Healing through touch is as old as civilization itself. Practiced extensively in all cultures, this ancient treatment is instinctive—it feels natural to rub or hold any part of one’s body that hurts and to do so for others. The ancient Egyptians used bandages, poultices, touch, and manipulation. Inside the Pyramids, illustrations thousands of years old show representations of one person holding hands near another, with waves of energy depicted moving from the hands of the healer to the body nearby. The oldest written documentation of the use of body touch to enhance healing comes from Asia. The Huang Ti Nei Ching is a classic work of internal medicine that was written 5,000 years ago. The Nei Ching, a 3,000- to 4,000-year-old Chinese book of health and medicine, records a system of touch based on acupuncture points and energy circuits. The ancient Indian Vedas also described healing massage, as did the Polynesian Lomi practice and the traditions of Native Americans.

During the height of classical Greek civilization, Hippocrates wrote of the therapeutic effects of massage and manipulation; he also gave instructions for carrying out these practices. He wrote during the time of the great Aesculapian healing centers, at which many whole-body therapies included touch. Touch therapies were also employed at the healing centers to assist individuals who wished to make the transition to a higher level of functioning. Massage was used as a mode of preparation for dream work, which was a significant part of therapy in the healing rites. The Roman historian Plutarch wrote that Julius Caesar was treated for epilepsy by being pinched over his entire body every day.

Biblical accounts of the healings performed by Jesus of Nazareth frequently include the use of
touch in the form of laying hands on the body. In two New Testament passages (using the new revised standard version [NRSV]), the human energy field is described. In Mark 5:25-34, a woman who had been bleeding for 12 years touched the back hem of Jesus’ garment with an inner sense of knowing that this would heal her. Jesus felt that “power had gone forth from him” and turned around quickly, asking who had touched his clothing. Luke 6:18-19 tells of a crowd that had come to be healed of their diseases and demons through Jesus’ touch, for “power came out from him and healed all of them.”

Both shamans and traditional practitioners used touch widely until the rise of the Puritan culture during the 1600s, including the shift from primitive healing practices to modern scientific medicine. Puritan culture equated touch with sex, which was associated with original sin. During the late nineteenth and early twentieth centuries, health care moved away from anything associated with superstition and primitive healing and was directed toward scientific medicine. All unnecessary touch was discouraged because of the association of touch with primitive healing, and because of the prevailing Puritan ethic. Consequently, touch as a therapeutic intervention remained undeveloped in U.S. health care until research into its benefits began in the 1950s.

The fact that many cultures, both ancient and modern, have developed some form of touch therapy indicates that rubbing, pressing, massaging, and holding are natural manifestations of the desire to heal and care for one another. However, attitudes toward touch vary among cultures. One society may view touch as necessary, whereas another may view it as forbidden. The nurse must be aware of personal and cultural views and reactions to touch in addition to particular gender prohibitions within cultures.

Philosophic and cultural differences have influenced the development of touch in various areas of the world. The Eastern worldview is founded on energy, whereas the Western worldview is based on reductionism of matter. This basic cultural difference has led to the evolution of widely differing approaches to touch. The Eastern worldview holds that qi (or chi), also described as energy or vital force, is the center of body function. A meridian is an energy circuit or line of force that runs vertically through the body. Magnetic or bioelectrical patterns flow through the microcosm of the body in the same way that magnetic patterns flow through the planet and the universe. Meridian lines and zones are influenced by pressure placed on points along those lines.

Expert practitioners in acupuncture and acupressure purport to send healing energy to the recipient via an energy flow that moves through the body and out through their hands. In contrast, the Western worldview holds that it is the physical effect of cellular changes occurring during touch that influences healing. For example, massage stimulates the cells and aids in waste discharge, promotes the dilation of the vascular system, and encourages lymphatic drainage.¹ Swedish and therapeutic massage techniques were developed to produce these physical changes.

A blending of Eastern and Western techniques has resulted in an explosion of new and widely practiced modalities. The modern-day renaissance in body therapies is probably a healthy response to the fast-paced technologic revolution that has swept Western culture, bringing back a sense of balance and caring.

Evidence is mounting that supports what healers have intuitively known—touch is a vital aspect of human health and well-being. Some of the first studies documenting the significance of touch involved infant monkeys and surrogate mothers.² In the 1950s, Harlow caged one group of infant monkeys with a monkeyshaped wire form that served as a surrogate mother, and a second group with a soft cloth mother surrogate. When frightened, the monkeys housed with the wire form reacted by running and cowering in a corner. The other group reacted to the same stimuli by running and clinging to the soft cloth surrogate for protection. These infant monkeys even preferred clinging to an unheated cloth surrogate mother to sitting on a warm heating pad. Although the cloth surrogate was unresponsive, the offspring raised with it developed basically normal behavior. This and other classic studies conclusively documented the significance of touch in normal animal growth and development.

Studies of human development soon followed. A study examining abandoned infants and infants whose mothers were in prison found that infants whom the nurses held and cuddled thrived, whereas those who were left alone became ill and died.³ These studies led to the development of the concept of touch deprivation.

These early studies in the 1950s and 1960s awakened scientific interest in the phenomenon of healing touch. Bernard Grad, a biochemist at McGill University, was one of the first to investigate healing by the laying on of hands. He conducted a series of double-blind experiments with the renowned healer Oskar Estebany.⁴ In these studies, wounded mice and damaged barley seeds were separated into control and experimental groups. After Estebany used therapeutic touch to manipulate the energy fields of the mice and seeds in the experimental groups, these groups demonstrated a significantly accelerated healing rate in comparison to the control groups. In a subsequent study, an enzymologist worked with Grad using the enzyme trypsin in double-blind studies.⁵ After the trypsin was exposed to Estebany’s treatments, its activity was significantly increased.

Within the past two decades there has been a renaissance in the use of touch as a therapeutic practice. A proliferation of research publications, books, continuing education offerings, and web resources document the effectiveness of these practices. Both the American Nurses Association and the National League for Nursing endorse the use of biofield and touch therapies. The North American Nursing Diagnosis Association includes the diagnosis Disturbed Energy Field, defined as a disruption of energy flow surrounding a person that disrupts harmony of body, mind, and/or spirit. Many healers who use biofield therapies claim that they either direct or channel energy to the recipient. Others say that energy will go where it is needed. Nurses are using hand-mediated therapies with increasing frequency as they seek ways to help or heal those for whom they care.

Data collected through in-depth interviews with eight experienced intensive care nurses reveal two substantive processes—the touching process itself and the acquisition of a touching style—neither of which had been previously reported in the literature. The touching process is more than skin-to-skin contact; it involves entering the patient’s space, connecting, talking, following nonverbal cues, and eventually touching. Nurses learn about touch from their culture, family, street knowledge, personal experience, and nursing school. The phenomenon of the healer’s touch has been researched and there are distinct characteristics that emerged. Touch is gestural, impactful, and reciprocal. This is inclusive of the fact that the practitioner will also experience these three responses. Emotions, past experiences, and receptivity to healing can emerge from the touch experience. As the practitioner touches the client, relaxation of the muscles may be felt and a change in the breathing pattern may be observed. An openness for the healing power of touch is necessary between the patient and the client, which constitutes the “I-Thou relationship.”⁶

There is power demonstrated through the use of touch and it is important for nurses to be mindful of this when using touch techniques. In Gueguen and Vion’s study, touch was used to emphasize and anchor a particular message regarding the taking of antibiotics. Those clients who were touched by the general practitioners while instructions were given had significantly higher compliance rates. This underscores the risk for touch to become coercive or to facilitate hierarchical relationships. Our intention as practitioners should always be examined and touch should be offered with the best of intention for our patients/clients.⁷

Touch is perhaps one of the most frequently used and yet least acknowledged of the five recognized senses. It is the first sense to develop in the human embryo and the one most vital to survival. Touch can vary from subtle fleeting brush strokes to violent physical attacks. Touch evokes the full range of emotions from hatred to the most intimate love. Figurative references to touch in our daily language such as “That speech really touched me,” or “This conversation helped me get in touch with my feelings” attest to its deep importance and value to us. As the largest and most ancient sense organ of the body, the skin enables us to
experience and learn about the environment. We use touch to help us perceive the external world.

A piece of skin the size of a quarter contains more than 3 million cells, 12 feet of nerves, 100 sweat glands, 50 nerve endings, and 3 feet of blood vessels. There are estimated to be approximately 50 receptors per 100 square centimeters —a total of 900,000 sensory receptors over the human body.⁸ Viewed from this perspective, the skin is a giant communication system that, through the sense of touch, brings messages from the external environment to the attention of the internal bodymindspirit.

Because health care is increasingly delivered in complicated technologic settings, nurses are concerned with ensuring that the human, spiritual, and social needs of patients are not overlooked. This is particularly valuable when working with the geriatric population, an often touch-deprived group. Yet nurses must take into account social contexts and cultural differences before engaging in efforts to provide touch therapy. In addition, it is important to remember that for many an experience of unwanted touch in the form of physical and/or sexual abuse may have occurred, leaving lasting fears related to receiving and giving touch. Nurses must respect and be vigilant about their own boundaries as well as their clients’ as related to touch. A nurse should never assume that a client will find touch comforting and should always ask before touching. If the suggestion evokes no response or a wary expression, the nurse may try a tentative touch and observe the client’s response carefully. To be truly effective, touch must be given authentically by a warm, genuine, caring individual to another who is willing to receive it. Unwelcome, uncaring, or boundary-violating touch is likely more upsetting than none at all.

Like any other nursing intervention, hugging and touching demand careful assessment. Nurses need to recognize their own feelings, as well as consider the client’s age, sex, and ethnic background. A few key questions (e.g., “Would a back massage help you relax?” or “Would it help if I held your hand?”) can help the client clarify his or her own beliefs, values, and desires regarding different types, locations, and intensities of touch.

There are many variations in and names for the touch therapies available for use as nursing interventions. Some are basic human contacts, such as hand holding and hugging. Holding hands with patients who have dementia has been noted as a form of communication by volunteers in a nursing home. This form of touch can be more profound than words for clients with moderate to advanced stages of Alzheimer’s disease.⁹ However, some clients react strongly to touch, especially if they have been exposed to inappropriate or uncomfortable touch at other times. The touch therapies described here are used by holistic practitioners who often advocate and teach healthy lifestyle behavior patterns to their clients to augment well-being during the course of the touch therapy treatments. The addition of guided imagery and/or music before and during treatment may heighten the relaxation response elicited during touch therapies. The type of setting —acute care, long-term care, home care, rehabilitation center, or wellness center—also affects the focus and length of the treatment.

The category of somatic and musculoskeletal therapies encompasses the generic work known as therapeutic massage. As a nursing intervention, therapeutic massage is effective in stimulating circulation of blood and lymph, dispersing nutrients, removing metabolic wastes, and enhancing relaxation. Several basic strokes are involved, including long smooth strokes (i.e., effleurage), kneading motions (i.e., petrissage), vibration, compression, and tapping (i.e., tapotement). Although they may be called by different names (e.g., Swedish massage, medical massage), many of the techniques of therapeutic massage are similar. Varying degrees of pressure and various types of oils or creams can be used, depending on client preference and the intention for the treatment. Therapeutic massage has also been referred to as “soft massage” and has been associated with helping the recipient reestablish balance and as a means to draw attention away from suffering.¹⁰

Nurses have routinely performed therapeutic massage primarily on the backs and sometimes on the hands and feet of their clients. Back care is not new; for decades, it has been incorporated into the standard bathing and evening care routine of most hospitals. Because of time constraints and traditional neglect of the body therapies in institutions, these patients receive only a portion of the complete range of touch therapies.

Learning full-body massage greatly augments and expands the nurse’s basic knowledge of massage techniques. Most practitioners learn these techniques in continuing education classes, but books on massage that illustrate the techniques are also available. Myriad styles of bodywork literally offer something for everyone. To use these specific techniques, the nurse must take special courses, which often grant a certificate of completion. Massage licensure laws vary from state to state; some states require that even registered nurses take an additional course to become certified prior to practicing massage therapy.

Because no two clients, either within or outside the institutional setting, have the same needs, the nurse must become skilled at adapting the therapy to the setting and the time available. Massage techniques that can be performed quickly—massage for the hands, feet, or neck and shoulders—may have beneficial results in short time periods. In randomized, controlled trials, acute care hospital nurses were assigned to either a group that received a weekly 15-minute back massage, or to a no-intervention control group. Data collected throughout the 5-week protocol included physiologic as well as psychological measures of stress. Urinary cortisol and blood pressure were measured at weeks 1, 3, and 5, and the State-Trait Anxiety Inventory (STAI) was administered at weeks 1 and 5. Although differences in the physiologic measures between groups did not reach statistical significance, the STAI scores of the experimental group decreased significantly, while the control group’s STAI scores increased. It was concluded that massage therapy can be a beneficial tool for reducing psychological stress levels in nurses.¹¹

Evidence supports the use of somatic and musculoskeletal therapies to enhance mood, cardiac health, immune function, pain relief, and treatment of clients with cancer. Over the last 20 years, evidence supports the use of massage therapies to relieve chronic lower back pain, cancer pain, and migraine headache; enhance natural killer cell function; and help relieve depression and anxiety.¹²

In a study involving 150 massage clients, it was found that the type of massage technique, length of session, and degree of pressure affected blood pressure (BP). In particular, Swedish massage was correlated with the greatest reduction in BP, while potentially painful styles of massage such as trigger point therapy and sport massage were associated with elevations in BP.¹³ Another study involving 151 clients with advanced cancer emphasized the effectiveness of massage therapy in palliative care. Outcomes included improved lymph drainage, increased relaxation, and improved attitude by the recipients toward touch. Many of the clients had previously associated touch with negative experiences such as needle sticks and invasive exams.¹⁴

Thirty-nine women with breast cancer undergoing chemotherapy, recruited from an oncology clinic in Sweden, were randomly assigned to either a massage group or a no-massage control group.
Both groups were seen for 20 minutes on five different occasions, and measures of nausea and anxiety were recorded on a visual analogue scale before and after each visit. They also completed the hospital anxiety and depression scale with each visit. Although the differences in anxiety and depression between the groups did not reach statistical significance in this study, the experimental group reported significant reductions in nausea when compared to the control group.¹⁵

Sixty-eight adults with osteoarthritis of the knee were assigned to either a treatment group (Swedish massage twice weekly for 4 weeks followed by 4 weeks of one session a week) or to a control group (no massage). The results showed significant improvement in the massaged group in the areas of pain, stiffness, range of motion, and physical function domains when compared with the control group.¹⁶

Massage is frequently combined with other therapies to amplify therapeutic benefit. Aromatherapy is frequently used in conjunction with massage through the use of essential oils, scented creams, and fragrant candles. The M Technique is an example of this. (See Chapter 25.) In a multicenter, randomized, controlled trial involving four cancer centers and a hospice, 288 cancer patients were randomly assigned to either a course of aromatherapy massage or to standard care. Patients who received aromatherapy massage reported significant improvement in clinical depression and/or anxiety 6 weeks into the trial when compared with control group participants. However, this effect was not as significant at 10 weeks into the trial. Interestingly, the patients receiving aromatherapy massage described greater improvements in anxiety at both the 6- and 10-week markers.¹⁷

Infants and children can benefit from massage therapy, and researchers are examining its use for this population. In a meta-analysis of literature examining potential benefits of massage for children with cystic fibrosis (CF), researchers hypothesized that this modality could provide relaxation, pain relief, decreased anxiety, improved mood and sleep, and enhanced pulmonary function. This information was based on known physiologic effects of massage, related research, and subjective reports of many youth with CF who were known to the researchers. These hospitalized youth received massage from an RN who was also licensed as a massage therapist. The youth routinely reported that massage made them feel more comfortable, more relaxed, and able to move more freely.¹⁸ The meta-analysis reveals that more research is needed to support the use of massage therapy from an evidence standpoint. In other words, these researchers conclude that the risks of negative side effects are small, and based on the subjective reports of the children with CF, the massage therapy will continue, but the research evidence is not yet in place. This illustrates the conundrum that pervades many complementary nursing modalities—their effects cannot always be measured in the same ways as, for example, pharmacologic agents. (See Chapter 34.)

So, although participants may not demonstrate pain reduction or other specific symptom reduction after receiving massage, they may actually have a greater sense of well-being. However, if well-being is not measured, a modality can be dismissed as having no significant, measurable, therapeutic benefit. Whenever pain reduction is desired, all of the factors that influence resistance to pain are important in the overall subjective experience for the client. Thus, improvement in well-being is a significant part of pain reduction because the overall degree of suffering is lessened.

The immune status of young, HIV-positive Dominican children improved as a result of massage therapy twice a week. Eligible children who had no access to antiviral drugs were assigned to the massage treatment group or to a “friendlyvisit” control group. Blood was drawn at the beginning of the study and at the end of the 3-month intervention. Despite similar baseline immune parameters, the children receiving massage therapy had significant improvements in CD4 and CD8 cell counts as well as CD41CD251 cells, and an increase in natural killer cells, particularly in the younger children.¹⁹

Infants in Ecuador, recruited from two orphanages, received massage therapy and demonstrated statistically significant differences in incidence of diarrhea. The massaged infants had 50% less risk of diarrhea than their nonmassaged control group counterparts.²⁰ In another study, 50 low-birth-weight (LBW) babies were cross-matched, controlled, and assigned to a massage group or a nonmassaged group. The massage consisted of gentle rubbing, stroking,
and passive movements of the limbs. The intervention lasted for 6 months. The findings suggest that infants receiving massage had better quality of sleep with greater daytime alertness than control group infants did.²¹

In another study involving infants, 68 preterm babies were randomly assigned to either moderate or light pressure massage therapy, and each received 15-minute massages three times per day for 5 days. The moderate versus light pressure massage group gained significantly more weight per day. In addition, they demonstrated greater relaxation and reduced arousability, both of which may have contributed to the significant increase in weight gain.²²