Therapeutic Touch and the Elderly

A paper of mine from a Eastern Movement and Philosophy in Holistic Health course which "explores the holistic wisdom embedded in Eastern movement forms such as Tai Chi, Qi Gong, Akido, or Yoga. Students are introduced to several different forms with a focus on the beginning practice depending on the instructor's expertise. The Eastern philosophy underlying the movement form is discussed as well as health benefits and the translation of Eastern movement forms into a Western lifestyle."

Therapeutic Touch and the Elderly

Therapeutic touch (TT) is a form of energy healing developed by Delores Krieger and Dora Kuntz in the 1970s. TT assumes the presence of universal life energy that can be perceived and manipulated by an adept to increase the comfort, health, and well-being of a patient. (Griffin and Vitro, 1998) If therapeutic touch works as suggested it would be of great help in the care of the institutionalized elderly, especially those with Alzheimer’s disease. A non-invasive, non-pharmacological intervention could increase the comfort, well-being, and safety of persons of advanced age, ill health, and reduced mental capacity without side effects. (Griffin and Vitro, 1998)

Therapeutic touch and similar Complimentary and Alternative Medicine (CAM) therapies have been challenged on a variety of fronts. The Roman Catholic Church regards the very similar Reiki theory of universal energy fields as contrary to its doctrine and superstitious to boot (Lori, et al., 2009). A study created by nine year old Emily Rosa tested an underlying assumption of TT, that practitioners can perceive the “bio-energy field” of another person as they manipulate it. Rosa found that 21 practitioners’ detection skills were no greater than chance. This famous study, done by a fourth-grader for her science fair, was published in JAMA. (Rosa, et al., 1998) Many scientists and physicians simply regard TT, energy healing, Reiki, and other CAM therapies as primarily evoking the well known placebo effect, which can induce powerful healing on its own. (Bausell, 2007) The proponents of TT strive to demonstrate their claim that energy healing works better than mere placebo and have published research to support their position.

In Western medicine the gold standard for proving the efficacy and safety of medical treatments is the randomized controlled trial (RCT). According to R. Barker Bausell, former Research Director at the NIH-funded Complementary and Alternative Medicine Specialized Research Center, there are many elements to look for in a credible RCT. The larger the study the better – there should be 50 to 100 subjects per group. The study should be placebo-controlled – randomly selected subjects should receive an active treatment, a placebo, or serve in a control group. Providing convincing placebos can be much more challenging when evaluating CAM therapies. Studies should be double-blinded (or even triple-blinded; where the statistician does not know the nature of the experiment being evaluated). Blinding when evaluating CAM generally, and therapeutic touch particularly, is difficult because the investigator knows whether he or she is providing verum or sham treatment and the subject may need to be aware of the treatment as it is performed. A credible study should have low experimental attrition – less than 20% and no more than 25%. Numbers can be skewed when subjects who know they are assigned to the control group, suspect they are in the placebo group, or are experiencing no positive benefit from treatment leave the trial. Ideally the results of the study should be published in high quality, peer-reviewed, scientific journals, such as JAMA, NEJM, The Lancet, etc. Publication in a journal catering to the discipline being evaluated raises the question of editorial bias. Ultimately the results should be independently validated by researchers at other centers. Studies that cannot be duplicated are not nearly as compelling as those that are. Other potentially confusing factors include causal inferences, the natural history of chronic pain, the placebo effect, cognitive dissonance, optimism, respect for authority, credulity, investigator disingenuousness, the “Hawthorne Effect” (sometimes any intervention creates a change), experimenter bias, ethics of informed consent, scientific acculturation, publication bias (positive results are published more often and more quickly than negative results), and a variety of arcane statistical artifacts, including regression to the mean, can all serve to confound accurate assessment of CAM therapies. (Bausell, 2007)

I initially selected three studies from those found in on-line journal databases using search terms such as “therapeutic touch,” “energy healing,” or “Reiki.” The field was narrowed by searching within results for terms such as “elderly” and “Alzheimer’s.” Only after deciding to evaluate each study using Bausell’s criteria did I read the articles which I had selected for their title keywords “therapeutic touch” and “elderly” or “Alzheimer’s.” As the first study I chose failed the criteria for an RCT on several levels I chose another for a total of four.

In “An Overview of Therapeutic Touch and its Application to Patients with Alzheimer's Disease” authors Griffin and Vitro found that when therapeutic touch was provided to Alzheimer’s patients the results included ceasing of rocking motions, relaxation of facial muscles, unclenching of fists, reduction in verbal anxiety, and a deep sigh reflecting total relaxation of the body. Weaknesses of this study include the lack of a control group, lack of a placebo group, the study was not blinded, and anecdotal reports from journal entries were provided instead of statistics. The article’s publication in American Journal of Alzheimer's Disease does not carry as much weight as those of higher profile but it’s acceptance by a journal intended for caregiver’s rather than CAM proponents should be noted. (Griffin and Vitro 1998)

The second paper, “Effects of Therapeutic Touch on Anxiety in the Institutionalized Elderly” by researchers Simington & Lain, was published in Clinical Nursing Research. This small study of 105 patients was divided into three subject groups, a therapeutic touch group received a back rub and TT, group one received a back rub by TT practitioner intentionally withholding energy transfer, and group two received only a back rub by a psychiatric nurse with similar credentials as the primary investigator but no training in TT. Anxiety levels were then assessed using a Speilberger State-Trait Anxiety Inventory (STAI). The assessor conducting the STAI was blinded, but practitioners were not. There was a statistically significant difference in scores between the TT group (back rub and TT) and group 2 (back rub only), but the score for backrub by TT practitioner withholding energy transfer fell between the two. The authors first admitted this called into question whether the TT provided anything more than a placebo effect, then they “moved the goal post” by theorizing that the TT practitioner providing a back rub while withholding energy transfer may have done an imperfect job of denying the patient energy transfer. They also suggested that the STAI might not have been the best tool to assess anxiety levels in elderly patients. The study had low attrition and was published by a journal directed toward caregiver’s. (Simington and Laing 1993)

The third paper, “The Effect of Therapeutic Touch on Agitated Behavior and Cortisol in Persons with Alzheimer’s Disease” by Woods and Dimond, hypothesized that therapeutic touch would reduce the frequency of agitated behavior, that therapeutic touch would reduce the level of salivary or urine cortisol or both, and that there would be a positive relationship between the level of salivary or urine cortisol and agitated behavior. This was a very small study of only 10 patients. It tracked patient behavior before, during, and after TT. Observers used a modified Agitated Behavior Rating Scale to measure behaviors suggesting patient agitation: rhythmic purposeless movements of the hands, fidgeting or tugging on restraints, haphazard searching through pockets and/or wandering into rooms and searching through drawers, tapping of fingers and/or feet, and mumbling or asking continuous questions. The study showed a reduction in the frequency of agitated behavior on the day of treatment but an increase in agitation behaviors after treatment was ended. The researchers documented no significant changes in cortisol levels during the study period. As for the third hypothesis there was a weak statistical correlation between cortisol levels and agitated behavior. Weaknesses of this study include its very small sample size, no placebo, no control, and no blinding. The study was published in Biological Research for Nursing. (Woods and Dimond, 2002)

As the first study chosen did not detail an RCT I selected another. Regrettably, “Therapeutic Touch: Its Application for Residents in Aged Care” was not an RCT either. But having selected it according to my simple protocol I include it here. While there were 121 subjects in this study of therapeutic touch they were not randomly selected. Therapeutic touch was given with the compassionate intention of alleviating the specific symptoms of a wide variety of maladies. Results were measured variously by physiological changes, pain level reports, and behavior changes depending on the precise nature of the patient’s original complaint. The result of this “exploratory study” was a significant improvement by all patients across all diagnoses. There was no control, no placebo, and no blinding. (Gregory and Verdouw 2005)

The researchers in these four studies perceived that therapeutic touch had a positive effect on elderly patients suffering from Alzheimer’s, other dementias, and other maladies associated with advanced age. But without a rigorous study design and sturdy statistical controls these studies evince little evidence for the effectiveness of therapeutic touch beyond that of the placebo effect. The investigation of TT applied to demented patients is an interesting approach. It may help prevent activation of patient expectation systems but at the same time communication difficulties seem to make accurate assessment problematic. Perhaps more carefully designed RCTs could be conducted that incorporate verum and placebo treatment, and a control group. If TT works as described then at least single blinding might be achieved by conducting the therapy on sleeping patients. While the issues of informed consent are daunting in such a population more detailed analysis of cortisol and other bio-markers of agitation might be pursued. Interpretation of such tests would be easily blinded.

In the final analysis, and especially in the Eastern view of such therapies, healing need not be about curing. If the soothing presence of a compassionate caregiver helps ease our elders’ discomforts and fears – whether by smoothing bio-energy fields, as the result of the placebo effect, or some other indirect cause – who will stand against more and better research?

References

Bausell, R. (2007) Snake oil science: the truth about complementary and alternative medicine. New York: Oxford University Press.

Gregory, S. and Verdouw, J. (2005) Therapeutic touch: its application for residents in aged care. Australian Nursing Journal, 2005; 12:07; 1-3.

Griffin, R. and Vitro, E. (1998) An overview of therapeutic touch and its application to patients with alzheimer's disease. American Journal of Alzheimer's Disease, July/August 1998.

Lori, W., Nienstedt, J., Blair, L., Serratelli, A., Gomez, J., Vigneron, A., McManus, R., and Wuerl, D. (2009) Guidelines for evaluating reiki as an alternative therapy. Committee on Doctrine, United States Conference of Catholic Bishops, March 25, 2009. Retrieved from http://www.usccb.org/dpp/Evaluation_Guidelines_finaltext_2009-03.pdf  June 19, 2009.

Rosa, L., Rosa, E., Sarner, L., and Barrett, S. (1998) “A close look at therapeutic touch” JAMA, 1998; 279:13; 1005-1010.

Simington, J. and Laing, G. (1993) Effects of therapeutic touch on anxiety in the institutionalized elderly. Clinical Nursing Research, 1993; 2:4; 438-450.

Woods, D. and Dimond, M. (2002) The Effect of Therapeutic Touch on Agitated Behavior and Cortisol in Persons with Alzheimer’s Disease. Biological Research for Nursing, 2002; 4; 104.