Touch: vital to patient-physician relationships.

Patterson • Editorial R I was talking to a boardcertified osteopathic internist whose practice also happens to be about 90% manipulative. He sees many patients with chronic pain in addition to his general internal medicine patients. He related a patient encounter that, to me, was amazing. A new patient came in with a sore lymph node in her neck. In the process of examining her, the internist palpated her upper back and found tense and fibrotic muscles. On questioning her, he saw that she became quite emotional. He asked what was wrong, and she replied that she had lymphoma about 25 years ago and that the subsequent radiotherapy had left her back muscles tense, atrophic, and rigid. She also noted worsening kyphotic curvature and more pain in her neck as her muscles further degenerated. She then said, almost in tears, that he was the first physician in 25 years to actually touch her, inquire about her condition, and offer a possible alternative to medications for her problem. She was both amazed and grateful that a physician actually noted her problem through palpation, and although the node was benign, her gratitude and appreciation for the physician’s touch were palpable. Touch is our most ancient sense. It can cause many different emotions and feelings. It has consequences of which we are not consciously aware. In Subliminal: How Your Unconscious Mind Rules Your Behavior,1 Mlodinow gives a very readable, well-documented, and cogent account of how touch influences behavior. In one example, he cites a study2 in which 40% of diners took a server’s suggestion to order the special of the day if not touched, but 60% ordered it if the server had lightly and briefly touched them on the forearm. In The Science and Clinical Application of Manual Therapy,3 UvnäsMoberg and Petersson provide a neurophysiologic rationale for the effects of touch on perception and, interestingly, on perception of trust. Oxytocin released in the brain both by the touch and by the perception of trust in a patient causes unconscious feelings of well-being, a heightened pain threshold, and many other positive physical and mental states. Thus, touch has direct physiologic effects that are now becoming understood as true alterations in brain function. In light of the many studies on the effects of touch and the unfolding story of how touch affects both physiologic and psychological function, it seems time to rethink the role of touch in osteopathic medical practice, especially in the realm of osteopathic manipulative treatment (OMT). It has become difficult in the current scientific climate to design a study of OMT effectiveness without including a “sham” group that is purported to factor out the “hands-on” effect. Perhaps it is time to rethink the role of touch in OMT. Is touch a peripheral factor in OMT, or does it play a more important role in the effectiveness of OMT? Is touch a minor player in the effects produced by OMT on function, or is it one of several active ingredients in treatment? I believe the evidence is that touch is one of the active ingredients of OMT and should be so recognized. Indeed, studies such as one by Licciardone et al4 have shown that a touch sham therapy can be as effective as an active OMT. As such, the role of touch and even physician presence should be more actively emphasized in osteopathic medical curricula and valued in studies on the effectiveness of OMT. The article by Elkiss and Jerome5 in the current issue of JAOA—The Journal of the American Osteopathic Associationpresents a wonderful overview of the importance and meaning of touch—the centerpiece of OMT—and how it affects the whole person. They summarize the effects of touch on the nervous system and hence on the immune, musculoskeletal, and other body systems. They describe an integrated musculoskeletal (M), immune (I), nervous (N), and endocrine (E) (MINE) system that helps readers understand the integration of touch sensations with these body systems. They remind us that touch is a 2-way street, with the patient not only being touched but also touching the physician, each giving and receiving information. The woman who became emotional at the touch of the internist was showing the effect of touch in a very tangible way. The article by Elkiss and Jerome,5 which explores such effects, should be read by all OMT practitioners.