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Cli i l J l f O l N i V l 12 N b 1 D Th i T h H l R d P i d A i ? 113

Emily Jackson, BSN, RN, Megan Kelley, BSN, RN,

Patrick McNeil, BSN, RN, Eileen Meyer, BSN, RN,

Lauren Schlegel, BSN, RN, and Melody Eaton, PhD, MBA, RN

With more than 10 million patients with cancer in the United States, pain and symptom management is an important topic

for oncology nurses. Complementary therapies, such as therapeutic touch, may offer nurses a nonpharmacologic method

to ease patients pain. Using 12 research studies, the authors examined the evidence concerning the effectiveness of this

type of treatment in reducing pain and anxiety.

Does Therapeutic Touch Help Reduce

Pain and Anxiety in Patients With Cancer?

At a Glance

F In 2007, 1,444,920 new cases o cancer were diagnosed in

the United States.

F Therapeutic touch is a complementary therapy that is used to

help with the anxiety and pain related to cancer treatment.

F Therapeutic touch is an energy therapy involving hand

movements to equalize and balance energy ow. Healing ispromoted when body energy is balanced.

Emily Jackson, BSN, RN, Megan Kelley, BSN, RN, Patrick McNeil, BSN,RN, Eileen Meyer, BSN, RN, and Lauren Schlegel, BSN, RN, all are seniornursing students, and Melody Eaton, PhD, MBA, RN, is an undergraduateprogram coordinator and associate proessor, all in the Nursing Depart-ment at James Madison University in Harrisonburg, VA. No fnanciarelationships to disclose. (Submitted June 2007. Accepted or publicationAugust 6, 2007.)

Digital Object Identifer: 10.1188/08.CJON.113-120

More than 10 million people in the United States

had some orm o cancer in 2007, including

1,444,920 newly diagnosed cases. Prostate and

breast cancer rank among the highest incidenc-

es at 29 and 26 percent, respectively (American

Cancer Society, 2007). A cancer diagnosis brings about eelings

o ear, pain, and anxiety. Billions o research dollars are spent

each year to nd better, more eective, and curative treatment.

Treatment currently varies depending on the type o cancer,

with chemotherapy and radiation regimens being used along

with traditional pain-control medications. Traditional medi -

cal management o patients symptoms does not consider the

holistic nature o the disease and the human healing process.

Patients should have access to care that helps ght the cancer

and alleviates ear, anxiety, and pain. Many therapies have been

researched to determine the best methods or alleviating cancer

symptoms and the side eects o treatment. Therapeutic touch

has shown promise in helping patients with cancer nd relie

rom pain, anxiety, and ear (American Cancer Society, 2006).

This evidence-based study examines research regarding the e-

ectiveness o therapeutic touch.

BackgrdTherapeutic touch is a therapy in which the hands are used

to acilitate the healing process (Lareniere et al., 1999). The

therapy was introduced in the early 1970s by Delores Krieger

and Dora Kuntz as a noninvasive nursing intervention derived

rom ancient Eastern orms o healing (Kelly, Sullivan, Fawcett,

& Samarel, 2004).

Several studies link nursing care to positive cancer therapy

outcomes and suggest a need to explore nontraditional therapy

modalities, such as therapeutic touch, as viable options to

complement standard cancer therapy. A randomized, controlled

study by Given et al. (2002) evaluated symptom management

during chemotherapy and ound that patients with cancer

experience pain and anxiety during chemotherapy. The 53

patients in the experimental group and 60 in the control group

were interviewed using a symptom experience scale, which

measured symptoms, physical impact, and social unctioning.

The patients received standard care and chemotherapy, but the

experimental group received additional nursing interventions

or symptom management. Those interventions were tailored

to individual issues and categorized as teaching, counseling

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114 F b 2008 V l 12 N b 1 Cli i l J l f O l N i

and support, coordination, and communication (Given et al.).

Analysis o variance, chi square, and logistic regression were

used to analyze the results. The investigators ound that admin-

istering drugs to patients was the extent o most treatment.

But the evidence suggested that nurses interventions with

the experimental group decreased the severity o the patientssymptoms (Given et al.).

A repeated measures study o chemotherapy symptoms by

Braud et al. (2003) showed that anxiety was one o the top side

eects reported by 49 patients. Declared baseline anxiety

scores were relatively high, suggesting that emotional distress

prior to [treatment] is unrecognized by the medical team

(Braud et al., p. 474). This suggests that the healthcare team may

not realize the emotional issues that patients are dealing with

during chemotherapy. The study emphasized the need or more

research to identiy how patients eel and what the healthcare

team can do to assist (Braud et al.).

In 1999, Zaza, Sellick, Willan, Reyno, and Browman examined214 healthcare providers and their knowledge and comort

with the use o complementary methods o pain management.

Healthcare proessionals were questioned about their percep-

tions o nonpharmacologic treatment strategies through a sel-

report survey. The survey included a list o nonpharmacologic

pain-management methods developed through expert clinician

consultation. The list o options included meditation, music and

art therapy, guided imagery, acupuncture or acupressure, mas-

sage, prayer, and therapeutic touch. A our- and ve-point Likert

scale was used to measure perceptions o pain and eectiveness

o nonpharmacologic treatment strategies, respectively. Most

o the healthcare proessionals surveyed in the study reportedthat chronic cancer pain diers rom chronic noncancer pain.

In addition, nurses rated the eectiveness o therapeutic touch

much higher than other complementary therapies, yet physi-

cians rated it as the lowest (Zaza et al.). That ndingpossible

physician resistance to therapeutic touchis useul as research-

ers continue to explore this therapy. Nurses showed interest in

learning more about therapeutic touch and may be appropriate

providers o this therapy (Zaza et al.).

Nursing care is based on the holistic view o treating the

whole person as well as the disease, including psychological dis-

tress and traditional physical symptoms. Little research exists in

the area o nonpharmacologic pain and anxiety-relie therapies

that nurses can use to help patients with cancer.

Eerg Feld TerTherapeutic touch centers on the theory that the body, mind,

and emotions combine to orm a complex energy eld. Accord-

ing to that theory, being in good health indicates a balanced

energy eld whereas illness represents imbalance (BassettHealthcare, 2002). Krieger and Kuntz based their theory o ther-

apeutic touch on the assertions o nursing theorist Martha Rog-

ers. Rogers emphasized that humans are surrounded by energy

elds that extend rom the skin surace (Hutchinson, DAlessio,

Forward, & Newshan, 1999). The theory states that energy elds

are symmetrical and balanced when a person is healthy, which

allows energy to fow evenly. Physical and psychological symp-

toms, such as pain and anxiety, cause imbalances in the elds.

Therapeutic touch is used to restore those imbalances (Gottlieb,

1995; Krieger, 1979)(see Figure 1).

Terapetc TreatmetsTherapeutic touch, healing touch, and Reiki are closely

linked touch-energy or hand-mediated energetic healing

therapies that oten are used interchangeably and have many

similarities but also some notable dierences. As noted previ-

ously, therapeutic touch is a therapy in which the hands are

used to direct human energy to acilitate healing (Krieger,

1979) (see Figure 2). Healing touch uses the principle and

1. Centering:The process o using meditation to center on the pres-

ent to begin a tension-ree ocus on healing the client.2. Assessment:Starting at the patients head and moving the hands

along and near the body (rom head to toe), the process assesses

energy ow irregularities.

3. Unrufing:This long sweeping motion with the hands evens out

areas o the body that have uneven or dense energy ow.

4. Modulating: Energy is directed rom the environment to the pa-

tients areas o uneven or dense energy.

5. Assessment: The clients energy is assessed to be even with no di-

erences.

Fgre 2. Caregg Steps Prdg Terapetc

Tc

Note. Based on inormation rom Krieger, 1979.

Fgre 1. Terapetc Tc Balacg Eerg Feld

Therapeutic touch is provided to the patient by a trained therapist.

Unbalanced

chakras or

energy centers

are caused by

cancer pain

and/or anxiety.

Balanced chakras or

energy centers are

restored because o

the reduction in can-

cer pain and anxiety,

which is a result o

therapeutic touch.

Note. Photos courtesy o Teresa French. Used with permission.

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Cli i l J l f O l N i V l 12 N b 1 D Th i T h H l R d P i d A i ? 115

practice o therapeutic touch, touch-energy methods, or a

group o therapies. Developed by Janet Mentgen and several

other nursing practitioners in the late 1980s and early 1990s,

healing touch uses the hands to equalize energy with dier-

ent treatment modalities (e.g., magnetic clearing, pain drain,

mind clearing, wound sealing) (Gastright, 1997; Healing Touch

International, 2007). Reiki, a Japanese method that uses the

hands to vitalize the lie energy fow, relaxes and promotes

healing. The goal is a high l ie orce energy level that maintains

wellness (International Center or Reiki Train ing, 2007). Thethree levels o Reiki training increase practitioners vibrations

and allow or the fow o higher healing requencies (Potter,

2003). Students rst practice Reiki on themselves and then,

upon reaching higher levels o instruction, are prepared to

use it on others. This is a process o attunement that is passed

down rom Reiki master to student (Potter).

Std PrpseThe purpose o the current study was to examine existing

research on the eectiveness o therapeutic touch and to de-

termine whether it decreases pain and anxiety in patients withcancer.

Metds

Data collection consisted o an in-depth search o sources

that investigated the use o therapeutic touch as a method or

decreasing pain and anxiety in patients with cancer. Keywords

such as healing touch and therapeutic touch were paired with

other terms such as cancer,pain, and anxiety. The compre-

hensive search did not ocus on a specic cancer diagnosis,

gender, or age group. Previous research on therapeutic touch

is limited; thereore, the inclusion criteria allowed or studies

that researched any type o cancer, used therapeutic touch as

an independent variable, and used pain and/or anxiety as the

dependent variable(s). The articles researched pain and anxiety

in patients with cancer but did not have to evaluate both depen-

dent variables. An initial literature review included articles vali-

dating that patients with cancer experienced pain and anxiety;

however, those articles were eliminated to better address the re-

search question. Sources that did not conduct a research study,

such as ar ticles discussing opinions about therapeutic touch as

a valid therapeutic method and patient-written narratives, were

excluded. Those criteria were applied to identiy higher-level

evidence-based research (Melnyk & Fineout-Overholt, 2005)

(see Table 1). The Cochrane Library, PubMed, and CINAHL

were used to retrieve ideal inormation sources. Five sources

were ound using the Cochrane Librar y, our using PubMed,

and three using CINAHL. This ar ticle reports on the 12 studies

identied through the databases.

Aalss ad Stess

Studies were organized according to level o evidence to best

structure the analysis. The seven levels o evidence were used

to rate the strength o each study (Melnyk & Fineout-Overholt,

2005). Each study provided inormation on sample size, level o

evidence, purpose, actors examined, method and instruments,

and outcomes (see Table 2).

Pain and anxiety were the two actors initially addressed

in the research; however, ater the researchers examined the

evidence, pain was studied in conjunction with other physical

symptoms, such as nausea, shortness o breath, and atigue.

Similarly, several psychological symptoms were studied with

anxiety, including mood, relaxation, and quality o lie. The

ocus o the research then was expanded into two broad cat-

egories: physical and psychological.

The best sources o evidence, level I, are rom evidence rom

a systematic review or meta-analysis o a ll relevant randomized

controlled trials or evidence-based clinical practice guidelinesbased on systematic reviews o [randomized controlled tri-

als] (Melnyk & Fineout-Overholt, 2005, p. 10). Research rom

Bardia, Barton, Prokop, Bauer, and Moynihan (2006) ell in this

category. The authors concluded that therapeutic touch is a

promising therapy but could not determine how eective the

therapy is in alleviating cancer pain.Sources assigned level II have evidence that was obtained rom

at least one well-designed randomized controlled trial (Melnyk

& Fineout-Overholt, 2005, p. 10). The our studies assigned level

II indicate and arm that therapeutic touch does improve physi-

cal and psychological symptoms. Giasson and Bouchards (1998)

ndings showed that therapeutic touch increased the sense owell-being in patients with terminal cancer. Categories showing

improvement were pain, nausea, depression, anxiety, shortness o

breath, activity, appetite, relaxation, and inner peace (p < 0.002)

Lareniere et al. (1999) ound that patients receiving therapeutic

touch showed increased vigor (p < 0.05) and a reduction in mood

disturbance (p < 0.01), tension (p < 0.05), conusion (p < 0.01),

and anxiety (p < 0.01) compared to the control group. Post-White

et al.s (2003) study showed that healing touch was eective in

reducing total mood disturbance (p = 0.06) and atigue (p =

0.03) in adult patients undergoing chemotherapy. Healing touch

also reduced respiratory rate (p < 0.001), heart rate (p < 0.001),

and systolic (p < 0.001) and diastolic blood pressure (p < 0.001).

Levels o pain lowered with healing touch (p < 0.01). Cook, Guer-

Table 1. Ratg Sstem fr Leels f Edece

LEvEL DESCRiPTion

Note. From Evidence-Based Practice in Nursing and Healthcare(p. 10), by B. Melnyk and E. Fineout-Overholt, 2005, Philadelphia:Lippincott Williams and Wilkins. Copyright 2005 by Lippincott Williamsand Wilkins. Adapted with permission.

I

II

III

IV

V

VI

VII

Evidence rom a systematic review o randomized, controlledtrials or evidence-based clinical practice guidelines based onsystematic reviews o randomized, controlled trials

Evidence rom at least one well-designed randomized, con-trolled trial

Evidence rom well-designed controlled trials without ran-domization

Evidence rom well-designed case control and cohort studies

Evidence rom systematic reviews o descriptive and qualita-tive studies

Evidence rom a single descriptive or qualitative study

Evidence rom authorities opinions and/or expert committeereports

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116 F b 2008 V l 12 N b 1 Cli i l J l f O l N i

Table 2. Researc Edece Srces fr Terapetc iterets

STuDy SAMPLE

Giasson &Bouchard,1998

Kelly et al.,2004

Lareniereet al.,1999

Olson etal., 2003

Post-Whiteet al., 2003

Samarelet al.,1998

20 patientsreceiving palli-ative care. Par-ticipants wereaged 1870

years, spokeFrench, andwere not pre-senting withsymptoms oconusion.

18 womenwith early-stage breastcancer

41 healthyemale volun-teers

9 men, meanage o 59.5

years, and 15women, meanage o 56years

II

VI

II

IV

II

III

LEvEL oF

EviDEnCE

To examinethe eect othree thera-peutic touchtreatments

on eelings owell-being

To comparetherapeutictouch withdialogue toa controlledquiet rest

To evaluatetherapeutictouchs eecton hormonaland neu-rotransmitterindicators,mood, andanxiety

To comparestandard opi-

oid manage-ment plus restwith standardopioid man-agement plusReiki

To determinewhether mas-sage therapyand healing

touch weremore eectivethan standardcare

To obtain pre-liminary dataand determineeasibility ora large-scaleexperimentalstudy

PuRPoSE

Pain, nausea,depression,anxiety, short-ness o breath,mobility, appetite,

relaxation, andinner peace inpatients receivingtherapeutic touchversus periodso rest

Perceptions othe eects odialogue andtherapeutic touchor quiet rest

Hormones andneurotransmitterlevels that regu-late vomiting:cortisol, dop-amine, and nitricoxide

Independentvariables such

as opioids, Reiki,and rest period,and dependentvariables suchas decreasedpain level andperceived qualityo lie

Heart rate, re-spiratory rate,blood pressure,pain, and nausea

levels in patientsin the controlgroups

Independentvariables such astherapeutic touch,quiet time, andmusic, and de-pendent variablessuch as mood,anxiety, and pain

RESEARCh

vARiABLES

Patients were divided into a controlgroup that did not receive thera-peutic touch and an experimentalgroup that received 1520 minuteso therapeutic touch several times

per week. Patients then completedan assessment tool evaluatingcomort, pain, nausea, anxiety,shortness o breath, appetite, re-laxation, and inner peace and anychanges in their condition.

Telephone interviews werecompleted ater experimentalor controlled nursing interven-tions were administered in thewomens homes.

Participants were randomly as-signed to an experimental groupthat received therapeutic touch orto a control group that completedquestionnaires but did not receivetherapeutic touch. Experimentalgroup patients listened to musicwhile a trained practitioner admin-istered therapeutic touch. Patientsthen rested or 510 minutes be-ore completing a questionnaire.

Patients rom an inpatient pal-liative unit, a hospice, and an

outpatient symptom managementclinic were randomly assigned toa group. Patients completed painand quality-o-lie assessmentson the frst and last days o study.Patients also kept diaries ratingand describing the pain at dierenttimes o the day. Patients assessedthe pain beore and ater the restperiod or the Reiki session.

Patients received our 45-minutesessions o intervention per weekand were assessed beore andater each session. Heart rate, re-

spiratory rate, and blood pressurewere recorded. Pain and nauseawere measured with the Brie PainIndex and rated on a 010 linearanalog scale.

Patients were tested using theState-Trait Anxiety Inventory, A-ects Balance Scale, and VisualAnalog Pain Scale. Testing wasdone seven days beore surgeryand 24 hours ater. Treatment was10 minutes o therapeutic touchand 20 minutes o dialogue.

METhoDS

AnD inSTRuMEnTS

Therapeutic touch treatmentsincrease sensation o well-beingin patients with terminal cancer(p < 0.0015). The experimentalgroup showed a mean increase

o 1.70 (on the well-being scale)with a standard deviation o 1.28,and the control group showed adecrease o 0.31 with a standarddeviation o 1.12.

Content analysis revealed ew di-erences in patients perceptions oexperimental and controlled inter-ventions. Patients expressed eelingso calmness, relaxation, security,comort, and a sense o awarenessregardless o the intervention.

Patients in the therapeutic touchgroup showed a signifcant reduc-tion in mood disturbance com-pared to the control group (p