The Importance of Touch

Touch is a very crucial element that can affect the way a person acts.  It has been around since the dawn of man and the way it influences a person's actions internally and externally may be a key element when treating patients.  A multitude of explanations may contribute towards having a positive treatment outcome. And of course it's difficult to tease out their respective influences independently. However I would like to discuss the influence touch can have on a person and its role in physical therapy. 

I have been passionate about the concept of a hands-on approach with every patient, no matter what age, sex, ethnicity, diagnosis, stage of healing, setting, etc.  The idea of touch produces many different physiological & psychological benefits that can influence a patient's overall outcome.  The benefits I want to speak of are as follows:

  • Promotes Circulation

    • The act of performing soft tissue mobilization on a patient whether it be effleurage or petrissage allows an increase in blood and lymph circulation. This increase assists in the clearance of metabolic byproducts of tissue damage and inflammation. It also assists in the delivery of oxygen and nutrients to tissue cells. It's important to note that the concept of blood flow is difficult to quantify during a given treatment without an objective assessment. The manual techniques being applied may have an immediate effect but whether that effect is short-term or long-term is hard to say without concrete evidence. 
  • Stimulates Autonomic Nervous System

    • The ANS is broken into the sympathetic nervous system (SNS) and parasympathetic nervous system (PNS). The SNS activates the "fight-or-flight" response whereas the PNS is activated for rest, digest and recover. When assessing a patient's physical response, we focus our attention on stimulating the parasympathetic nervous system to help the patient relax. By activating the PNS, we can assist in alleviating a patient's stress/anxiety by stimulating the Vagus nerve which lowers heart rate, reduces blood pressure and decreases cortisol. 
  • Provides Pain Relief

    • A great way for touch to facilitate a pain-relief effect can be understood by a brief understanding of the Gate Control Theory: 
      • There's a noxious stimuli (pain) that can be represented as A(delta) and C fibers. Then there's a distraction stimuli (rubbing, modalities, touch, etc) that can be represented as A(alpha) and A(beta) fibers. The order of conduction velocity in which the fibers travel are A(alpha) > A(beta) > A(delta) > C Fiber. This is also concurrent with the axonal diameters meaning the bigger the fibers, the faster signals should travel. 
        • The different signals get sent to the transmission cell in the spinal cord allowing the "gate" to be opened or closed depending on the traveling fibers which ultimately get sent to the sensory cortex. Because Alpha/Beta travel faster than C/Delta fibers, it should theoretically inhibit some of the painful stimuli that is being sent to the brain allowing an overall relief of pain. 
    • In addition to modulating pain through the gate-control theory, manual treatments have also been shown to reduce pain through descending inhibition. There are many mechanisms by which this occurs. including the release of Beta-endorphins and oxytocin (see below), and the specific mechanism(s) depends on the type of manual treatment.
  • Releases Oxytocin

    • Oxytocin is known as the "love hormone" and is initially released by the hypothalamus and is transferred to the pituitary gland allowing distribution into the blood stream. It is responsible for breast feeding and childbirth. It also promotes attachment, solidifies relationships, reduces stress, boosts sexual arousal, can reduce drug cravings/additions, improves social skills, triggers protective instincts, induces sleep, and fosters generosity. 
  • Builds Rapport

    • When introducing ones self to a patient, it's typically in the form of a handshake. This handshake is the first gesture towards building a bond with that person. It allows them the opportunity to determine the confidence that is exuded from an initial interaction. It sets the stage for the rest of the patient interaction. When good rapport is developed, it allows trust to be formed between patient & therapist. This trust can allow additional hands-on techniques that may otherwise be uncomfortable for the patient but beneficial for proper rehabilitation. For example, a patient may be pain-limited with shoulder abduction but demonstrates an empty-end feel. By gaining their trust, they may allow you to passively bring them through the pain-limited motion. That opportunity can also be used educate the patient of their actual ROM to help facilitate a functional pain-free motion. 
  • Improves function

    • For every patient, having proper biomechanical function and motor control is important for their everyday activities of daily living. It is paramount to regain any loss of function or correct any dysfunction so the patient can live comfortably.  By applying hands-on techniques, this is achievable. External manual cues can facilitate or inhibit movement, promote proper timing & sequencing during gait, improve coordination, assist in building strength and gain full range of motion.
  • Delivers Value

    • When a patient is coming into the clinic, it's important to provide valuable treatment that is beneficial for the patient. In general, patients will present with different insurances that have variable co-pays. They could also present as a cash-based patient or workers compensation.  In any case, performing hands-on techniques sends the message of value to each and every one of them - that they're getting their money's worth. Rather than performing "massage", applying PNF strengthening/stretching patterns can demonstrate confident hands-on skills to the patient.  Using resistive bands to facilitate a specific muscle group activation can be used to implement a 1-on-1 interaction. There's also the simple tapping gesture on someone's back as acknowledgement of their well-being and even taking measurements to provide constructive feedback on their overall progress. As physical therapists, we spend roughly 30-60 minutes evaluating new patients. During that time, it provides opportunity to assess using our hands which exemplifies our worth in comparison to a normal physician visit of 5-10 minutes. 

I put together a little diagram below to summarize the importance of applying touch in a rehab setting. It can be used as a simple reminder to help others implement the concept of applying a hands-on approach with each patient. Please leave a comment if this is what you use in the clinic and how it has affected the overall treatment or if there's another aspect of touch that I did not cover that may contribute!