The Continuum of TouchThe Continuum of Touch

From prebirth

Infancy

Adulthood and Old age

-- perhaps the first form of medicineperhaps the first form of medicine

- described in ancient texts in China, described in ancient texts in China, India & EgyptIndia & Egypt

- described by Hippocrates in 400 BCdescribed by Hippocrates in 400 BC

- touch is considered a form of therapy in touch is considered a form of therapy in many parts of the worldmany parts of the world

History of Touch History of Touch

ShiatsuReflexology

Touch TherapyTouch Therapy

MassageMassage TherapiesTherapies

Ayuverdic Massage

Thai Massage

Infant Massage

Kangaroo Care

Kangaroo CareKangaroo Care

Infant Infant

Co-sleepingCo-sleeping

DoulaDoula

Mailman CenterMailman Center

Touch Research InstitutesTouch Research Institutes

• Established in 1992 by Dr. Tiffany Field with a grant from Johnson & Johnson.

• The TRI was the first center in the world devoted solely to the study of touch and its application in science and medicine.

www.JJPI.comwww.JJPI.com

To date, we have conducted over 100To date, we have conducted over 100 scientific scientific studies on touch therapy effects and we have studies on touch therapy effects and we have established two other TRIs (Philippines, Paris).established two other TRIs (Philippines, Paris).

www.miami.edu/touch-research

www.JJPI.comwww.JJPI.com

Touch Research InstitutesTouch Research Institutes

Continuum of Touch Continuum of Touch

FromFrom PregnancyPregnancy ….. …..

toto LaborLabor

….. ….. to Infancyto Infancy

Pregnancy Massage

Field, Hernandez-Reif, Hart, et al., (1999), Field, Hernandez-Reif, Hart, et al., (1999), J of Psychosomatic Obstetr GynJ of Psychosomatic Obstetr Gyn

Field, Diego, Dieter, Hernandez-Reif, et al., (2004), Field, Diego, Dieter, Hernandez-Reif, et al., (2004), Infant Behavior & Dev.Infant Behavior & Dev.

Field, Hernandez-Reif, Diego, et al,. (2004), Field, Hernandez-Reif, Diego, et al,. (2004), J of Psychosomatic Obst GynJ of Psychosomatic Obst Gyn

Progressive Muscle Progressive Muscle

Relaxation (PMR)Relaxation (PMR)

Study DesignStudy Design

• two 20-minute sessions per weektwo 20-minute sessions per week of Pregnancy Massage or PMRof Pregnancy Massage or PMR

for 5 weeks starting in 2for 5 weeks starting in 2ndnd

• focus on the head, neck, back, focus on the head, neck, back, arms, legs, and facearms, legs, and face

Pregnancy Pregnancy AnxietyAnxiety

0

10

20

30

40

50

Massage Relaxation

PrePost

* *

Pregnancy Pregnancy Back PainBack Pain

1

2

3

4

5

Massage Relaxation

*

PregnancyPregnancyDisturbed SleepDisturbed Sleep

0

12

24

36

48

Massage Relaxation

*

PregnancyPregnancySupplemental Sleep (Naps)Supplemental Sleep (Naps)

0

10

20

30

40

Massage Relaxation

*

Birth OutcomesBirth Outcomes

0

30

60

90

120

150

OCS PNF

MassageRelaxation

**

**

Pregnancy Pregnancy Depressed MoodDepressed Mood

0

1

2

3

Massage Relaxation

PrePost

*

Pregnancy and Pregnancy and Depressed MoodDepressed Mood

10-30% of women are 10-30% of women are

depresseddepressed during pregnancy during pregnancy

Pregnancy Depression Pregnancy Depression on Maternal Cortisolon Maternal Cortisol

100

200

300

400

Depressed Non-Depressed

Prenatal Cortisol

ng/m

g

**

Prematurity and Prematurity and Depressed PregnancyDepressed Pregnancy

0%

20%

40%

60%

80%

100%

Depressed Non-Depressed

Prematurity

Per

cen

t of

Gro

up

> 37< 37

*

Low Birthweight andLow Birthweight andDepressed PregnancyDepressed Pregnancy

0%

20%

40%

60%

80%

100%

Depressed Non-Depressed

Low Birth Weight

Per

cen

t of

Gro

up

> 2500g< 2500g

*

Dieter, Field, Hernandez-Reif, et al., (2002).

Prenatal DepressionPrenatal Depression Effects on Neonate Effects on Neonate

100

200

300

400

500

600

Depressed Non-Depressed

Neonatal Cortisol

ng/m

g

100

200

300

400

Depressed Non-Depressed

Prenatal Cortisol

ng/m

g**

**

Prenatal DepressionPrenatal Depression

0

10

20

30

40

50

60

Depressed Non-Depressed

Neonatal Indeterminate Sleep

Per

cent

Tim

e**

Prenatal DepressionPrenatal Depression

-0.2

-0.15

-0.1

-0.05

0

0.05

Depressed Non-Depressed

Mothers

Fro

ntal

EE

Asy

mm

etry

-0.1

-0.05

0

0.05

Depressed Non-Depressed

InfantsF

ront

al E

E A

sym

met

ry

F3F3 F4F4

Depressed Pregnancy Depressed Pregnancy Effects Include:Effects Include:

For mothersFor mothers::

- Elevated cortisol (stress hormone)Elevated cortisol (stress hormone)

- Greater chance of having a preterm Greater chance of having a preterm baby baby

- Greater chance of having a lowbirth Greater chance of having a lowbirth weight babyweight baby

Depressed Pregnancy Depressed Pregnancy Effects Include:Effects Include:

For fetusFor fetus::

- - Greater fetal activityGreater fetal activity

For infantsFor infants::

- - Elevated cortisol & greater chance of Elevated cortisol & greater chance of being born preterm or low birthweightbeing born preterm or low birthweight

- Greater Indeterminate sleepGreater Indeterminate sleep- Greater relative right frontal EEG Greater relative right frontal EEG

activationactivation

Partners Massaging Partners Massaging Depressed Pregnant WomenDepressed Pregnant Women

Demographics

• N = 84 depressed pregnant women

• Mean age = 28.8 (SD = 5.7)

• Mean g.a.= 22.9 wks at recruitment

• 46% Caucasian, 39% Hispanic, 12% African American and 3% Asian

Pre-Post Test DesignPre-Post Test DesignRecruited from Ob Gyn clinics in 2nd semester &

assigned to Massage, PMR group or control .

Massage Therapy (by partner)

• Two 20 min. massages per week for 16 weeks at home.

PMR

• Two 20 min. relaxation exercise sessions per week for 16 weeks.

Maternal Maternal Cortisol Change (ng/ml)Cortisol Change (ng/ml)

-76

-16

6

-80

-70

-60

-50

-40

-30

-20

-10

0

10

*-5

Massage PMR ControlMassage PMR Control

Obstetric ComplicationsObstetric Complications(higher score is optimal)(higher score is optimal)

91

78

102

0

25

50

75

100

Massage Relaxation Control

**

Mothers’ Mothers’ AnxietyAnxiety

0

10

20

30

40

50

Massage Relaxation Control

PrePost**

Mothers’ depressionMothers’ depression

0

10

20

30

Massage Relaxation Control

PrePost

**

Infant Depressed SymptomsOn Brazelton Neonatal

Assessment Scale (BNBAS)

0

1

2

3

4

5

6

Massage Relaxation Control

**

Overall ConclusionsOverall ConclusionsPregnancy massagePregnancy massage is a safe and effective intervention for is a safe and effective intervention fordepressed and non-depressed mothers:depressed and non-depressed mothers:

stress hormones (cortisol)anxiety and depressed mood disturbed sleepObstetric complications and postnatal complications, hence improving neonatal outcomes, including reducing the incidence of prematurity.

**These data also highlight the efficacy of using a **These data also highlight the efficacy of using a significant other to deliver the massage intervention.significant other to deliver the massage intervention.

Touch Therapies during LaborTouch Therapies during Labor

Continuum of Touch Touch therapies during Labor –

Doula - companion woman who stays in touch with the laboring mother (stroking, holding, speaking to her).

Studies from the 1980s by Klaus & Kennell revealed that 127 of 128 non-industrial societies included a woman present with the mother-to-be during labor.

Doula vs No Doula

0

10

20

30

40

50

60

70

80

Complications

DoulaNo Doula

0

5

10

15

20

Medication

DoulaNon Doula

Klaus et al, 1986 (Study on 417 laboring women in Guatemala)

Doula vs No Doula

02468

101214161820

C-Section

DoulaNo Doula

0

2

4

6

8

10

12

14

Labor Hrs.

DoulaNon Doula

Klaus et al, 1986 (Study on 417 laboring women in Guatemala)

Benefits of a Doula Present at the Birth of a Child (Stein, Kennell &

Fulcher, 2004)

• 50% reduction in C-sections50% reduction in C-sections

• 40% reduction in use of forceps40% reduction in use of forceps

• 60% reduction60% reduction in epidural in epidural analgesiaanalgesia

• 25% decrease in labor length25% decrease in labor length

0

10

20

30

C-Section

Father Fa + Doula

23%23%

14%14%

Labor Massage by PartnerLabor Massage by Partner

Field, Hernandez-Reif. et al., (1997). J of Psychosom Ob Gyn.

Labor MassageLabor Massage

Conducted by Conducted by partner partner every hour for 5 hoursevery hour for 5 hours.

20-min sequence consisting of stroking20-min sequence consisting of stroking for 5-5-min each of the following regions: min each of the following regions:

1) head, 2) neck, shoulders and back, 1) head, 2) neck, shoulders and back,

3) hands and arms and 4) legs and feet.3) hands and arms and 4) legs and feet.

Control groupControl group who did other activities who did other activities (breathing exercises), but no massage.(breathing exercises), but no massage.

Labor Massage Labor Massage (MOOD 1(MOOD 1stst session) session)

0

2

4

6

8

10

12

14

16

Massage Control

PrePost

**

Labor Massage Labor Massage (Pain 1(Pain 1stst session) session)

0

1

2

3

4

5

Massage Control

PrePost

**

No. of Hours in LaborNo. of Hours in Labor

0

4

8

12

Massage Control

**

8.58.5 11.311.3

Post LaborPost Labor DepressionDepression

0

4

8

12

16

20

Massage Control

**

15.415.4 19.819.8

Skin-to-Skin (Kangaroo care)

• KC - consists of holding the infant (in diaper) against the bare KC - consists of holding the infant (in diaper) against the bare chest with an over-covering.chest with an over-covering.

• This practice started in Bogota Colombia by Drs. Rey and This practice started in Bogota Colombia by Drs. Rey and Martinez in the 1970s, because of overcrowding in their Martinez in the 1970s, because of overcrowding in their NICU, NICU, few resources and high mortality and infection rate.few resources and high mortality and infection rate.

• KC was introduced to the mother (benefit of access to KC was introduced to the mother (benefit of access to breastfeeding) who did KC for 24/7 and later to the fathersbreastfeeding) who did KC for 24/7 and later to the fathers

• Can begin in the delivery or recovery room between 30-40 min Can begin in the delivery or recovery room between 30-40 min postbirth to help stabilize the infant or can begin earlier.postbirth to help stabilize the infant or can begin earlier.

Research Benefits of KC

• Thermal synchrony – maternal temperature regulates infant’s temperature

• Regulate heart rate and respiration

• More deep sleep

• Fewer days in incubators

• Greater weight gain and earlier discharge.

Preterm Infant Preterm Infant Massage TherapyMassage Therapy

•Can be started as soon as Can be started as soon as preterm infant is stablepreterm infant is stable

•Can be taught to parents Can be taught to parents or performed by nurseor performed by nurse

•Takes 15 minutes and Takes 15 minutes and involves rubbing & flexion involves rubbing & flexion and extension of limbs and extension of limbs (kinesthetics)(kinesthetics)

Introduction

Premature infants receiving massage therapy:– Have shorter hospital stays

– Show a 21-47% greater increase in weight gain

GI ActivityFood Absorption Hormone Release

Vagal Activity

Pressure/ Bar Receptor Stimulation

Weight Gain

Massage Therapy

Proposed mechanism for the effects of massage therapy in stimulating preterm infant weight gain

Method (Participants)48 Medically stable premature infants assigned to48 Medically stable premature infants assigned to

• Massage therapy (n=16)Massage therapy (n=16)• SHAM massage therapy (n=16)SHAM massage therapy (n=16)• Standard care control group (n=16)Standard care control group (n=16)

Group assignment based on a random stratification Group assignment based on a random stratification procedure designed to ensure equivalence across procedure designed to ensure equivalence across groups on the following variables:groups on the following variables:

(a)(a) Gestational age (± 2 wks)Gestational age (± 2 wks)(b)(b) Birthweight (± 150 g)Birthweight (± 150 g)(c)(c) Gender Gender (d)(d) Days in the NICUDays in the NICU(e)(e) Study entry weightStudy entry weight

Method (Procedure)

Massage Therapy: Massage Therapy:

Baby on stomach: 1Baby on stomach: 1stst & last 5-min. & last 5-min. Rubbing the head, shoulders, back, Rubbing the head, shoulders, back, legs and armslegs and arms

Baby on back: 5 min of flexion and Baby on back: 5 min of flexion and extension of the arms and legs and extension of the arms and legs and

SHAM massage:SHAM massage: • Identical to the massage therapy Identical to the massage therapy

procedure exception that the procedure exception that the lightlightpressure rubbing pressure rubbing was used.was used.

Weight Gain (gms p/day)

0

5

10

15

20

Groups

ControlMassageShamLinear (Control)

Pre During Post

3.0

3.5

4.0

4.5

Control Massage SHAM

Pre During Post

Pre During Post

Vagal Activity

Gastric MotilityGastric Motility

Pre During Post

6.0

7.0

8.0

Gas

tric

Mo

tili

ty (

2-4c

pm

EG

G)

Control Massage SHAM

Pre During Post

Pre During Post

• Has been replicated in Taiwan, Philippines,Israel, and China

• Nurses and parents can be trained to conduct the therapy and has been shown to reduce mothers’ depression.

• Simple to do, safe and reduces hospital costs because of earlier discharge.

Preterm Infant Massage Effects

Fathers’ Massaging BabiesFathers’ Massaging Babies

• 32 fathers (M age = 33) and their

infants (R: 3-14 mo) were studied.

• Predominantly middle class

• ½ were taught to do infant massage

and the other half were on a wait-list

Cullen, Field, Escalona & Hartshorn (2000). Cullen, Field, Escalona & Hartshorn (2000). Early Child Dev. & CareEarly Child Dev. & Care

Fathers’ Massaging BabiesFathers’ Massaging Babies

3

3.2

3.4

3.6

3.8

4

Massage Control

Express Warmth Accept

Cullen, Field, Escalona & Hartshorn (2000). Cullen, Field, Escalona & Hartshorn (2000). Early Child Dev. & CareEarly Child Dev. & Care

Fathers’ Massaging BabiesFathers’ Massaging Babies

0

10

20

30

40

50

Massage Control

1st dayLast day

Caregiving Score (feeding, cleaning, playing, etc)Caregiving Score (feeding, cleaning, playing, etc)

Touch can Span Across the Ages