each time | Reduced vertigo, increased appetite, improved sleep, strengthening feeling, less fatigue and improved concentration, anxiety and panic states become increasingly weaker, increase in libido, improved self-awareness |
Schober ( |
Prospective case study | 17/male, spastic tetraparesis | RE, substance/region unspecified, 14× in 7 weeks | Observation, interviews, schematic progress documentation | Warming sensation in the whole body, improved mobility, loosening feeling, improved gross and fine motor skills, vitalizing feeling |
Schwarz ( |
Prospective case study | 64/male, Morbus Parkinson | RM, substance unspecified, different regions, 11× in 11 weeks | Observation, interviews, schematic progress documentation, medical findings of the general practitioner, diary | Increased flexibility in facial expression, deepened breathing, improved balance and upright posture, improved sense of smell, improved sleep and mood |
Schwinger ( |
Prospective case study | 61/female, burnout syndrome | RM, substance/region unspecified, 21× weekly in 3 cycles over 6 months | Observation, interviews, schematic progress documentation, SF-36, assessment each time | Improved self-awareness, mood, well-being, and sleep, vitalizing and relaxing effect |
Seedheeyan et al. ( |
Prospective case study | 50/female, hypoxic brain injury, hypersensitivity to sensory stimuli, pain | RM, substance/region/number unspecified | Pain assessment tools: Body map to indicate location, Wong-Baker Faces Pain Rating Scale, response to qualitative pain description words | Reduced levels of hypersensitivity, anxiety and confusion, improved self-awareness: perception of and ability to describe pain |
Uhlenhoff ( |
Prospective case study | 11/male, on the autism spectrum | RM, substance/region unspecified, 14× biweekly in 7 weeks | Observation, interviews, schematic progress documentation, SF-36 | Warming sensation, deepened breath, increased tolerance for touch; |
Amman Albertin ( |
Retrospective case report | 68/female, asthma bronchiale, hypertension, bilateral osteoarthritis | RM, substance/region/number unspecified | Use of clinical and personal records of the patient | Improvements in asthma symptoms, withdrawal of pharmaceutical therapy, decrease in blood pressure |
Börner ( |
Retrospective case report | 6/male, restlessness, sleeping problems, social anxiety, and conflicts | RM, substance/region unspecified, weekly for 6 months | Observation, interviews with parents, schematic progress documentation | Relaxation, improved sleep, improved social interaction |
Maier-Schnorr ( |
Retrospective case report | 38/female, migraines, vomiting, nausea, restless, mood swings, | RM of the lower back, hips, abdomen, arms, substance/number unspecified | Observation, interviews | Reduction of vomiting, improvement in restlessness, mood swings, increased attention on avoiding personal overexertion |
Meyer ( |
Retrospective case report | male, pelvic obliquity, scoliosis, muscle tension in the lumbar spine region | RM of the lower back, substance unspecified, biweekly for 3 months, occasional follow-up in following months | Observation, interviews | Improved perception of and strength in the back, ability to lift heavy loads and to work physically without triggering pain or cramps, feeling of well-being and possibility to become active |
Vajnai et al. ( |
Retrospective case series | 59/male, mid-cerebral artery stroke, pain, and spasticity after surgery | RM, substance/region/number unspecified | Observation, interviews | Improved pain management and spasticity management |
Weidtke ( |
Retrospective case series | 41/female, operated mammary carcinoma | RM, 3× per week, substance/region/timeframe unspecified | Self-report | Warming sensation, relief of congestion after 1 or 2 days, relieving sensation, relaxing/flowing/healing feeling, feeling of comfort during the after-rest |
68/female, metastasized mammary carcinoma | RM, substance/region/number unspecified | Self-report | Deepened breath, deep relaxation, vitalizing, harmonizing, strengthening, releasing and re-identifying feeling | ||
50/female, sigmoid carcinoma | RM with various oils (melissa, aurum, lavendula, sloe), region unspecified, 3× | Observation, interviews, schematic progress documentation | Increased comfort in the body, strengthening feeling | ||
Praxl ( |
Prospective case study | Not specified/female, hereditary motor sensory neuropathy | RE, substance/region unspecified, 10× in 7 weeks | Observation, interviews, schematic progress documentation, diary | Warming sensation in the legs, improved sensibility in the legs and walk, improvement in sleep and mood, deep relaxation during RE |
Reisinger ( |
Prospective case study | 55/female, depression, multiple abdominal complaints | RE, substance/region unspecified, 7× in 7 weeks | Observation, interviews, schematic progress documentation | Improvement of bloating and abdominal complaints, warming sensation in the whole body, improved wellbeing |
Roggatz ( |
Prospective case study | 79/female, sleep disturbance | RE with aroma oil with peat and lavender extracts, on the feet and calves, in the evening for 4–6 weeks | Observation, interviews | RE feel beneficial, pleasant heaviness in the body, light feeling in the feet, relaxation of the body: slower breathing, calmer pulse, relaxed muscles, enhanced warming of the skin after each time; |
Voit ( |
Prospective case study | 23/female, exam anxiety | RE, substance/region unspecified, 7× in 7 weeks | Observation, interviews, schematic progress documentation, SF-36, assessment each time | Warming sensation, regulating effect on anxiety and well-being, relaxing and releasing, improved self-awareness and confidence |
Pressel ( |
Retrospective case series | 21/female, neck tension, sleep disturbances, amenorrhea | PM in classic regimen, substance unspecified, 6× | Observation, interviews | Improvement of neck tension, return of menorrhea and stable cycle, improved sleep |
34/female, sleep disturbances, depression | PM calf and back massages, substance unspecified, 40× | AE: Headaches, hemorrhage on the calf with accompanying swelling and sensitivity throughout the leg, tiredness, improved sleep | |||
53/female, chronic fatigue, sleep disturbance | PM calf and back massages, substance unspecified, 10× | Initiation of menstrual bleeding, release of headache, feeling of release and inner alignment, increased well-being | |||
56/female, recurrent cystitis and appendicitis | PM calf massage, substance unspecified, 1× | Following day after massage: severe pain in the lower abdomen and discharge of blood coagulum, no further bleeding in the following 4 years; |
|||
Robert ( |
Retrospective case report | 65/female, chronic pain syndrome, chronic depression | PM in classic regimen, substance/number unspecified, weekly sessions | Observation, interviews | Improvement of mobility, sensation of self-healing powers and revitalization, feeling of well-being and new drive |
Therkleson and Stronach ( |
Prospective case study | 82/female, psychological trauma/characteris-tics diagnosed as Broken Heart Syndrome | RM with aroma oil with peat and lavender extracts, region unspecified; lavender footbath; oxalis ointment compress to the abdomen, 4× weekly sessions | Observation, schematic progress documentation | Warming sensation, increased attention, improved sleep, relaxation, more able to cope with life’s issues, feeling grounded and more integrated |
Deckers et al. ( |
Retrospective case report | 61/male, episode of prolonged postoperative ileus, pain | RM with melissa oil to the abdomen; abdominal compress with thuja and argentum ointment, 1× | Observation, schematic progress documentation | Gradual improvement of symptoms over the next 10 days; no prokinetic medications were needed to manage the episode, decrease in pain |
Abstract, only abstract of study available; AE, adverse effect; gray, study from gray literature; RM, rhythmical massage; SF-36, Health-Related Quality-of-Life questionnaire short form; PM, Pressel stream massage.
Summary of case reports on compresses.
Reference | Type of study | Participant: Age/gender, diagnosis | Intervention: Modality, substance, body region, number/time span | Main outcome assessment | Main results: Improvements of outcome parameters |
Glaser et al. ( |
Retrospective case series | 49/female, recurrent influenza, herpes corneae | Ginger kidney compress, unspecified number | Observation, interviews | Warming sensation, feeling overwhelmed by inner images with following positive processing and feeling of dissolution |
55/female, food intolerance, diarrhea | Ginger kidney compress, 31× in 2 cycles | Observation, interviews | Warming sensation, feeling of release, improved sleep quality, relaxation, feeling of inner support; |
||
50/male, asthma bronchiale | Ginger kidney compress, 9× | Observation, interviews | Warming sensation, relaxation; |
||
33/female, asthma bronchiale | Ginger thorax compress, 7×; ginger kidney compresses, number unspecified | Observation, interviews | First AE: Feeling tightness, coughing, after break: warming sensation, improvement of expectoration | ||
70/female, spastic bronchitis | Ginger thorax compress, number unspecified | Observation, interviews | Warming sensation | ||
55/female, depression, restlessness | Ginger kidney compress, 7× | Observation, interviews | Warming sensation, relaxation, increased duration of sleep | ||
48/female, back and joint pain, adipositas | Ginger kidney compress, 10× | Observation, interviews | Warming sensation, relaxation; |
||
47/male, back pain, subfebrile temperature, leukocytosis | Ginger kidney compress, 8–10× | Observation, interviews | Warming sensation, but no pain release, relaxation | ||
68/female, pancreatic carcinoma, abdomen/back pain | Ginger kidney compress, 17× | Observation, interviews | Warming sensation, pain release (only before noon) | ||
79/female, abdomen carcinoma, skin metastases, ascites | Ginger kidney compress, 12× | Observation, interviews | Warming effect, calming effect on respiration, increased appetite, decreased ascites | ||
33/male, colon carcinoma, liver metastases etc. | Ginger kidney compresses over 3 weeks, number unspecified | Observation, interviews | First AE: Feeling tightness and restlessness, then warming sensation and relaxation | ||
48/female, pneumonia | Ginger thorax compress, 1× | Observation, interviews | Increasing warming effect, energized feeling | ||
83/female, pneumonia after cardiac arrest | Ginger kidney compress, 9×, treatment discontinued | Observation, interviews | First improvement: respiration, expectoration, sleep; later decrease in effect | ||
56/female, primary chronic polyarthritis, joint pain | Ginger kidney compress, 4×, treatment discontinued | Observation, interviews | First warming sensation, later AE: Weakening, discomfort of the skin in form of burning, itching, and redness | ||
28/female, melanoma, sleep disturbance | Ginger kidney compress, 2×, treatment discontinued | Observation, interviews | AE: Sensation of wetness and cold, restlessness | ||
27/female, eating disorder, underweight, sleep disturbance | Ginger kidney compress, 5×, treatment discontinued | Observation, interviews | AE: Subjective sensation of cooling, no feeling of release, continued sleep disturbance | ||
Therkleson ( |
Prospective case study | >65/male, osteoarthritis, pain | Ginger kidney compress, 7× in 7 consecutive days; patch self-treatment at home for a further 24 weeks | Arthritis HAQ, pain VAS, diary; assessment daily, 8 days BT until 6 days AT, and after 24 weeks | Diary: Warming sensation, increase in flexibility and mobility, decrease in pain; improvement of global effect, fatigue, and mobility, continued improvements in global effect, fatigue, and mobility over the 24-week of self-treatment |
Schier and Bruchner ( |
Prospective case study | 40/male, seminoma, in the third chemotherapy cycle | Yarrow liver compress during chemotherapy, 5× daily | Observation, interviews, schematic progress documentation, self-reports | Symptom relief compared to the first two cycles of chemotherapy: No symptoms of nausea, loss of appetite or tension during the application days, enhanced appetite, warming sensation, feeling of relaxation |
Deckers ( |
Retrospective case report | 20/male, pneumonia, pain | Mustard compress on the chest followed by lavender oil, 1× | Observation, interviews, schematic progress documentation | Hyperemia of the skin followed by pain reduction, deepened breathing, expectoration |
AE, adverse effects; AT, after treatment; BT, before treatment; gray, study from gray literature; HAQ, Health Assessment Questionnaire; VAS, Visual Analog Scale.
Of the 45 included studies, 21 studies originated from Germany (
Participants were recruited during inpatient treatment in integrative AM clinics in 10 studies (
In total, 45 studies reported results on 815 participants. Seventy of them participated in different study parts and are, therefore, part of multiple publications. The reported age of the participants ranged from 6 to 83 years, with some studies reporting mean age, some median age, some age ranges, and some not reporting the age of the participants at all. Of the participants in all studies, 74% were female participants and 20% were male participants. In 6% (3 studies), the authors did not report the gender of the participants (
Seven studies included patients with various symptoms among the participants (
Of the 45 studies, 34 were on massage interventions and 11 on compress interventions.
The number of studies per application type and substance.
External application/Number of studies |
Massages: 34 |
Rhythmical massage: 23 |
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Rhythmical embrocation: 6 |
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Pressel stream massage: 2 |
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Massage with other applications: 3 |
|
Compresses: 11 |
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Of the 34 massage studies, 23 studies were on RM, of which 2 studies were on RM with aroma oil with peat and lavender extracts (
Of the 11 studies on compresses, 5 studies were on ginger powder compresses (
Of the 4 RCTs, 2 compared RM with aroma oil with peat and lavender extracts to RM with neutral oil and sham massage with neutral oil (
The 13 included quantitative studies focused on both the subjective assessment of physical outcomes such as symptom manifestation and therapy effectiveness and objectively measured physical and psychological outcomes.
Physiological outcomes were assessed using subjective instruments by the 24-Item List of Somatic Complaints (B-L) (
Objective measures of physiological parameters assessed autonomic regulation using heart rate variability data from electrocardiogram assessments in 3 studies (
The mental state was assessed in 3 studies by the Multidimensional Questionnaire on Mental State (MDBF) (
Quality of life (QoL) was assessed by Health-Related Quality-of-Life questionnaire short forms SF-36 (
All quantitative studies assessed short-term effects, while 3 studies also assessed long-term effects (
The qualitative studies included interviews (
While most studies assessed positive effects on the patients, there were 4 quantitative studies (
The
Effect themes and subthemes.
Studies on massages | Studies on compresses | ||||||||
Rhythmical massage (23 studies) | Rhythmical embrocation (6 studies) | Pressel stream massage | Massage/compress/footbath (3 studies) | Ginger (5 studies) | Yarrow (2 studies) | Mustard (1 study) | Lemon (1 study) | Mixed/different compresses (2 studies) | |
1.1.1 Decrease in blood pressure | × | ||||||||
1.1.2 Deepened breathing | × | × | × | × | |||||
1.1.3 Improvement of skin texture | × | ||||||||
1.1.4 Increase of appetite | × | × | |||||||
1.1.5 Increase of body temperature/blood circulation | × | × | × | ||||||
1.1.6 Increase of libido | × | ||||||||
1.1.7 Stimulation of HRV | × | ||||||||
1.1.8 Strengthening/vitalizing/overall improvement | × | × | × | × | |||||
1.1.9 Warming sensation | × | × | × | × | × | × | × | ||
1.1.9.1 Different quality of warmth in ginger/mustard | × | ||||||||
1.2.1 General symptom relief/rating as effective | × | × | |||||||
1.2.2 Expectoration | × | ||||||||
1.2.3 Discontinuation of medication (pain, sedatives etc.) | × | × | × | ||||||
1.2.4 Improvement of ascites | × | ||||||||
1.2.5 Improvement of asthma symptoms | × | ||||||||
1.2.6 Improvement of digestion/bloating | × | × | × | ||||||
1.2.7 Improvement of fatigue | × | × | |||||||
1.2.8 Improvement of fever | × | ||||||||
1.2.9 Improvement of cognitive functions | × | ||||||||
1.2.10 Improvement of mobility | × | × | × | × | |||||
1.2.11 Improvement of sensitivity in the legs | × | ||||||||
1.2.12 Improvement of vertigo | × | ||||||||
1.2.13 Reduction of headaches | × | × | × | ||||||
1.2.14 Reduction of pain and muscle relaxation (local) | × | × | × | × | × | × | |||
1.2.15 Regulation of menstruation | × | ||||||||
2.1.1 Feeling of release, liberating | × | × | × | × | |||||
2.1.2 Improvement of confidence | × | ||||||||
2.1.3 Improvement of mood/feeling light | × | × | × | × | × | × | |||
2.1.4 Improvement of quality of life/health satisfaction | × | × | × | ||||||
2.1.5 Psychological activation | × | ||||||||
2.2.1 Feeling of relaxation | × | × | × | × | × | × | |||
2.2.1.1 Relaxation only in the after rest | × | ||||||||
2.2.2 Improvement of sleep | × | × | × | × | × | ||||
2.2.3 Pleasant and restful feeling | × | × | × | × | |||||
2.3.1 Feeling in balance/stable/Sense of coherence | × | × | × | × | × | × | |||
2.3.2 Improved regulation of anxiety | × | × | |||||||
2.3.3 Improvement in symptom management (pain etc.) | × | × | × | ||||||
2.3.4 Improvement of competencies in daily life | × | × | × | × | |||||
2.3.5 Improvement of self-awareness | × | × | × | × | |||||
2.3.6 Improvement of social skills | × | × | |||||||
3.1 Being uncaged à re-identifying à being empowered | × | ||||||||
3.2 Long-term effect | × | × | × | ||||||
3.3 Improvement of effect after multiple applications | × | × | × | × | × | ||||
3.4 Decrease in effect after multiple applications | × | ||||||||
4.1.1 No symptom relief/no effect | × | × | × | ||||||
4.1.2 Symptom aggravation | × | ||||||||
4.1.3 Exhaustion/tiredness | × | × | |||||||
4.1.4 Flattening of breath | × | ||||||||
4.1.5 Irritation of the skin | × | ||||||||
4.1.6 Occurrence of cardiac palpitations | × | ||||||||
4.1.7 Occurrence of coughing | × | ||||||||
4.1.8 Occurrence of hypotension | × | ||||||||
4.1.9 Occurrence of pain: Abdomen | × | ||||||||
4.1.10 Occurrence of pain: Headache, dental pain | × | ||||||||
4.1.12 Occurrence of vertigo | × | ||||||||
4.1.13 Sensation of cold and wetness | × | ||||||||
4.2.1 Emotional agitation/feeling depressed/restless | × | × | × | ||||||
4.2.2 Overwhelmed by touch | × |
In the studies on massage interventions, physiological effects were presented in the form of various reactions of the body and symptom relief. Reactions of the body showed in form of improvement of general condition and vitalization (
The quantitative studies on massage interventions revealed significant effects for some of the stated physiological outcomes: RM treatment for 3 months compared to treatment as usual (TAU) led to a significant reduction in pain intensity in patients with dysmenorrhea between groups (
Effects on physical parameters in the studies on compress interventions were extracted as reactions of the body such as an improvement of general condition and vitalization (
Significant effects of compress interventions on physical outcomes were significantly reduced fever (measured temperature) (after treatment:
The effects of massages on psychological outcomes were presented as activating effects such as an improved mood and feeling light (
Rhythmical massage had significant positive effects on QoL in patients with chronic diseases (physical and mental:
The effects of compresses on psychological outcomes were extracted in the form of activating, relaxing effects, and effects of competencies as well: After compresses, patients described improvement in mood and feeling light (
Daily yarrow liver compresses for 7–14 days led to a significant reduction in fatigue (
In the massage studies, development of effects over time was described in manifesting an increase of effects after multiple applications in various studies (
One study on patients with various indications reported significant long-term effects in a pre-post reduction in disease manifestation (
The studies on compresses depicted a development of effects over time as well, shown in an increase of effects after multiple applications (
Adverse physical effects in massage studies were symptom aggravation, arterial hypotension, cardiac palpitations, vertigo after treatment (
In the compress studies, adverse effects were only reported in a case series on ginger compressions in the form of exhaustion after the treatment, irritation of the skin, cough, an unpleasant sensation of cold and wetness, emotional agitation, and feelings of restlessness (
Since the study methodologies, the outcome measurements and the samples were heterogeneous and the studies were generally of low quality, the data did not allow for meta-analysis of the results. Study quality according to LoE, QA-Tool, and RoB is presented in
Summary of the assessment of study quality and risk of bias in the quantitative studies.
Quality assessment | Risk of bias assessment | |||||||||||||||||
Reference | Level of evidence | Selection bias: Representation of |
Study design: Design, randomization | Confounders: Detection and controlling |
Blinding of outcome assessors |
Data collection methods: Tools |
Withdrawals and dropouts: |
Quality: Global rating | Random sequence generation: |
Allocation concealment: Selection bias | Blinding of participants and personnel: |
Blinding of objective outcome assessment: |
Blinding of subjective outcome assessment: |
Incomplete outcome data: |
Selective reporting: Reporting bias | Other bias | Risk of bias: Global rating | |
Massages | Kanitz et al. ( |
II | strong | strong | strong | mod.q. | strong | strong | strong | low | low | high | high | high | low | low | low | mod.r. |
Seifert et al. ( |
II | mod.q. | strong | strong | mod.q. | strong | mod.q. | strong | low | low | high | high | n.a. | low | low | high | mod.r. | |
Vagedes et al. ( |
II | weak | strong | mod.q. | weak | strong | strong | weak | low | low | high | high | high | high | low | low | mod.r. | |
Hamre et al. ( |
IV | strong | mod.q. | weak | weak | strong | mod.q. | weak | high | high | high | uncl. | high | low | low | uncl. | high | |
Wälchli et al. ( |
IV | mod.q. | mod.q. | weak | weak | strong | mod.q. | weak | high | high | high | uncl. | high | low | low | uncl. | high | |
Wälchli et al. ( |
IV | mod.q. | mod.q. | weak | weak | mod.q. | mod.q. | weak | high | high | high | high | n.a. | low | uncl. | high | high | |
Ostermann et al. ( |
IV | mod.q. | mod.q. | weak | weak | strong | strong | weak | high | high | high | n.a. | high | low | low | uncl. | high | |
Vieira et al. ( |
IV | mod.q. | mod.q. | weak | weak | weak | strong | weak | high | high | high | n.a. | high | low | low | high | high | |
Compresses | Ghadjar et al. ( |
II | mod.q. | strong | strong | weak | strong | weak | weak | low | uncl. | high | n.a. | high | high | low | high | high |
Stritter et al. ( |
IV | weak | mod.q. | mod.q. | mod.q. | strong | strong | mod.q. | high | high | high | n.a. | high | low | low | high | high | |
Klich-Heartt ( |
IV | weak | weak | weak | weak | mod.q. | weak | weak | high | high | high | high | high | low | low | high | high | |
Therkleson ( |
IV | weak | mod.q. | weak | weak | strong | strong | weak | high | high | high | n.a. | high | low | high | high | high | |
Simoes-Wüst et al. ( |
VI | weak | weak | weak | weak | weak | weak | weak | high | high | high | n.a. | high | low | low | high | high |
Strong, strong quality; mod.q., moderate quality; weak, weak quality; low, low risk of bias; mod.r., moderate risk of bias; high, high risk of bias; uncl., unclear risk of bias; n.a., not applicable.
The assignment of the individual studies to the heuristic of LoE resulted in a distribution of the studies between the levels according to their methodology (
Studies on EAAM per level of evidence category reported in absolute terms.
Out of the 13 quantitative studies, 2 had strong quality (
Out of the 13 quantitative studies, 3 had a moderate risk of bias (
This mixed methods systematic review of 45 studies on EAAM included 34 studies on massage interventions and 11 studies on compress interventions. In both groups, various substances were applied. The methodologies of the included studies ranged from RCTs to cohort, retrospective, mixed methods and qualitative studies, and case series and reports. While a broad range of possible indications for applications could be identified by the
Overall, the results of this review are applicable mainly to European patients interested in integrative medical treatments and might be most applicable to the female gender. Further studies on EAAM applied to different participants are needed to ensure the external validity of the results. The employed methodology and the results of the quality and risk of bias assessments limit the interpretability of the results. More studies of high quality with low risk of bias need to be conducted and compared before conclusions can be drawn about the impact of EAAM.
The results on the effects of EAAM in this review suggest various health promoting effects, and therefore, match the findings on the health promoting capacities of the application of warmth and substances (
While scientific medical and psychological research investigates if and how treatments affect individuals, Anthroposophy and AM already present views on effect mechanisms (
However, as underlined by the findings of this review, the explanations of EAAM effect mechanisms according to AM do not translate directly into evidence according to conventional scientific research standards. To bridge this gap between the findings of this review and conventional scientific research, a digression into other scientific theories on health can provide alternative models to explain the effects of EAAM.
External applications from anthroposophic medicine use interpersonal attention and touch. While the health-promoting capacities of touch have been described repeatedly (
External applications from anthroposophic medicine are performed in a defined recurrent way, similar to rituals, and are often based on beliefs in their specific effect mechanisms according to AM. An approach to explain the efficacy of including a certain meaning in medical treatments is the
External applications from anthroposophic medicine are presumed to have health-promoting effects, to affect health holistically and dynamically. Holistic and positive support models underscore this, such as approaches of positive psychology and positive health [Seligman (
This is the first review of EAAM. We used the design of a mixed methods systematic review to cover the heterogeneous empirical literature on the different types of EAAM, sample characteristics, methodologies, and outcome parameters (
However, the heterogeneity of the included studies limits their generalizability. Only a small number of quantitative studies could be identified, which limits the expressiveness of the review. Many of the studies were only accessible in the form of gray literature and/or abstracts. As assessed by the LoE classification, the validity of the included studies had to be described as low in many of the studies. Study quality was assessed as low and the risk of bias as high in most studies. The safety of EAAM could only be assessed qualitatively on the basis of a few of the included studies reporting it.
We used a combination of the 3 tools LoE assessment, QA-Tool, and RoB to sort and adequately evaluate the quality and validity of the heterogeneous studies. Quality assessment of the included studies was conducted by two members of the research group (IM, JE). However, the QA-Tool and the RoB are repetitive in some domains and would have benefited from better tailored tools for the evaluation.
The implementation of complementary EAAM in clinical practice can be an opportunity to consider the patient’s needs for caregiving as well as spiritual needs in some patients in a manner of person-centered medicine.
Since the interpretability of the evidence found in this review is limited by the methodological quality of the included studies, we endorse studies of high quality on the different EAAM for different patient groups. These studies should ensure rigorous methodology and reports (
Users should adhere to the procedure specifications of the different EAAMs, and caution is advised with regard to the mentioned adverse effects. EAAM is not indicated in patients with adverse attitudes toward touch or in patients with sensitive skin or tissue damage. As illness was described in sections by Steiner and Wegman as depending on personal faculties (
The mixed methods systematic review illustrates the potential benefits of the different EAAM modalities as complementary treatments. The data reveal a broad spectrum of effect themes, suggesting that EAAM is suitable to address physical and psychological health indicators by improving the general condition and inducing symptom relief as well as psychologically activating and relaxing effects. Limitations in study quality, varying application modalities, different outcome assessments, and different sample characteristics complicate a substantiated comparison of the outcomes. We recommend further clinical studies exploring the effects and safety of distinguished EAAM modalities on defined patient groups to determine to what extent EAAM can be considered an effective and safe treatment option.
The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.
IM contributed to the conceptualization, methodological planning, data analysis, writing, and revision of the manuscript. SB contributed to the revision and editing. JE contributed to the data analysis. HC and GS contributed to the supervision, revision, and editing. WS contributed to the conceptualization, supervision, revision, and editing. All authors contributed to the article and approved the submitted version.
This study was funded by the Christophorus Foundation (Grant No. 373 CST). The funders had no role in the design and conduct of the review; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
We thank Jan Keller for his valuable remarks, all experts and institutions for contributing literature and sources and the Christophorus Foundation for the financial support.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.