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Objective: The objective of this study was to explore client perceptions of the short-term and longer-term effects of shiatsu. Design: The study design was a prospective, 6-month observational, pragmatic study. Setting: There were 85 shiatsu practitioners in three countries involved in the study: Austria, Spain, and the United Kingdom. Subjects: There were 948 clients receiving shiatsu from 1 of these practitioners. Interventions: Shiatsu as delivered by the practitioner in routine practice. Outcome measures: The outcomes measures were symptom severity, changes in health care use (baseline, 3 and 6 months), shiatsu-specific effects, uptake of advice (3 and 6 months), achieved expectations and occurrence of adverse events (4–6 days after first session, 3 and 6 months). Results: Six hundred and thirty-three (633) clients provided full follow-up data (a response rate of 67%). A typical shiatsu user was female, in her 40s, in paid employment, and had used shiatsu before. At “first-ever” use, the most typical reason for trying shiatsu was “out of curiosity.” At “today's” session, the dominant reason was health maintenance. The most mentioned symptom groups were problems with “muscles, joints, or body structure,” “tension/stress,” and “low energy/fatigue.” Symptom scores improved significantly over the 6 months (all symptom groups, Austria and the United Kingdom; two symptom groups, Spain), with moderate effect sizes (0.66–0.77) for “tension or stress” and “body structure problems” (Austria, the United Kingdom), and small effect sizes (0.32–0.47) for the other symptom groups (Spain, 0.28–0.43 for four groups). Previous users reported significant symptom improvement from “first ever” to baseline with moderate effect sizes. Across countries, substantial proportions (≥ 60%) agreed or agreed strongly with shiatsu-specific benefits. At 6 months, 77%–80% indicated that they had made changes to their lifestyle as a result of having shiatsu, and reductions in the use of conventional medicine (16%–22%) and medication (15%–34%). Ten (10) adverse events were reported by 9 clients (1.4%); none of these clients ceased shiatsu. Conclusions: Clients receiving shiatsu reported improvements in symptom severity and changes in their health-related behaviour that they attributed to their treatment, suggestive of a role for shiatsu in maintaining and enhancing health. [ABSTRACT FROM AUTHOR]