Johns Hopkins Magazine - September 1996 Issue

Healing Hands

By Melissa Hendricks
Kadi Martin dabs a bit of white lotion onto one of her palms and rubs her hands together. Her hands are the color of peaches. Her fingers, surprisingly long considering her petite frame, are fleshy and strong. "Hi Leon.* Hello, sweetpea," she says. A tiny wrinkled pea of a baby boy ever-so-slightly unfurls from the fetal position in which he's been napping and struggles to open an eye. "Okay buddy, let's take your shirt off." Leon fully opens his eyes and yawns.

Martin cups Leon's left foot in one palm, and with her other hand she gently strokes the skinny leg downward from the hip to the ankle--the Indian milking massage stroke--and upward from his ankle to his hip--the Swedish milking stroke. She then rubs two fingers around his kneecap. Leon half-closes his eyes, blinks, and stares at Martin. "Yeah, that's better," she whispers.

As Martin gently picks up Leon's other leg, the baby flails, startled. She releases the leg, and it jerks upward, bent at the knee. "Premature babies don't know how to relax," says Martin, a senior clinical nurse in the Johns Hopkins Hospital Neonatal Intensive Care Unit. She caresses the backs of Leon's hands, strokes his tummy and chest, and rubs his temples. All the while she speaks to him in soft tones.

When Martin is through with the 15-minute massage, she places Leon on his tummy with his knees tucked up to his chest. She presses lightly on his back with one hand, and pushes upward on the base of his feet. "A lot of times this helps babies go to sleep," she says. Snuggled up, safe and warm, Leon lies still and sucks on a pacifier.

The massage is one of Leon's rare moments of physical contact when he is touched for the sake of touch alone--not to have his heart listened to, his heel pricked, or his feeding tube changed. Leon, who has lived in the NICU since he was born several weeks prematurely a month ago, weighs only about three pounds. He lies in a Plexiglas isolette with two portholes through which Martin put her hands to massage him. A web of wires attaches him to the monitors, feeding tube, and oxygen supply that keep him nourished and breathing. The NICU, in fact, is a flotilla of plastic bubbles, each a lifeboat built with the world's best life-giving technology. Into this meshwork of wires and computers, for a few minutes each day, comes the touch of Kadi Martin.

Martin is one of those people who seem to glide through life on fuzzy slippers, whose mellifluous voice is like a healing caress that strokes the back of your neck, unclenches your gut, and uncurls your toes. A nine-year veteran of the NICU, Martin intubates infants, draws their blood, listens to heartbeats, changes diapers. Out of necessity, sometimes she must inflict pain. But when she has the time, she also gives the babies her comforting welcome to the world.

Research has demonstrated that massage can improve the health of infants, says Martin. A recent study conducted by Tiffany Field at the University of Miami School of Medicine Touch Research Institute, for example, found that premature infants who were massaged gained more weight than those who were not. Field, a professor of pediatrics, psychiatry, and psychology, also found that massage improved weight gain and motor skills in premature infants who had been exposed to cocaine in the womb.

Martin, who is certified in infant and relaxation massage, believes these benefits are tied to the fact that massage helps infants relax. "They sleep better and don't use as much energy, so they gain weight better," she says. "Massage also provides range of motion and keeps the circulation moving."

Massage also gives the parents of premature babies a structured way of touching their infants, says Martin, who teaches the technique to adults. Many parents of preemies are afraid to touch their fragile newborns, who can be as small as an adult's hand. Martin once cared for an infant who had been declared brain dead and was being kept on life support. "We'd give her a massage because we knew she needed it," says Martin. "She didn't move, so we had to get her circulation moving, to keep her from getting bedsores. She was there six weeks while her parents were [struggling] to cope with it." The parents finally decided to remove their child from life support. As the mother watched Martin massage her infant and learned some techniques herself, she had a chance to know her daughter, says Martin. And perhaps that helped the mother when she had to decide to let go.

Touch is the most primitive sense, and one we often use first to learn about the world. We also use touch to confirm other sensory input. A contract may outline a business deal, but a handshake always closes the deal.

We all need touch for our emotional, social, and maybe even our physical well-being. But in our hectic world, it is easy to neglect this sense. Just think about how long a person-- particularly a single person--can go without physical contact with another human being. So many of us speed through the drive- in at our local fast food chain, receive cash and make deposits at automated tellers, spend our leisure time sitting in front of the TV.

In the high-tech world of medicine, touch is also a precious commodity. More medical technology and the push to cut costs and hold nursing staffs lean mean that nurses spend more time monitoring equipment for more patients, less time directly touching individual patients.

"Everything is high tech," says Susan Sartorius, a clinical trials research nurse in the Oncology Department and a certified massage therapist. Many hospitals now even have automatic blood pressure monitoring devices. "A nurse could put the cuff on, push a button on the machine, and walk out of the room," says Sartorius. "You don't even have to carry on a conversation."

In the NICU, Martin tries to massage the baby in her primary care daily. Occasionally, she will massage those not her primary responsibility, as she did Leon, but she rarely has time. If the NICU is filled with sick babies, she does not even have time to massage her primary charge. Though she has taught massage techniques to a few other nurses, who occasionally give a baby a massage following a bath, Martin says she would like to do more.

A century ago, touch in general played a larger role in nursing, says Susan Appling, an associate professor at the School of Nursing. Nursing texts written at the beginning of the century devoted entire chapters to instruction in massage, she says. That's because at that time, nurses had little else to offer. Now we have antibiotics that can destroy armies of germs; we have oxygen respirators, heart monitors, and dozens of pain relievers.

Amid these interventions, it could be easy for medical professionals to forget such a simple thing as touch. Yet in 1993, the New England Journal of Medicine reported that a third of all Americans used unconventional therapies. Alternative therapies--including acupuncture, chiropractic, and osteopathic-- often directly involve touch.

In the field of childbirth, there's been a similar trend. According to the National Center for Health Statistics, the number of babies delivered by nurse-midwives in hospitals more than tripled between 1981 and 1992, from 55,000 to 176,000. Nurse-midwives generally use more physical contact than obstetricians do in helping laboring women, and they usually remain with the expectant mother throughout her labor.

Jan Krebs, a certified nurse-midwife at Johns Hopkins Hospital, uses massage to help mothers-to-be relax. Many women tense their arms and legs during contractions, she says. "If you're tensing during a contraction, you aren't going to do a thing for your uterus. Lightly stroking the arms and legs helps women focus the effort where it needs to be." She also shows women how to do effleurage, a delicate fluttering of the fingers on the abdomen. "It helps distract the woman," she says.

Healthcare providers may also be looking toward alternative treatments such as massage in response to a changing patient population. "We've acquired diseases, like AIDS, that we may not be able to cure," says Frank Herlong, associate dean for student affairs at the School of Medicine. "And people are living longer, meaning there are more cases of chronic diseases. These patients have exhausted their medical options. So now there is a growing re-emphasis on how to comfort patients."

Hospice nurse Nancy Statler (MSN '95) has used a form of therapy called therapeutic touch on AIDS patients and Alzheimer's patients. "I believe when a person has some chronic disease where there really is no cure, we have to be more creative," she says. Therapeutic touch looks something like giving a massage without actually touching the skin. The therapist places her hands a few inches away from the first area to be treated, and moves them around in a prescribed pattern.

"The theory," says Statler, "is that an energy field extends beyond the skin of a person. You can detect changes in an energy field that can be related to pain. If you smooth the energy field, you can create changes in a person's condition, whether it be pain or restlessness."

In a pilot study conducted for her master's thesis, Statler concluded that nightly sessions of therapeutic touch given to a small group of Alzheimer's patients for five days helped improve their behavior. Nurses who had been blinded to the purpose of the study evaluated the patients several times each night. They reported that patients who received the therapeutic touch had fewer verbal or physical outbursts, and were less agitated, depressed, anxious, and phobic. Interestingly, Statler also found that a control group of patients who had their hands held for 10 minutes a night improved as well, although in slightly different ways than the patients who received therapeutic touch. They spent less time wandering or in purposeless or illogical activity, and their daytime sleeping improved.

Without further evidence, however, some members of the medical community are withholding judgment on the benefits of therapeutic touch. No one knows why therapeutic touch works, acknowledges Statler. "You can't say the effects of treatment were solely related to therapeutic touch." She notes that patients who had their hands held improved as well. "The patient had to be in a quiet place during the treatment. Whether that was a factor is hard to say." However, she believes it works. "I believe it promotes a feeling of a patient being intensely cared about." Barbara de Lateur, director of physical medicine and rehabilitation at Johns Hopkins Hospital, believes Statler's study could demonstrate a phenomenon known as the Hawthorne effect: "When people think you're doing something nice, they respond positively."

Among the courtesies that doctors and nurses should employ with their patients, touch is only one in a therapeutic array, adds de Lateur. She always shakes a patient's hand, addresses patients by Mr., Miss, or Mrs. and their last name--"first names are patronizing"--and sits down when talking to them. "If a patient needs encouragement, I'll touch them on the wrist or shoulder, never on the head." During the physical exam, "probably more important than touching a patient is asking permission to touch: 'I'd like to take a look at your abdomen, may I?'"

So, yes, in many ways, medicine is now more impersonal than it was 100 years ago. But, no, touch in healthcare is not dead. It may even be needed more than ever, says nurse Sartorius. She believes John Nausbit says it best, in the book Megatrends: "The more high technology around us, the greater the need for human touch."

Touch can do things technology cannot, says Sartorius, who in her private massage therapy practice treats many patients with cancer, severe muscle degenerative illnesses, and other chronic illnesses. "Just by touching a person you can help them let down their emotions. You can touch certain areas that evoke an old response," she says.

"I had a patient, a young woman, who recently had had a bone marrow transplant. I would massage her feet, arms, and legs before bedtime. On the third night, when I was massaging her arms and hands, suddenly she began to cry. She finally realized that she might die before her mother. None of those feelings had been elicited before by her social worker or anyone else. I think that through that quiet contact, that touch contact, people really open up.

"For our well-being and survival, we need touch," says Sartorius. "I realize that's a broad statement, but I think it is true."

Melissa Hendricks is the magazine's senior science writer.

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