Touch in health professional practice: a review

Adverse childhood experiences and trauma informed care for chiropractors: a call to awareness and action

BACKGROUND

Trauma is an emotional response to distressing events where coping and subsequent recovery are absent. Adverse Childhood Experiences (ACEs) are traumas, occurring before the age of 18 years, such as child abuse or neglect, caregiver instability, and household dysfunction. Sixty-four percent of the U.S. population report experiencing at least one ACE, with over 1 billion children experiencing abuse and neglect annually worldwide. Chronic exposure to stressful circumstances or multiple traumatic events has negative physiologic impacts. Persons who experience 3 or more ACEs in childhood are at greater risk of poor mental health outcomes and may be more likely to engage in high-risk behaviors, predisposing them to long-term health impacts, such as metabolic diseases, anxiety, depression, substance use, and chronic pain. Trauma informed care (TIC) is a recommended approach to healthcare delivery across professions, especially when a trauma history is suspected. This commentary aims to increase awareness of the impact of ACEs on health outcomes and introduce TIC concepts as they may apply to chiropractic care for adults with a history of ACEs.

DISCUSSION

This commentary reviews an introductory model (4R's: realize, recognize, respond, resist re-traumatization) as one TIC framework used by healthcare practitioners. Prior trauma can lessen trust, alter perceptions of physical touch, and hands-on examinations and chiropractic treatments may trigger stress responses. Using TIC after appropriate training, includes referrals to multidisciplinary providers to address trauma-related concerns outside the scope of chiropractic, and screening for ACEs if deemed appropriate. Creating safe spaces, communicating clearly, avoiding victimizing language, explaining procedures, asking for consent before physical contact, and giving patients choice and control in their own care may avoid triggering prior traumas.

CONCLUSION

Given the high worldwide prevalence of persons experiencing 3 or more ACEs, TIC principles are practical adaptations to chiropractic care for use with many patient populations. As TIC and ACEs are emerging concepts within chiropractic, students and practitioners are encouraged to undertake additional training to better understand these complex and sensitive topics. Exploratory research on the incidence, presentation, and impacts of various trauma types, including ACEs, to support adoption of TIC in chiropractic settings is essential.

Sexual Modesty in Sexual Expression and Experience: A Scoping Review, 2000 - 2021

Sexual modesty is the social, cultural, interpersonal, and psychological systems - defined by the tenets of Script Theory - that regulate individuals' sexual expression and experience at the social, legal, and interpersonal boundaries of acceptable/not-acceptable, private/public, and personal/social. Almost all aspects of sexual expression and experience are touched by the pervasive modesty standards for sexual communication, sexual display, sexual relations, and sexual behaviors. Sexual modesty influences an array of sexual and reproductive health outcomes. Many aspects of sexual modesty are enforced by legal as well as social, cultural, and religious proscriptions, including social shaming and ostracism as well as corporal and capital punishments. The purpose of this paper is to summarize a diverse literature related to sexual modesty from the years 2000 to 2021 in order to clarify its role in sexual health and sexual wellbeing and to identify directions for new research.

Assessing individual differences in attitudes towards touch in treatment settings: Introducing the touch & health scale

Individuals commonly receive touch in treatment settings, but there is limited research on how they perceive it. The current project sought to address this gap by: 1) developing the Touch & Health Scale (THS) - a novel instrument to measure attitudes to touch in treatment settings 2) assessing inter-individual differences in THS scores, and 3) examining the association between individuals’ THS scores and wellbeing. Data of a large U.K. adults sample ( N > 12,000) were used. THS showed Cronbach’s α between 0.636 and 0.816 and significant correlations ( p < 0.001) with day-to-day attitudes to touch. THS scores differed as a function of extraversion and avoidant attachment style. Participants with more positive attitudes to touch in treatment settings showed greater wellbeing. Overall, the study highlights the importance of a personalised approach to touch in treatment settings and provides a new scale that may act as a screening tool for this purpose.

Relationship-specific Encoding of Social Touch in Somatosensory and Insular Cortices

Humans use touch to maintain their social relationships, and the emotional qualities of touch depend on who touches whom. However, it is not known how affective and social dimensions of touch are processed in the brain. We measured haemodynamic brain activity with functional magnetic resonance imaging (fMRI) from 19 subjects (10 males), while they were touched on their upper thigh by either their romantic partner, or an unfamiliar female or male confederate or saw the hand of one of these individuals near their upper thigh but were not touched. We used multi-voxel pattern analysis on pre-defined regions of interest to reveal areas that encode social touch in a relationship-specific manner. The accuracy of the machine learning classifier to identify actor for both feeling touch and seeing hand exceeded the chance level in the primary somatosensory cortex, while in the insular cortex accuracy was above chance level only for the touch condition. When classifying the relationship (partner or stranger), while keeping the toucher sex fixed, amygdala (AMYG), orbitofrontal cortex (OFC), and primary and secondary somatosensory cortices were able to discriminate toucher significantly above chance level. These results suggest that information on the social relationship of the toucher is processed consistently across several regions. More complex information about toucher identity is processed in the primary somatosensory and insular cortices, both of which can be considered early sensory areas.

Embodying empathy: A phenomenological study of physician touch

CONTEXT

Empathic physician behaviour is associated with improved patient outcomes. One way to demonstrate empathy is through the use of non-verbal communication (NVC) including touch. To date, research on NVC, and specifically touch, has been relatively limited in medicine, which is surprising given the central role it plays in conveying affective and empathic messages. To inform curriculum development on NVC, this study aimed to examine physicians' experiences of communicating by touch.

METHODS

We conducted an interpretative phenomenological study. A total of 15 physicians (seven women and eight men) from different specialties, including both recent graduates and experienced doctors, described in detail specific instances of touch drawn from their clinical practices. Interview prompts encouraged participants to recall exact details such as the context, their relationship with the patient they touched and their physical experience of touching. Interviews (45-100 minutes) were analysed with template analysis, followed by a process of dialectic questioning, moving back and forth between the data and researchers' personal reflections on them, drawing on phenomenological literature to synthesise a final interpretation.

RESULTS

Participants described two dimensions of the experience of touch: 'choosing and inviting touch' and 'expressing empathy.' Touch was a personal and fragile process. Participants interpreted non-verbal patient cues in order to determine whether or not touch was appropriate. They interpreted facial expressions and body language in the present to make meaning of patients' experiences. They used touch to share emotions, and to demonstrate empathy and presence. Participants' experiences of touch framed it as a form of embodied empathic communication.

CONCLUSIONS

Touch is a powerful form of NVC that can establish human connection. Phenomenological accounts of empathy, which emphasise its embodied intersubjective nature, can be used to theoretically enrich pedagogical approaches to touch in medical education and to deepen our understanding of empathy.