American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, September 28, 2015

Healing and human touch

Early this summer, I spent several days in a hospital bed, tethered to an IV, with what proved in retrospect to be anaplasmosis (a nasty bit of tick-borne business), complicated by viral meningitis. The latter was likely due to the immunosuppression of the primary infection. It was all rather unpleasant.

Among other things, I had a constant, moderate headache punctuated by crushing head pain, easily the worst headaches I've ever experienced. I was given narcotics when the pain was at its worst, and they didn't do much for me, despite their 2 distinct advantages. The first is that these drugs are genuinely effective at treating pain; the second is that I had every reason to expect them to work.

The latter matters, because placebo effects are real. They are not a therapeutic effect attributable to the specific actions of a drug or modality. They are a therapeutic effect that is independent of that specific action, and are thus deemed “nonspecific.” They relate to our expectations. When we expect a treatment to work, our body reacts accordingly, and that, in turn, can be therapeutic.

This should be no great surprise. Most of us have heard of the “endorphins” accountable for a runner's high. These, essentially, are the body's native narcotics, and it is receptors to such compounds that explain why non-native narcotics work at all. They are chemically enough like our own, endogenous analgesics to bind to the same receptors.

In any event, narcotics really do work; and, as a physician who has prescribed them many times to good effect, I had every reason to expect them to work. Even so, they didn't do much for my headaches.

In contrast, my wife's head massages were stunningly effective. This may in part be due to the fact that massage is effective in the treatment of pain. Colleagues and I have studied massage for osteoarthritis, and published very encouraging results. That research, sponsored by the NIH, is on-going, as we explore longer term effects, cost-effectiveness, and mechanisms.

For now, those mechanisms remain mostly speculative. Massage may influence local blood flow, and inflammation. Its immediate effects may relate partly to the phenomenon known as “gating,” in which sensory stimuli simply block out the transmission of pain stimuli in the spinal cord, although this does not explain the benefits that persist long after the massage is done. Much of the on-going work suggests that the effects of massage may relate principally to relaxation responses, and the autonomic nervous system.

I will go out on a limb, though, beyond the limits of the scientific evidence we have, to suggest that my wife's loving hands had something unique to do with it. Catherine is not a trained massage therapist. She is, in fact, a neuroscientist, although that is not necessarily relevant. I think the relevant consideration is that she loves me. She put her hands on my head in a fervent effort to relieve my pain and did.

At the time, I was just greatly relieved, and deeply grateful. Catherine's hands held the answer that narcotics did not have. These weeks later, with those headaches receding into memory, and the episode into family lore, I am reflecting on the therapeutic modality of human touch.

To some extent, the mechanisms of my relief may have been those of massage in general, whatever exactly those are. But there are reasons to speculate further, just as there is cause for cautious skepticism.

A device called Cefaly prevents migraines in roughly 50% of those who try it according to the available data. Structurally a visor (or, perhaps, tiara), the device produces an electromagnetic field. According to the company, the device “generates precise micro-impulses in order to stimulate the nerve endings of the trigeminal nerve.” This, in turn, so goes the tale, prevents migraines.

This is particularly intriguing because the visor merely sits on the head, rather as my wife's hands sat against my own. There are no direct connections between Cefaly and the trigeminal nerve; no wires running into the central nervous system. The device generates an electromagnetic field on the surface of the body, and the rest ensues.

Human beings generate electromagnetic fields as well. This is not conjecture; technology exists to image these fields. Since the fields emanate around our bodies, they overlap as we approximate 1 another before ever we touch.

In fact, the distinction between touch and proximity is substantially a matter of virtual (albeit, obviously important) reality. The surfaces of solid objects cannot truly touch, as they are held apart by atomic forces and the vacant spaces they populate. What we perceive as surface against surface, in all of its variations from momentary to momentous, agony to ecstasy, is really the juxtaposition of the energy field of one object with that of another.

This raises provocative questions about the contentious non-touch modalities of touch particular to “alternative” medicine, such as Reiki and therapeutic touch. My wife is trained in neither, but she was acutely sensitive to my pain, and passionate about relieving it. Did that contribute?

I cannot say. Nor can anyone say for sure at this point that non-touch modalities of touch are effective. But some are inclined to say they cannot be, and that, too, is beyond the pale of evidence, and even inattentive to some. Certainty against, like certainty for, given mechanisms in the absence of full understanding is comparably anathema to the progress of science. Were it otherwise, the sun would still be revolving around our planet, rather than vice versa.

That electromagnetism can be used to treat at least certain varieties of pain seems to be an established, data-born fact. That human beings generate such fields, and that these fields overlap when human beings are in close proximity to one another, are also factual assertions. What rests for now in the realm of conjecture and competing claims is whether or not some people, by training or innate aptitude, can discern such fields as some animals are known to do; whether such fields can be willfully manipulated; whether the willful manipulations of any such field elicits meaningful, predictable responses in a neighboring field; whether intention has anything to do with any such effects; and whether there is real therapeutic potential in the mix. Presently consigned to the realm of informed conjecture, reliable answers await an array of fastidiously thoughtful studies, yet to be done. My contribution is to note that those who contend such effects cannot exist are at least as disrespectful to the current state of evidence and understanding as those who make exaggerated claims in the other direction.

For now, I am uniquely qualified to declare the surprising efficacy of my wife's scalp massage, by whatever sundry mechanisms. Not because I am a physician; not because I am a researcher; not because I have studied pain and pain relief, and published relevant studies, all of which are true.

Rather, and simply, because the pain, and the relief, were entirely in my own head.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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