- Email: [email protected]
Touch: The magic of therapy and communication
( GUEST EDITORIAL
J
Touch: The Magic of Therapy and Communication Listening-explaining-and touching the patient truly represents the art of hand therapy. Evelyn Mackin 12
John W. Moore, MS, OTR Formerly Chief, Occupational Therapy Section Walter Reed Army Medical Center Presently, Director of Rehabilitation Northwest Therapy and Rehabilitation Tacoma, Washington
ome time ago Evelyn J. Mackin wrote and S asked if I would contribute a guest editorial based, in part, on my 27 years as an occupational therapist. Caught up at the time with a number of concerns both at work and elsewhere, I placed her request in the "to be done" file. From time to time a phrase in an article would catch my eye or I would see something in the clinic that reminded me of my need to write the piece, but I couldn't get a clear picture of what I wanted to say. Then, while reading an article in Yankee magazine by Phyllis Austin 2 describing her reaction to a skiing accident that almost cost her life, I was impressed with the following: From the time I was out of surgery, I was touched and held-my hands, feet, and head. The first thing that family, friends, and strangers did upon entering my room was "laying on of hands." It seemed instinctive, because only a few of them actually were believers in therapeutic touch. To me it was revelational, removing any doubt I might have had about the healing powers of touch. Touch is a magic ingredient in therapy and one of our greatest forms of communication. Several years ago I wrote an article about the initial interview out of concern that therapists were often missing something as they proceeded to gather data and work with their patients. 14 At the time my conclusion was that,in the communication process, therapists were John W. Moore was Chief of Occupational Therapy, Walter Reed Army Medical Center, Washington, D.C. when the editorial was written. Correspondence and reprint requests: John W. Moore, 2121 South 19th St., Tacoma, WA 98405-2997.
spending too much time talking and not enough time listening to their patients. In the ensuing 15 years I have come also to the conclusion that many therapists are missing another essential ingredient in their repetoire of skills-touch. A. Joy Huss started me thinking along these lines with her Eleanor Clarke Slagle Lecture titled, "Touch With Care or a Caring Touch?"ll A scant year after Ms. Huss delivered her lecture, the American Society of Hand Therapists was formed and the literature coming from this dedicated group is filled with references to the need for and value inherent in touch. Why is touch so important in our lives? What role does it have in the therapeutic process? How much touch should be given and is there a best time to employ touch?
NATURE OF TOUCH From a neurophysiological basis, touch is one of the first systems to develop and mature. A fetus experiences touch as early as the eighth week gestation ll and, at birth, infants use touch as their first and most fundamental means of communication. u Weiss points out that touch has a positive influence on perceptual and cognitive functions, 16 whereas Montague has shown that infants will not thrive normally even if there is adequate nourishment when there is loss of appropriate touch. 13 From before birth touch is an integral and vital part of the developmental process. January-March 1991
Moving into the adult realm, touch has a number of factors that must be taken into consideration. Weiss states there are four primary qualities of touch: location, intensity, action, and duration. 16 Location is simply that part of the body being touched. The importance of location from a physiological standpoint rests in its innervation, causing various body parts to be more sensitive than others. The hand and fingers, in particular, are most sensitive. Intensity may be felt as strong, moderate, or weak, depending on the degree of skin indentation. In this realm, a weak stimulus may have no effect whereas a painfully strong stimulus may cause a distortion in perception . Action refers to such things as stroking, rubbing, holding, lifting, or squeezing. Here sociocultural overtones 3J;'e brought into play, as well as the different ways in which the actions stimulate an individual. The action of touch has an effect not only on the skin but also on deeper structures, such as muscles, tendons, and joints. The last quality, duration, refers to the length of time touch is initiated . As with intensity, touch of short duration may occur at levels that are below identification or that are ignored. If an individual is going to integrate the sensory stimulus brought on by touch, the duration must be of sufficient length for cortical integration to take place. Although physical characteristics are an important consideration in touch, it is more important, I believe, to look at the actual intent of touch. In a therapeutic setting touch is governed by the motivation or incentive to touch and falls into two broad categories: (1) procedural touch and (2) comforting touch. 16 In the former, touch is driven by a specific task to be performed, such as range of motion or application of a splint. In comforting touch, the basic motivation is more altruistic in nature, with relief of physical or psychological distress as the primary goal. 17 Procedural Touch Range of motion, friction massage, splint fabrication, dressing changes, and transfer are examples of procedures requiring touch. They are very straightforward and necessary acts to bring about a change in condition or to gather information. The bottom line is usually to cure the patient or prevent further complications. However, some authors have noted that people in health professions are uncomfortable in touching patients. 4 .11 As a result, these people tend to move through their procedures as rote exercises. Not long age I underwent a series of diagnostic tests to pinpoint the cause of a nagging case of low back pain. X-rays and a CT scan were part of the workup. Although in pain and concerned not only for the now but also the future, I tried to focus on what was happening to me as I shifted roles from being caregiver to that of patient (care receiver). If a single word could be used to describe the two exams, I would elect perfunctory . I came away from both exams feeling as though I had been processed in a mill. The x-ray technician said as little as possible. With practiced, mechanical precision he moved me from one position to the next and disappeared behind 2
JOURNAL OF HAND THERAPY
a protective screen with each exposure taken . The CT scan was more of the same only worse, because the operator left the room for 20-30 minutes after having given me an absolute minimum amount of information about what was going to happen . This dehumanizing process sent a clear message to me: although the procedures were performed in a technically correct manner, little attention was being paid to my needs as a patient. Comforting Touch Comforting touch should be viewed from the perspective of helping a patient cope with illness/ disease and the inherent stress that is attendant to that process. Comforting touch is the "magic" of therapy, an act showing empathy and an awareness of the feelings and psychological needs of the patient. In contrast to the performance of a specific procedure, comforting touch is employed to reduce stress and anxiety. It may be employed to set the stage for procedural touch. Dominion feels that individuals have a much greater need for this type of touch during illness or injury. 6 An example of the need to employ comforting touch occurred not long ago when a young woman walked into the clinic holding her right hand to her chest; eyes red and swollen from crying. Unable to see her immediately, I had her sit where I could observe her, as I was concerned about what appeared to be happening. The rhythmic rocking, the darting of her eyes, and cradling of her hand indicated she was afraid and in pain. When I was finally able to see her, she was shaking from shoulder to finger tips and tears continued to well in her eyes. A brief history revealed that the woman had just received a steroid injection to treat moderately severe de Quervain's syndrome. Her physician was asking Occupational Therapy to provide a routine splint. At that particular moment she did not need a splint; rather, she needed simple human contact. The physician had made a diagnosis and "promised" that the injection would take away the pain and the splint would help keep it away. Unfortunately, the pain did not go away, it got considerably worse. Now she was tired from being in the hospital for several hours, hungry, and, most of all, angry and afraid . As I talked to this patient, I asked permission to hold her hand and examine it. With her affirmative answer, I gently cradled her hand in both of mine, being careful to keep from touching the first dorsal compartment. I started a gentle exam just above the injection site, all the while talking to her in a calm voice. As I sat holding and stroking her hand, I acknowledged her pain and anger. Within a minute she visibly relaxed; her shoulders and hand stopped trembling and her general body tone became more relaxed. I then explained what de Quervain's is in terms she could understand and very carefully traced the outline of the extensor tendons using my fingers as a "pencil" on her skin. Although all this did not make the pain go away, she did experience a lessening of the discomfort because she was relaxing her
muscles and allowing her own reasoning process to take over from her fear, anger, and general frustration at not understanding what was happening to her body. At that point a simple static splint was made to protect the first dorsal compartment, and the injection and rest provided by the splint performed their "cure." Hiatt addresses several positive functions of human touch in her discussion on working with elderly people. 10 Within the discussion she talks of touch offering a sense of self-validation, of signifying acceptance and offering social information about appearance. With hand injuries, appearance and social acceptance can be critical issues. Patients tend to focus on how they look, particularly in the early stages of an injury, with bulky dressings, scars and stitches, edema, discoloration, and an occasional spot of blood. They are worried not only about their ability to function but also about how they will be perceived as they move about in social contact with their noninjured counterparts. It is critical, therefore, to assure hand patients that while from their perspective the picture may look bleak at the moment, all is not lost. I often show these patients pictures of a fresh injury and a 6-month follow-up to emphasize that change is forthcoming and positive. In addition, I spend a lot of time touching in the injured area in an attempt to demonstrate that, although the injury is unattractive for the moment, it doesn't preclude human contact. And, when possible, I schedule hand patients with non-hand patients with the thought in mind that contact with "other problems" will facilitate the acceptance process. Fess summarized comforting touch rather succinctly when she wrote " ... the touch of a human hand allows us to know that we are not alone." 7
TOUCH AND THE COUNSELING PROCESS As a therapist, I often find myself in the position of having to explain what has happened or will be happening to a patient with a hand problem. Physicians are often too busy to adequately explain what they have done, or the emotional climate at the time is not conducive to retention of information. Therapy, on the other hand, is the ideal time to explain in nontechnical terms what took place in the operating room or what will be happening over the course of the rehabilitation program. Even ,with a well-established rapport between therapist and patient, there are techniques which enhance the learning process. As pointed out by Alagna et al., 1 touch may facilitate the process of communication by increasing the likelihood that the interaction will be positively evaluated. The very act of touching tends to focus attention. When I am in a "teaching" mode, I take extra pains to maximize touch. In explaining a tendon repair or the pathologic changes of carpal tunnel syndrome, I actually trace the tendons and nerves on the patients hand. By so doing, I am attempting to insure that the patient is investing his or her time
and energy in listening to what I have to say. Weiss may have said it most succinctly: "[W]hat one perceives through the other senses as reality represents nothing more than a good hypothesis, subject to the confirmation of touch."16
The Other Side of Touch Touch should be, and generally is, a pleasurable experience. We look forward to the warmth that touch generates and the affirmation it brings. But there are times when touch is inappropriate or unwanted. Some authors have written about the role of sex differences in the area of touch and have concluded that the strongest positive relationship exists when touch is generated between members of the opposite sex. 15 However, these authors were generally dealing with a counseling relationship and not a specific therapeutic relationship, in which some touch at the very least is expected. When dealing with hand patients, I find that there are few problems with touch generated between members of either the same sex or the opposite sex. Pain can be a strong modulator in the perception of touch as pleasurable or distasteful. Joints distended from disease or trauma are generally painful, especially when moved either actively or passively. Newly created incisions/wounds still in the inflammatory stage of healing are sensitive, as may be the nerve-disrupted tissue immediately adjacent to the incision/wound. Simple touch and movement to these areas and joints may cause an increase in pain that thwarts the therapeutic process. Of course, some pain is to be expected and tolerated, but there are ways to hold the pain at minimal levels. For instance, with stiff PIP or DIP joints, I always have the patient attempt active motion first and tell me where he or she experiences discomfort. In most instances the perception of discomfort will be either along the dorsal midline or on the lateral aspect of the involved joint. I then use this information as a reference point to avoid touching in performing passive range of motion (PROM). I try to be extra careful around sensitive scars or where a neuroma is causing discomfort. If desensitization is needed as a treatment adjunct, I add it to the program. One group of patients requiring special consideration in terms of touch are those who have been injured in attacks of violence or held as hostages and tortured. Not too long ago I was asked to work with a young woman whose husband had attacked her with a knife and inflicted considerable damage. Both arms and hands had been badly cut, including artery, nerve, muscle, and tendon damage. During the initial interview period I positioned myself across from her at the treatment table but made sure my chair was moved away from the table so I couldn't touch her. We just talked. I asked her to show me what had happened to her hands-making sure that I kept my hands in my lap with no attempt to touch her. The next day, while clarifying a point from the previous day, I asked her permission to touch and move her hands. Even with her permission I took extra care to January-March 1991
3
explain each step I was going to take before I took it and waited for her to get ready. Within a few days we had established enough trust that I could not only touch her but also initiate new therapeutic actions without going into lengthy details.
ARE WE "OVER-GADGETED" IN HAND THERAPY? In September 1989 I attended the American Society of Hand Therapists' annual meeting. During the conference, I browsed through the exhibits area and came away amazed and awed by the prolifuration of mechanical gadgets that can be employed by hand therapists. It seems that almost everything these days is being turned into a mechanical device that alleviates the necessity of "laying on of hands." I was reminded of Fullenwider's quote from her address on "Commercialism in Hand Therapy: Spirit and Method" in which she chastised those who believe, "If it doesn't have a digital read-out, it must not be that good."9 Mechanical devices range from a plethora of continuous passive motion (CPM) machines to computerized work simulation devices, and even an electronic goniometer. In recent visits to busy hand clinics I have seen most of these tools in use and have been impressed by their versatility and apparent accuracy. I am concerned, however, with the dehumanization that occurs with the use of a machine and the patients willingness to transfer responsibility for rehabilitation from self to machine. Patients are scheduled for treatment on specific machines in 15 to 30 minute increments. The fact that contact with the therapist is at a minimum bothers me. I am not opposed to the use of a well-researched machine. Quite the contrary, I think they are great adjunct to innovative hand therapy. Nevertheless, hand therapy is still a discipline where human touch is of vital importance to successful outcomes. The ability to interpret sensory feedback generated through touch helps shape and drive the programs of therapy prescribed for each patient. A classic example comes to mind concerning the patient who, when attempting to bring his fingers into flexion, tries so hard that he produces an unintentional co-contraction in the long extensors, which effectively blocks the flexors and causes a claw-type hand posture. The co-contraction is easily picked up by gently grasping the patient's proximal forearm and feeling the unconscious contraction of both flexors and extensors. Usually with careful patient education this can be overcome, but if the patient continues to have difficulty, then a two-channel myoelectric feedback mechanism can be employed with considerable success.
CONCLUDING THOUGHTS Touch is a vital part of our daily life. The pleasures of touch start even before birth; it is such an important aspect of life that it is one of the first senses 4
JOURNAL OF HAND THERAPY
to mature in the developmental sequence. Examples of touch surround us daily: a child reaching for and grasping a toy-including an occasional foray into oral exploration; young lovers and a tight embrace in the waning hours of a date; a grocery shopper diligently attempting to determine the ripeness of a piece of fruit with repeated prods with his or her fingers; a skilled surgeon deftly tying a knot to conclude a surgical procedure. In rehabilitation, touch is used to perform routine procedures or to provide some element of comfort. Both are important to the outcome of therapy. Failure to convey the proper message of caring in either may result in an ultimate therapeutic failure. Mackin put it succinctly when she said, "If the patient is left with an impersonal feeling as a result of an unsatisfactory relationship with the 'surgeon he never sees' or the therapist 'who doesn't seem to care,' the exchange has failed in a vital respect." 12 Fess spoke with eloquence not about touch per se, but about hands as the instruments of touch. She reminds us that hands have the "ability to communicate at both conscious and subconscious levels, allowing others to perceive through posture, gesture, and appearance the inherent moods and personalities of their owners." 7 Touching can run the gamut from simply placing a hand upon a shoulder to convey your presence to a complex diagnostic act as seen when a therapist attempts to pick up subtle firings of newly re-innervated muscle fibers. How touch is perceived is the most important aspect of the process. The rapid, purposeful manipulations of an accomplished x-ray technician maneuvering a patient through a series of "poses" have much less meaning in terms of the power of touch than the purposeful but gentle touch of a health care provider that converys "I'm here if you need me." Cannon reserved the topic of touch for the concluding remarks of her Presidential address to the American Society of Hand Therapists. 5 She implied that a "caring touch" is a learned response. While Phyllis Austin lay in a hospital bed recovering from a serious injury, she experienced the "healing power of touch" as friends came to visit. Cannon is speaking at a different level; she is addressing touch at a universal level of acceptance, not just visiting a friend. Young therapists are often ill at ease when it comes to touching a patient. They are unsure of their skills and are still spending time transferring didactic materials into practical treatment plans. The "caring touch" addressed by Cannon and the "art" mentioned by Mackin are part of the maturation process experienced by therapists. In my own case, I found myself much more comfortable in "touching" following graduate school and a degree in counseling. A final note on touching centers on the fact that not all touching is physical in nature but, rather, is part of the total process of caring. A patient came by my office not long ago and said: "I want to thank you and the entire staff-you really care for all the patients in the clinic." She concluded her remarks with: "I was really touched by the way I was treated." In this instance, touch is not just a physical act but
a compendium of processes taking place between the patient and the staff-from secretary/receptionist to therapist. The "caring touch" may be perceived as embodying the total philosophy of the clinic and its relationship toward the clients it serves. The "magic" comes from comments such as that above and from the positive outcomes experienced between therapist and client.
REFERENCES 1. Alagna FJ, Whitcher SJ, Fisher JD, Wicas EA: Evaluative reaction to interpersonal touch in a counseling interview. JCounsel Psychol 26:465, 1979. 2. Austin P: Impaled: Cross-country ski accident. Yankee 54: 76-81, 1990. 3. Barnett K: A theoretical construct of the concepts of touch as they relate to nursing. Nurs Res 21:102-110, 1972. 4. Burton A, Heller LG: Touching of the body. Psychoanal Rev 51:127-133, 1964.
5. Cannon NM: Maintaining "excellence" in hand therapy. J Hand Ther 2:213-220, 1990. 6. Dominion J: The psychological significance of t-ouch. Nurs Times 67:896, 1971. 7. Fess EE: Hands, changes, guality, and survival, J Hand Ther 3:1-6, 1990. 8. Frank LK: Tactile communication. Genet Psychol Monogr 56: 211-251, 1957. 9. Fullenwider L: Commercialism in hand therapy: Spirit and method. J Hand Ther 2:1-4, 1989. 10. Hiatt LG: Touchy about touching? Nurs Homes 29:42, 1980. 11. Huss AJ: 1976 Eleanor Clarke Slagle Lecture: Touch with care or a caring Touch? Am J Occup Ther 31:11-18, 1977. 12. Mackin E: Building a legacy through mentorship. J Hand Ther 1:105-108, 1988. 13. Montague A: Touching: The significance of the human skin. New York, Columbia University Press, 1971. 14. Moore ]W: The initial interview and interaction analysis. Am J Occup Ther 31(1): 1977. 15. Nguyen J, Heslin R, Nguyen M: The meaning of touch: sex differences. J Commun 25:92, 1975. 16. Weiss SJ: The language of touch. Nurs Res 28:76-80, 1979. 17. Weiss SJ: Psychophysiologic effects of caregiver touch on incidence of cardiac dysrhythmia. Heart Lung 15:495-505, 1986.
1991 Continuing Education Courses offered by the
American Society of Hand Therapists Hands-On Splinting Workshop Apri119-21 , 1991 Marriott City Center Charlotte, NC Intermediate to Advanced
1991 Upper Extremity EXPO June 21 - 23, 1991 Hyatt Newporter Newport Beach, CA Beginner - Intermediate - Advanced
Continuing Education: the building blocks to a successful future
14th Annual Conference "Florida Style" September 25 - 28, 1991 Buena Vista Palace Walt Disney World Village, FL Beginner - Intermediate -Advanced
For additional information or registration forms, contact: Sherri Powell, National Meeting Planner ASHT Central Office, 1002 Vandora Springs Road, Suite 101, Garner, NC 27529. (919) 779-2748.
January-March 1991
5
J
Touch: The Magic of Therapy and Communication Listening-explaining-and touching the patient truly represents the art of hand therapy. Evelyn Mackin 12
John W. Moore, MS, OTR Formerly Chief, Occupational Therapy Section Walter Reed Army Medical Center Presently, Director of Rehabilitation Northwest Therapy and Rehabilitation Tacoma, Washington
ome time ago Evelyn J. Mackin wrote and S asked if I would contribute a guest editorial based, in part, on my 27 years as an occupational therapist. Caught up at the time with a number of concerns both at work and elsewhere, I placed her request in the "to be done" file. From time to time a phrase in an article would catch my eye or I would see something in the clinic that reminded me of my need to write the piece, but I couldn't get a clear picture of what I wanted to say. Then, while reading an article in Yankee magazine by Phyllis Austin 2 describing her reaction to a skiing accident that almost cost her life, I was impressed with the following: From the time I was out of surgery, I was touched and held-my hands, feet, and head. The first thing that family, friends, and strangers did upon entering my room was "laying on of hands." It seemed instinctive, because only a few of them actually were believers in therapeutic touch. To me it was revelational, removing any doubt I might have had about the healing powers of touch. Touch is a magic ingredient in therapy and one of our greatest forms of communication. Several years ago I wrote an article about the initial interview out of concern that therapists were often missing something as they proceeded to gather data and work with their patients. 14 At the time my conclusion was that,in the communication process, therapists were John W. Moore was Chief of Occupational Therapy, Walter Reed Army Medical Center, Washington, D.C. when the editorial was written. Correspondence and reprint requests: John W. Moore, 2121 South 19th St., Tacoma, WA 98405-2997.
spending too much time talking and not enough time listening to their patients. In the ensuing 15 years I have come also to the conclusion that many therapists are missing another essential ingredient in their repetoire of skills-touch. A. Joy Huss started me thinking along these lines with her Eleanor Clarke Slagle Lecture titled, "Touch With Care or a Caring Touch?"ll A scant year after Ms. Huss delivered her lecture, the American Society of Hand Therapists was formed and the literature coming from this dedicated group is filled with references to the need for and value inherent in touch. Why is touch so important in our lives? What role does it have in the therapeutic process? How much touch should be given and is there a best time to employ touch?
NATURE OF TOUCH From a neurophysiological basis, touch is one of the first systems to develop and mature. A fetus experiences touch as early as the eighth week gestation ll and, at birth, infants use touch as their first and most fundamental means of communication. u Weiss points out that touch has a positive influence on perceptual and cognitive functions, 16 whereas Montague has shown that infants will not thrive normally even if there is adequate nourishment when there is loss of appropriate touch. 13 From before birth touch is an integral and vital part of the developmental process. January-March 1991
Moving into the adult realm, touch has a number of factors that must be taken into consideration. Weiss states there are four primary qualities of touch: location, intensity, action, and duration. 16 Location is simply that part of the body being touched. The importance of location from a physiological standpoint rests in its innervation, causing various body parts to be more sensitive than others. The hand and fingers, in particular, are most sensitive. Intensity may be felt as strong, moderate, or weak, depending on the degree of skin indentation. In this realm, a weak stimulus may have no effect whereas a painfully strong stimulus may cause a distortion in perception . Action refers to such things as stroking, rubbing, holding, lifting, or squeezing. Here sociocultural overtones 3J;'e brought into play, as well as the different ways in which the actions stimulate an individual. The action of touch has an effect not only on the skin but also on deeper structures, such as muscles, tendons, and joints. The last quality, duration, refers to the length of time touch is initiated . As with intensity, touch of short duration may occur at levels that are below identification or that are ignored. If an individual is going to integrate the sensory stimulus brought on by touch, the duration must be of sufficient length for cortical integration to take place. Although physical characteristics are an important consideration in touch, it is more important, I believe, to look at the actual intent of touch. In a therapeutic setting touch is governed by the motivation or incentive to touch and falls into two broad categories: (1) procedural touch and (2) comforting touch. 16 In the former, touch is driven by a specific task to be performed, such as range of motion or application of a splint. In comforting touch, the basic motivation is more altruistic in nature, with relief of physical or psychological distress as the primary goal. 17 Procedural Touch Range of motion, friction massage, splint fabrication, dressing changes, and transfer are examples of procedures requiring touch. They are very straightforward and necessary acts to bring about a change in condition or to gather information. The bottom line is usually to cure the patient or prevent further complications. However, some authors have noted that people in health professions are uncomfortable in touching patients. 4 .11 As a result, these people tend to move through their procedures as rote exercises. Not long age I underwent a series of diagnostic tests to pinpoint the cause of a nagging case of low back pain. X-rays and a CT scan were part of the workup. Although in pain and concerned not only for the now but also the future, I tried to focus on what was happening to me as I shifted roles from being caregiver to that of patient (care receiver). If a single word could be used to describe the two exams, I would elect perfunctory . I came away from both exams feeling as though I had been processed in a mill. The x-ray technician said as little as possible. With practiced, mechanical precision he moved me from one position to the next and disappeared behind 2
JOURNAL OF HAND THERAPY
a protective screen with each exposure taken . The CT scan was more of the same only worse, because the operator left the room for 20-30 minutes after having given me an absolute minimum amount of information about what was going to happen . This dehumanizing process sent a clear message to me: although the procedures were performed in a technically correct manner, little attention was being paid to my needs as a patient. Comforting Touch Comforting touch should be viewed from the perspective of helping a patient cope with illness/ disease and the inherent stress that is attendant to that process. Comforting touch is the "magic" of therapy, an act showing empathy and an awareness of the feelings and psychological needs of the patient. In contrast to the performance of a specific procedure, comforting touch is employed to reduce stress and anxiety. It may be employed to set the stage for procedural touch. Dominion feels that individuals have a much greater need for this type of touch during illness or injury. 6 An example of the need to employ comforting touch occurred not long ago when a young woman walked into the clinic holding her right hand to her chest; eyes red and swollen from crying. Unable to see her immediately, I had her sit where I could observe her, as I was concerned about what appeared to be happening. The rhythmic rocking, the darting of her eyes, and cradling of her hand indicated she was afraid and in pain. When I was finally able to see her, she was shaking from shoulder to finger tips and tears continued to well in her eyes. A brief history revealed that the woman had just received a steroid injection to treat moderately severe de Quervain's syndrome. Her physician was asking Occupational Therapy to provide a routine splint. At that particular moment she did not need a splint; rather, she needed simple human contact. The physician had made a diagnosis and "promised" that the injection would take away the pain and the splint would help keep it away. Unfortunately, the pain did not go away, it got considerably worse. Now she was tired from being in the hospital for several hours, hungry, and, most of all, angry and afraid . As I talked to this patient, I asked permission to hold her hand and examine it. With her affirmative answer, I gently cradled her hand in both of mine, being careful to keep from touching the first dorsal compartment. I started a gentle exam just above the injection site, all the while talking to her in a calm voice. As I sat holding and stroking her hand, I acknowledged her pain and anger. Within a minute she visibly relaxed; her shoulders and hand stopped trembling and her general body tone became more relaxed. I then explained what de Quervain's is in terms she could understand and very carefully traced the outline of the extensor tendons using my fingers as a "pencil" on her skin. Although all this did not make the pain go away, she did experience a lessening of the discomfort because she was relaxing her
muscles and allowing her own reasoning process to take over from her fear, anger, and general frustration at not understanding what was happening to her body. At that point a simple static splint was made to protect the first dorsal compartment, and the injection and rest provided by the splint performed their "cure." Hiatt addresses several positive functions of human touch in her discussion on working with elderly people. 10 Within the discussion she talks of touch offering a sense of self-validation, of signifying acceptance and offering social information about appearance. With hand injuries, appearance and social acceptance can be critical issues. Patients tend to focus on how they look, particularly in the early stages of an injury, with bulky dressings, scars and stitches, edema, discoloration, and an occasional spot of blood. They are worried not only about their ability to function but also about how they will be perceived as they move about in social contact with their noninjured counterparts. It is critical, therefore, to assure hand patients that while from their perspective the picture may look bleak at the moment, all is not lost. I often show these patients pictures of a fresh injury and a 6-month follow-up to emphasize that change is forthcoming and positive. In addition, I spend a lot of time touching in the injured area in an attempt to demonstrate that, although the injury is unattractive for the moment, it doesn't preclude human contact. And, when possible, I schedule hand patients with non-hand patients with the thought in mind that contact with "other problems" will facilitate the acceptance process. Fess summarized comforting touch rather succinctly when she wrote " ... the touch of a human hand allows us to know that we are not alone." 7
TOUCH AND THE COUNSELING PROCESS As a therapist, I often find myself in the position of having to explain what has happened or will be happening to a patient with a hand problem. Physicians are often too busy to adequately explain what they have done, or the emotional climate at the time is not conducive to retention of information. Therapy, on the other hand, is the ideal time to explain in nontechnical terms what took place in the operating room or what will be happening over the course of the rehabilitation program. Even ,with a well-established rapport between therapist and patient, there are techniques which enhance the learning process. As pointed out by Alagna et al., 1 touch may facilitate the process of communication by increasing the likelihood that the interaction will be positively evaluated. The very act of touching tends to focus attention. When I am in a "teaching" mode, I take extra pains to maximize touch. In explaining a tendon repair or the pathologic changes of carpal tunnel syndrome, I actually trace the tendons and nerves on the patients hand. By so doing, I am attempting to insure that the patient is investing his or her time
and energy in listening to what I have to say. Weiss may have said it most succinctly: "[W]hat one perceives through the other senses as reality represents nothing more than a good hypothesis, subject to the confirmation of touch."16
The Other Side of Touch Touch should be, and generally is, a pleasurable experience. We look forward to the warmth that touch generates and the affirmation it brings. But there are times when touch is inappropriate or unwanted. Some authors have written about the role of sex differences in the area of touch and have concluded that the strongest positive relationship exists when touch is generated between members of the opposite sex. 15 However, these authors were generally dealing with a counseling relationship and not a specific therapeutic relationship, in which some touch at the very least is expected. When dealing with hand patients, I find that there are few problems with touch generated between members of either the same sex or the opposite sex. Pain can be a strong modulator in the perception of touch as pleasurable or distasteful. Joints distended from disease or trauma are generally painful, especially when moved either actively or passively. Newly created incisions/wounds still in the inflammatory stage of healing are sensitive, as may be the nerve-disrupted tissue immediately adjacent to the incision/wound. Simple touch and movement to these areas and joints may cause an increase in pain that thwarts the therapeutic process. Of course, some pain is to be expected and tolerated, but there are ways to hold the pain at minimal levels. For instance, with stiff PIP or DIP joints, I always have the patient attempt active motion first and tell me where he or she experiences discomfort. In most instances the perception of discomfort will be either along the dorsal midline or on the lateral aspect of the involved joint. I then use this information as a reference point to avoid touching in performing passive range of motion (PROM). I try to be extra careful around sensitive scars or where a neuroma is causing discomfort. If desensitization is needed as a treatment adjunct, I add it to the program. One group of patients requiring special consideration in terms of touch are those who have been injured in attacks of violence or held as hostages and tortured. Not too long ago I was asked to work with a young woman whose husband had attacked her with a knife and inflicted considerable damage. Both arms and hands had been badly cut, including artery, nerve, muscle, and tendon damage. During the initial interview period I positioned myself across from her at the treatment table but made sure my chair was moved away from the table so I couldn't touch her. We just talked. I asked her to show me what had happened to her hands-making sure that I kept my hands in my lap with no attempt to touch her. The next day, while clarifying a point from the previous day, I asked her permission to touch and move her hands. Even with her permission I took extra care to January-March 1991
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explain each step I was going to take before I took it and waited for her to get ready. Within a few days we had established enough trust that I could not only touch her but also initiate new therapeutic actions without going into lengthy details.
ARE WE "OVER-GADGETED" IN HAND THERAPY? In September 1989 I attended the American Society of Hand Therapists' annual meeting. During the conference, I browsed through the exhibits area and came away amazed and awed by the prolifuration of mechanical gadgets that can be employed by hand therapists. It seems that almost everything these days is being turned into a mechanical device that alleviates the necessity of "laying on of hands." I was reminded of Fullenwider's quote from her address on "Commercialism in Hand Therapy: Spirit and Method" in which she chastised those who believe, "If it doesn't have a digital read-out, it must not be that good."9 Mechanical devices range from a plethora of continuous passive motion (CPM) machines to computerized work simulation devices, and even an electronic goniometer. In recent visits to busy hand clinics I have seen most of these tools in use and have been impressed by their versatility and apparent accuracy. I am concerned, however, with the dehumanization that occurs with the use of a machine and the patients willingness to transfer responsibility for rehabilitation from self to machine. Patients are scheduled for treatment on specific machines in 15 to 30 minute increments. The fact that contact with the therapist is at a minimum bothers me. I am not opposed to the use of a well-researched machine. Quite the contrary, I think they are great adjunct to innovative hand therapy. Nevertheless, hand therapy is still a discipline where human touch is of vital importance to successful outcomes. The ability to interpret sensory feedback generated through touch helps shape and drive the programs of therapy prescribed for each patient. A classic example comes to mind concerning the patient who, when attempting to bring his fingers into flexion, tries so hard that he produces an unintentional co-contraction in the long extensors, which effectively blocks the flexors and causes a claw-type hand posture. The co-contraction is easily picked up by gently grasping the patient's proximal forearm and feeling the unconscious contraction of both flexors and extensors. Usually with careful patient education this can be overcome, but if the patient continues to have difficulty, then a two-channel myoelectric feedback mechanism can be employed with considerable success.
CONCLUDING THOUGHTS Touch is a vital part of our daily life. The pleasures of touch start even before birth; it is such an important aspect of life that it is one of the first senses 4
JOURNAL OF HAND THERAPY
to mature in the developmental sequence. Examples of touch surround us daily: a child reaching for and grasping a toy-including an occasional foray into oral exploration; young lovers and a tight embrace in the waning hours of a date; a grocery shopper diligently attempting to determine the ripeness of a piece of fruit with repeated prods with his or her fingers; a skilled surgeon deftly tying a knot to conclude a surgical procedure. In rehabilitation, touch is used to perform routine procedures or to provide some element of comfort. Both are important to the outcome of therapy. Failure to convey the proper message of caring in either may result in an ultimate therapeutic failure. Mackin put it succinctly when she said, "If the patient is left with an impersonal feeling as a result of an unsatisfactory relationship with the 'surgeon he never sees' or the therapist 'who doesn't seem to care,' the exchange has failed in a vital respect." 12 Fess spoke with eloquence not about touch per se, but about hands as the instruments of touch. She reminds us that hands have the "ability to communicate at both conscious and subconscious levels, allowing others to perceive through posture, gesture, and appearance the inherent moods and personalities of their owners." 7 Touching can run the gamut from simply placing a hand upon a shoulder to convey your presence to a complex diagnostic act as seen when a therapist attempts to pick up subtle firings of newly re-innervated muscle fibers. How touch is perceived is the most important aspect of the process. The rapid, purposeful manipulations of an accomplished x-ray technician maneuvering a patient through a series of "poses" have much less meaning in terms of the power of touch than the purposeful but gentle touch of a health care provider that converys "I'm here if you need me." Cannon reserved the topic of touch for the concluding remarks of her Presidential address to the American Society of Hand Therapists. 5 She implied that a "caring touch" is a learned response. While Phyllis Austin lay in a hospital bed recovering from a serious injury, she experienced the "healing power of touch" as friends came to visit. Cannon is speaking at a different level; she is addressing touch at a universal level of acceptance, not just visiting a friend. Young therapists are often ill at ease when it comes to touching a patient. They are unsure of their skills and are still spending time transferring didactic materials into practical treatment plans. The "caring touch" addressed by Cannon and the "art" mentioned by Mackin are part of the maturation process experienced by therapists. In my own case, I found myself much more comfortable in "touching" following graduate school and a degree in counseling. A final note on touching centers on the fact that not all touching is physical in nature but, rather, is part of the total process of caring. A patient came by my office not long ago and said: "I want to thank you and the entire staff-you really care for all the patients in the clinic." She concluded her remarks with: "I was really touched by the way I was treated." In this instance, touch is not just a physical act but
a compendium of processes taking place between the patient and the staff-from secretary/receptionist to therapist. The "caring touch" may be perceived as embodying the total philosophy of the clinic and its relationship toward the clients it serves. The "magic" comes from comments such as that above and from the positive outcomes experienced between therapist and client.
REFERENCES 1. Alagna FJ, Whitcher SJ, Fisher JD, Wicas EA: Evaluative reaction to interpersonal touch in a counseling interview. JCounsel Psychol 26:465, 1979. 2. Austin P: Impaled: Cross-country ski accident. Yankee 54: 76-81, 1990. 3. Barnett K: A theoretical construct of the concepts of touch as they relate to nursing. Nurs Res 21:102-110, 1972. 4. Burton A, Heller LG: Touching of the body. Psychoanal Rev 51:127-133, 1964.
5. Cannon NM: Maintaining "excellence" in hand therapy. J Hand Ther 2:213-220, 1990. 6. Dominion J: The psychological significance of t-ouch. Nurs Times 67:896, 1971. 7. Fess EE: Hands, changes, guality, and survival, J Hand Ther 3:1-6, 1990. 8. Frank LK: Tactile communication. Genet Psychol Monogr 56: 211-251, 1957. 9. Fullenwider L: Commercialism in hand therapy: Spirit and method. J Hand Ther 2:1-4, 1989. 10. Hiatt LG: Touchy about touching? Nurs Homes 29:42, 1980. 11. Huss AJ: 1976 Eleanor Clarke Slagle Lecture: Touch with care or a caring Touch? Am J Occup Ther 31:11-18, 1977. 12. Mackin E: Building a legacy through mentorship. J Hand Ther 1:105-108, 1988. 13. Montague A: Touching: The significance of the human skin. New York, Columbia University Press, 1971. 14. Moore ]W: The initial interview and interaction analysis. Am J Occup Ther 31(1): 1977. 15. Nguyen J, Heslin R, Nguyen M: The meaning of touch: sex differences. J Commun 25:92, 1975. 16. Weiss SJ: The language of touch. Nurs Res 28:76-80, 1979. 17. Weiss SJ: Psychophysiologic effects of caregiver touch on incidence of cardiac dysrhythmia. Heart Lung 15:495-505, 1986.
1991 Continuing Education Courses offered by the
American Society of Hand Therapists Hands-On Splinting Workshop Apri119-21 , 1991 Marriott City Center Charlotte, NC Intermediate to Advanced
1991 Upper Extremity EXPO June 21 - 23, 1991 Hyatt Newporter Newport Beach, CA Beginner - Intermediate - Advanced
Continuing Education: the building blocks to a successful future
14th Annual Conference "Florida Style" September 25 - 28, 1991 Buena Vista Palace Walt Disney World Village, FL Beginner - Intermediate -Advanced
For additional information or registration forms, contact: Sherri Powell, National Meeting Planner ASHT Central Office, 1002 Vandora Springs Road, Suite 101, Garner, NC 27529. (919) 779-2748.
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