Yehonatan Moshe Hertzman

THE ROLE OF TOUCH IN

MANUAL THERAPY – AN INTEGRATIVE LITERATURE REVIEW

Degree Programme in Physiotherapy

2016
 THE ROLE OF TOUCH IN
MANUAL THERAPY – AN INTEGRATIVE LITERATURE REVIEW
Hertzman, Yehonatan Moshe
Satakunnan ammattikorkeakoulu, Satakunta University of Applied Sciences
Degree program in Physiotherapy
November 2016
Supervisor: Kangasperko, Maija
Number of pages: 28
Appendices: 0

Keywords: touch, manual therapy, the skin, chronic pain, neuropathic pain
____________________________________________________________________
The objective of this study was to identify the role of touch in the context of manual
therapy as an intervention. For this purpose, the importance of the skin was addressed
as to provide a wider understanding of the topic. In addition, investigations of the ef-
fects of manual therapy on pain were questioned.

The method used to write this thesis was an integrated literature review with resem-
blance to a systematic literature review. Relevant articles published from 2006 to 2016
established a preliminary inclusion criterion. Moreover, the search was conducted us-
ing three databases: PubMed, Science Direct and a collection of references mentioned
in the body of the text. Mesh Terms included the combination of “manual therapy”
AND “skin”, “manual therapy” AND “therapeutic touch”, “chronic pain” AND thera-
peutic touch”, “neuropathic pain AND the skin” In addition, manual assessment of the
included references was performed by the author of this thesis.

It can be asserted that the role of touch in manual therapy stems from an individual,
psychophysiological response to the interaction between the therapist and the client.
Furthermore, activation of the c-fiber system using pleasurable touch in manual ther-
apy provides an opportunity for pain management, somatosensory activation and
building rapport in the physiotherapeutic settings.
CONTENTS

1 INTRODUCTION ................................................................................................... 4
2 SKIN ........................................................................................................................ 5
2.1 The structure of the skin ................................................................................ 5
2.2 Hormones and affects .................................................................................... 7
3 TOUCH ................................................................................................................... 8
3.1 Definition ....................................................................................................... 8
3.2 The physiology of touch ................................................................................ 9
3.3 The psychology of touch .............................................................................. 11
4 PAIN ...................................................................................................................... 12
4.1 Definition ..................................................................................................... 12
4.2 Classification of pain ................................................................................... 14
5 MANUAL THERAPY .......................................................................................... 15
6 PURPOSE AND OBJECTIVE OF THE THESIS ................................................ 17
7 INTEGRATIVE LITERATURE REVIEW .......................................................... 17
7.1 Clarification of methodology ....................................................................... 17
7.2 A checklist for writing an integrative literature review ............................... 19
7.3 The checklist report...................................................................................... 20
8 RESULTS .............................................................................................................. 21
8.1 Searching strategy ........................................................................................ 21
8.2 The role of touch in manual therapy ............................................................ 24
9 CONCLUSION AND DISCUSSION ................................................................... 24
REFERENCES........................................................................................................... 26
 4

1 INTRODUCTION

The topic of touch and the skin has been the interest of researchers and manual thera-
pists alike, with the shared goal of better understanding the relationship between treat-
ments used and their perceived results. Surely, it is of practical essence when working
as a clinician, to participate in a variety of manual therapy courses and seminars in
order to acquire new professional tools and be able to address the vast spectrum of
client needs.

Therefore, various techniques of manual therapy are under ongoing research in order
to validate their attributed benefits; however, in certain cases, even when evidence is
lacking and results challenge the existing assumptions, course participation grows and
sound clinical reasoning is cast aside, thereby raising questions regarding the current
paradigm. (Parreira Pdo et al. 2014, 90).

For this purpose, the thesis will question the contemporary consensus of manual ther-
apy by exploring possible affects and effects of touch, an element that is integral to all
forms of manual interventions, as well as the skin, an organ in charge of the perception,
interpretation, propagation and response regulation of touch. In addition, the limita-
tions of manual therapy as an intervention must also be addressed as part of this inves-
tigation. (Lumpkin et al. 2010, 237-238).

Interestingly, research regarding the skin may provide new information regarding pain
mechanisms and its possible treatments; for example, a nerve-based approach targeting
afferents or critical evaluation of prevalent interventions for neuropathic clients.
(Lloyd et al. 2015, 321). Coincidentally, the international federation of orthopedic ma-
nipulative physical therapy convention has taken place in July of this publication year,
starring prominent physiotherapy figures such as Brian Mulligan, Lorimer Moseley
and others (Jesse 2016). Manual therapists attending the convention were perplexed
with the contradictory evidence and mechanisms behind some of the interventions; for
instance, Brian Mulligan spoke of biomechanically influencing structures through
manual therapy, whereas Lorimer had proposed the biopsychosocial model; a wider
perspective of pain treatment via manual therapy and noted its limitations.
 5

It is beyond the scope of this thesis to systematically review every technique of manual
therapy and report the results; nevertheless, by questioning the current neurophysio-
logical understanding underlying common manual therapies’ analgesic effect, we
should be able to understand the attributed benefits it can claim.

Regardless of which type of manual therapy intervention is chosen, an interaction with

the skin of the client via touch is a form of communication with their nervous system.
Hence, an acknowledgement of the peripheral mechanoreceptors found in the skin and
activated through touch is essential for the physiotherapist.
The following thesis is also an attempt to provide relevant information for manual
therapists considering an intervention in clinical settings. For further information re-
garding the complexity of the skin, one may pursue further education.

2 SKIN

2.1 The structure of the skin

Figure 1. The different layers of the skin (the website of Openstax)

 6

The skin is the largest organ in the human body, in fact, it consists 6% of our total
body weight, with many functions to play in our mundane survival against both exter-
nal and internal threats; the layers of the skin can be classified from superficial to deep
(Figure 1), with the main role of retaining homeostasis. (Tobin 2006, 52-53.)

The top layer of the skin is the Epidermis – described as the superficial layer, albeit
lacking in vascular supply, it offers protection from UV Rays of the sun and houses
sensory cells called Merkel cells (MC) allowing sensitive manipulation of objects with
the fingers by recognizing edges and curves. Another function of the MC is the release
of a hormone called glutamate, which is an excitatory neurotransmitter in the brain. In
excess, this hormone induces chronic pain changes by hyper sensitizing neuronal struc-
tures. For example, receptors known as nociceptors, which are prevalent in the free
nerve endings reaching the epidermis, shape the perception of pain and warn of possi-
ble harmful stimuli. However, these receptors can often become hyper sensitized.
(Lumpkin et al. 2010, 243-244; Tobin 2006, 53-54).

The Dermis – houses the vascular, neural and lymphatic system as well as the skins’
various glands and sensory nerve receptors; this layer consists mostly of fibroblast
proteins which are the essential cells in maintaining structural integrity of tissues (To-
bin 2006, 58). The receptors of this layer consist of Pacinian and Meissner corpuscles
(Figure 2) that are vibration, pressure and touch receptors. In addition, Ruffini corpus-
cles serve as mechanoreceptors specialized in recognizing skin stretch or sustained
pressure, whereas lanceolate endings sense hair movements (e.g. sensing an ant walk-
ing on our skin) (Tobin 2006, 53).

Hypodermis – A deep, adipose rich tissue layer that connects the dermis to the skeletal
tissue and houses the deepest structures and receptors of the skin. Overall, it seems
that the skin is fairly simple in the function of its receptors, however, even in its deepest
layer each receptor has a specific firing rate that affects its sensory response and func-
tion; For instance, in the hypodermis, Pacinian receptors and Meissner corpuscles fire
in cases of sustained touch and are thought to release neurotransmitters to shape their
response according to the level of pressure applied. (Lumpkin et al. 2010, 237; Tobin
2006, 53).
 7

Figure 2. Somatosensory receptors of the skin (the website of Openstax)

2.2 Hormones and affects

In greater detail, the somatosensory receptors of the skin can sense a change in the
homeostasis of the human skin by distinguishing a variety of tactile inputs and affect
the neurons by closing and opening sensitive ion channels. (Lumpkin et al. 2010, 241).
In addition to its input differentiation, the skin produces hormones such as endorphins,
gender hormones, melatonin, serotonin and thyroid stimulating hormone receptors
alongside immune system secretions necessary for retaining homeostasis. (Garrison et
al. 2012, 135; Tobin 2006, 63-65).

Even the human hair follicle, used to be thought of as non-essential, plays a role in the
release of hormones for itself in events related to tissue stress. Hence, a remarkable
variety of hormonal secretions (e.g. sex steroid hormones, corticotrophin-release hor-
mone) and immunological responses occur in many levels, with anti-inflammatory
agents such as KOR, suppressing the T-lymphocytes secretion (i.e. white blood cell)
or alternatively promoting inflammatory agents such as MOR. Furthermore, unmye-
linated C type fibers trigger as a response to light touch in the hairy skin. (Bigliardi et
al. 2009, 428; Tobin 2006, 61).

Another aspect of the skin is its interpretation of stimuli via motivational-emotional

pathways for touch during interpersonal contact, thus making the skin a communi-
cating organ with the outside world, thereby coining the term “the outside of our
brains” (Morrison et al. 2010, 306).
 8

Empirically, this exemplary brain-skin relationship is seen between the epidermis and
peripheral nerve fibers, where opioid receptors are abundant. Interestingly, opioid re-
ceptors encourage research due to their attributed modulation of immune cells and an-
algesic effect. Clinically, it is worth considering that the peripheral nervous system
receives its sensory input from the skin’s entire surface and this in turn affects the cell
differentiation, migration, and immune system secretions of cytokeratin and cytokine
expressed in the human epidermis. (Bigliardi et al. 2009, 424-426).

3 TOUCH

3.1 Definition

Touch is a sense that helps us discriminate the location of a stimulus on the skin sur-
face, explore objects, identify and manipulate objects. It is also connected with the
sense of one self. Fundamentally, touch is classified as dynamic when it is “continuous
movement over the skin from one point to another, and can often be repetitive, as in
stroking, rubbing and caressing” or simple when “brief, intentional contact to a rela-
tively restricted location on the body surface of the receiver during a social interaction”
It has been shown that simple touch can induce an altruistic effect, thus promoting
compliance, which can be utilized in clinical settings when building the therapist-client
rapport, regardless of how old or verbally communicative the client is. (Morrison et al.
2010, 306).

Alternatively, pleasurable touch is further classified to (a) interpersonal touch, (b)

grooming, (c) massage and (d) relief by itch. Interpersonal touch is essential for proper
cognitive development in mammals and its presence or absence can have long-lasting
effects. In addition, it can promote neurogenesis of cells in the dorsal root ganglion
(Figure 3) following injury, plays a part in subtle communication between people, and
is rated as more pleasurable than self-touch. (Lloyd et al. 2015, 323-323; Morrison et
al. 2010, 307).
 9

Grooming is a social mammalian phenomenon mediated by the hormone of affinity,

oxytocin. Surprisingly, the techniques used by Swedish massage have shown similar-
ity to grooming, and could account for the hormonal release of dopamine in manual
interventions where pleasurable touch is used (Testa et al. 2016, 2). Lastly, the relief
of itch by scratching has also shown to activate our somatosensory map even without
an existing itch stimulus. (Lloyd et al. 2015, 323-323; Morrison et al. 2010, 307).

3.2 The physiology of touch

Figure 3. The Dorsal root ganglion (DRG) from the peripheral nervous system pro-
jecting to the central nervous system (CNS) (website of Openstax)

The understanding of touch must consider its neurophysiological interpretation by the

central, peripheral and autonomic nervous system. In addition, investigation of how
the different types of touch affect the brains response will aid in choosing the manual
therapy intervention technique that will primum non nocere (Lorimer 2013).
 10

The sensory neuron fibers are grouped to Aβ, Aδ or C-fibers (Table 1) they reside in
the Dorsal root ganglia in the spinal nerves (Figure 3) and are classified according to
their myelin thickness, mechanical threshold and stimulus specific responses. For ex-
ample, Aβ myelin-rich afferents are responsible for sensing light touch and are low-
threshold, whereas C-fibers and Aδ afferents are unmyelinated or thin in myelin, are
nociceptor based with high threshold and project to the central nervous system through
the DRG (Figure 3) Exceptionally, there are also low threshold C fibers that are below
the nociception range which offer clinicians an opportunity to treat clients without pain
aggravation or perhaps avoid posttreatment pain altogether. (Lumpkin et al. 2010, 3).

Table 1. Classification of sensory fibers.

Classification Mechanical Receptors Myelin Sensation
threshold

Aβ Low Muscle spindles Heavy Proprioception

Meissner corpuscle Superficial touch
Merkel receptor Deep touch
Pacinian corpuscle Vibration
Ruffini ending
Hair receptor
Aδ High Nociceptors Low Pain
Temperature
C High/Low Nociceptors Low/None Pain
Temperature
Itch
Light touch

C fibers are abundantly found in the hairy skin, especially in the face and arms, and
are associated with interoceptive feelings such as itch or pain which effect the internal
organs. Furthermore, using these pleasant touch receptors activates certain parts of the
brain that are associated with reward, grooming, addiction, food cravings and the pla-
cebo effect. Among these are the orbitofrontal cortex, posterior & anterior insula, pre-
genual ACC, prefrontal cortex, inferior parietal lobe, cerebellum and ventral striatum.
Bearing in mind that different body sites respond to the same touch stimuli differently,
 11

with the head being most sensitive. (Lloyd et al. 2015, 1-3; Loken et al. 2009, 1;
McCabe et al. 2008, 7-8).

Finally, even the sight of touch results in neuromodulation. In the McCabe et al. study
(2008, 7-8) where cream described as rich moisturizing cream was being applied to
another participant while the teste was watching, similar areas of the teste’s brain, in-
cluding the parietal area 7, orbitofrontal cortex and S1 were activated. However, when
the rich cream was applied to the teste, different somatosensory representations were
activated, with primarily the middle and posterior insula.

3.3 The psychology of touch

Psychological theories suggest that touch is a powerful tool that promotes genuineness
and openness in the therapeutic relationship. Certain psychological theories such as
Gestalt therapy use touch to improve self-esteem and general psychological well-be-
ing. However, there are contradicting opinions claiming that touch can create a power
differential between the client and therapist or that touch may also be misunderstood
as sexual. (Jones et al. 2014, 1-2).

Moreover, lack of touch negatively affects the behavior of mammals, whereas an am-
ple amount can positively affect the alleviation of stress or anxiety. More importantly,
touch is a mediator of social communication, increasing the liking of a person or place
and promotes trust in the social context. Therefore, it is not surprising then that empa-
thy is also related to touch; where the mere sight of another’s painful experience brings
distraught to the ‘uninvolved’ spectator. Thus, relationships are affected by touch,
where anxious individuals report an increase need for secure bonds providing the alle-
viation from the anxiety felt otherwise. Simply put, touch can be used to convey or
understand thoughts and feelings, as well as regulate them. (Morrison et al. 2010, 305-
307).
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4 PAIN

4.1 Definition

As of November 2016, the international association for the study of pain has revised
the definition of pain as follows: “pain is a distressing experience associated with ac-
tual or potential tissue damage with sensory, emotional, cognitive and social compo-
nents” (Williams et al. 2016 ,2420-2423). Pain is then an output from the nervous sys-
tem affecting various domains. For instance, when an individual puts his or her hand
above the fire; it is the sensation of immediate threat, sent from the peripheral nervous
system to the CNS and back, causing the hand to be withdrawn and thus protect the
tissue from additional noxious input. In effect, the barrage of nociceptive input when
the hand was burnt above the fire, activates the touch receptors (through sensory C and
Aβ fibers), which send the signal of threat through the DRG to the dorsal horn and up
the lateral spinothalamic tract (Figure 3) all the way to the cortex through the 1st, 2nd,
3rd order neurons to interpret the sensation as harmful, then descends to the hand with
the command of removing the hand from the fire. (Gifford 2014, 56-61).

Evidently, pain does not necessarily correlate with the state of the tissue following an
injury. From an evolutionary perspective, pain represents an implicit awareness of the
body that a certain tissue is in danger and is a protective mechanism. (Lorimer 2013).
 13

Inputs to body-self neuroma- Outputs to brain areas that

trix from: produce:
Body-self
neuromatrix
Cognitive-related brain areas Pain perception
Memories of past experience, Sensory, affective, and cogni-
Attention, meaning, anxiety tive dimensions

Sensory signaling system Action program

Cutaneous, visceral, musculo- Involuntary and voluntary ac-
skeletal inputs tion patterns

Emotion-related brain areas Stress-regulation programs

Limbic system and associated Cortisol, noradrenalin, and endorphin
homeostatic/stress mechanisms levels immune system activity

Time

Figure 4. Sensory, affective and cognitive factors influencing pain (Redrawn from
"Pain and the Neuromatrix in the brain" by R. Melzack, 2001, Journal of dental edu-
cation, 1382)

Additional physiological factors that influence pain following injury can be inflamma-
tory mediators, increased tissue temperature and blood flow that increase the summa-
tion of nociceptive activity. The perception of pain is also influenced by anxiety, ex-
pectation and attitude of the individual regarding his or her own pain among other
factors (Figure 4). It is not surprising then that a pain behavior occurs to alter postural
and voluntary muscles after the injury (Lorimer 2013).

Overall, the topic of pain has been widely researched among the physiotherapy com-
munity and is accepted as an integral part of client education. In fact, it is acceptable
that pain is a complex subjective quality and in the therapeutic context, belittling or
giving too much importance to the clients’ pain can be a detrimental factor for recov-
ery. (Morrison et al. 2010, 311).
 14

4.2 Classification of pain

Traditionally, acute pain was defined as “the normal, predicted physiological response
to an adverse chemical thermal or mechanical stimulus… associated with surgery,
trauma and acute illness” (Carr et al. 1999, 2051). This definition provides an expected
progression for an acute pain state without considering the factors discussed (Figure
5). On the other hand, a chronic pain state occurs when the acute pain threat persists
over 3 months, resulting in altered representation of painful body parts in the primary
sensory cortex map. In turn, these changes effect motor control since body control
relies on the adjacent somatosensory map to produce unhindered, quality movements.
(Lorimer 2013; Vardeh et al. 2016, 51). Fillingim et al. (2016, 245) of the American
pain society includes chronic pain condition diagnoses such as central and peripheral
neuropathic pain, musculoskeletal pain, orofacial and head pain, visceral, pelvic and
urogenital pain as well as disease associated pains.

Acute and chronic pain are classification of 4 pain states: Nociceptive, inflammatory
neuropathic and centralized. Nociceptive pain is a localized pain, occurring due to in-
creased activation of high threshold mechanoreceptors following an injury or in-
creased mechanical forces. On the other hand, inflammatory pain is the result of in-
flammatory mediators such as cytokines among others. These signaling molecules sen-
sitize nociceptors to produce pain. The cardinal symptoms of inflammatory pain are
redness, warmth and swelling of the affected area. (Vardeh et al. 2016, 52-53).

The work of Wall (1991, 632) suggests 7 characteristics of neuropathic pain: the pain
is described as ongoing, with little influence by peripheral stimuli, a sensation of lan-
cinating spontaneous stabs triggered by an innocuous stimulus and a reduced sensitiv-
ity to stimuli. Moreover, some pains may appear immediately after a nerve injury and
other with delay. Provocation of pain requires repetition of the stimulus and demon-
strates a delay and build up after the beginning of the stimulus.

Neuropathic pain is physiologically complex to treat; manifesting in several bouts per

day or is ever-constant. Contemporarily, lesions are classified as focal or systemic
based on pathology, and structure (i.e. fibre density) does not significantly correlate
with pain. For example, localized nerve lesions produced the highest pain ratings of
 15

the two when the fibre density of the epidermis was mildly reduced, whereas in the
case of systemic lesions, significant reduction of fibre density at sub epidermal and
dermal fibre did not produce greater pain ratings. Clinically, light touch (i.e. allodynia)
was perceived as painful in clients with localized lesions far more than systemic le-
sions (i.e. 12/19 and 4/17 respectively) and is perceived as less pleasant in hereditary
autonomic neuropathy type V. (Morrison et al. 2011, 1116-1119; Schley et al. 2012,
1418-1423; Sommer 2012, 1345).

Centralized pain is exceptional in that it is not trigger by a noxious stimulus, inflam-

mation or damage in the nerves. Therefore, the mechanism is that of reduced central
inhibition by the interneurons previously described (Figure 4) For example; patholo-
gies such as fibromyalgia or irritable bowel syndrome are considered central sensitiv-
ity syndromes. (Vardeh et al. 2016, 56).

5 MANUAL THERAPY
Manual therapy is a hands-on treatment for musculoskeletal conditions that is utilized
by health care providers internationally. It is used for evaluation as well as treatment
and involves palpation of structures, which is an adjunct used to determine which in-
tervention in the manual therapy world is most suitable for the individual client. Fol-
lowing evaluation, the palpable findings are addressed according to the healthcare pro-
fessional performing the examination. These findings are named: lesions, subluxa-
tions, somatic dysfunctions or hypo mobile joints. The treatments used are spinal ma-
nipulations and mobilizations to address the aforementioned structural abnormalities.
(Bahram 2016).

Contemporarily, in the case of chronic low-back pain, manual therapy has been shown
to produce a moderate effect at best and mechanisms of common interventions are
repeatedly debunked by studies. Such is the case of the mechanisms underlying the
effects of kinesiotaping, purporting importance to the direction and convulsions of the
skin in certain positions while taping. The application allegedly promotes an increase
of lymphatic fluid and blood flow. Nevertheless, when quantified, these claims did not
 16

alter pain intensity or disability after 4 or 12 weeks in a significant manner. (Parreira

Pdo et al. 2014, 36-37).

Ostensibly, when choosing manual therapy as an intervention, words are of importance

and technique (e.g. velocity and pressure applied) must target specific sensory affer-
ents. As clinicians, considering the previous experience, treatment expectation, cul-
ture, as well as the area and type of pain treated (e.g. chronic, neuropathic or acute)
will affect treatment outcomes. In effect, manual therapy is activating the cortical rep-
resentation of the treated area to increase body awareness and thus affect pain levels.
(Lorimer 2013).

Moreover, the chosen wording of an intervention, such as rich or basic cream resulted
in a top-down effect (i.e. orbitofrontal, pregenual ACC and ventral striatum), giving
great significance to our verbal presentation of an intervention; we also know that the
experience of being touched, activates the somatosensory map more effectively than
its sight or when self-touch is utilized (e.g. sensory rehabilitation for stroke survivors)
(McCabe et al. 2008, 7-8; Morrison et al. 2010, 310).

In practice, affective touch top-down effects are achieved by lightly touching the cli-
ent, at medium (i.e. 1-10 cm/s) stroking velocity over the skin for a period of up to 5
minutes. Consequently, light touch releases endorphins to reduce stress, anxiety and
depressive symptoms by decreasing heart rate, heart rate variability, systolic blood
pressure and chronic pain levels. (Lumpkin et al. 2010, 10; Lloyd et al. 2015, 323-324;
Lindgren et al. 2010, 105-110).

On another note, the bodily responses of clients receiving light touch are affected by
the therapist’s fingertip size, spacing of finger print ridges and the client’s epidermal
stiffness. This perhaps can explain some of the variability seen in research regarding
manual therapy outcomes for the same intervention, when different therapists of the
same skill level are being assessed. (Lloyd et al. 2015).

According to a study by Lloyd et al. (2015, 323-324) c-fiber systems are possible tar-
gets for affecting chronic pain conditions (e.g. atopic dermatitis, burns, stroke patients
and other sensory dysregulation illnesses) through affective touch interventions. In
 17

conjunction with our interventions, considering prospective pharmacological options

to target ion channels or genes (e.g. TRPC1 and SCN9A) related to central sensitiza-
tion may provide additional tools in the future. (Garrison et al. 2012,548; Lumpkin et
al. 2010, 1-7).

6 PURPOSE AND OBJECTIVE OF THE THESIS

The purpose of this thesis is to provide information for practitioners about the role of
touch in manual therapy. Therefore, exploration of the role of the skin is necessary, for
it is the medium where touch occurs. Moreover, this thesis clarifies the neurophysio-
logical mechanisms of pain and the attributed effects manual therapy can have on pain
alleviation.

There is a large body of contradictory evidence in recent years regarding the effects of
manual therapy on pain. This thesis is an attempt to find a common ground between
prevailing approaches, through the investigation of touch. The research question of
this literature review is as follows:

1. What is the role of touch in manual therapy?

7 INTEGRATIVE LITERATURE REVIEW

7.1 Clarification of methodology

In this thesis, the chosen research method is that of an integrative literature review,
including three databases. Nevertheless, the thesis includes an inclusion and exclusion
criteria with the purpose of increasing the reliability of the study, thereby having re-
semblance to a systematic literature review. The contrast between the study and sys-
tematic literature review is elaborated in the following paragraphs. A systematic liter-
 18

ature review provides level 1 evidence and is used in modern medical healthcare re-
search. Its goal is to provide comprehensive evidence summaries for busy clinicians.
A systematic review should include the PRIMSA and AMSTAR guidelines if they
wish to decrease the risk of bias associated with the systematic review. A systematic
review should include the PICO search strategy which stands for Population focused
on, intervention researched, comparison and outcome. This is done by using for exam-
ple randomized controlled trials and outcome. The goal of this strategy is to retrieve
relevant studies. Following the search, there is an inclusion and exclusion process of
the literature selected, followed by assessment of the quality of the included studies.
(Sayers 2008, 136).

A literature review is based on updated studies and presents a professional point of

view. Moreover, there must be a study regarding the chosen subject and the study may
include between two to several studies. To write a literature review, one must define a
topic and audience, search and re-search the literature, take notes while reading,
choose the type of literature you wish to write, keep the review focused but make it of
broad interest, incorporate critical thinking, find a logical structure, make use of feed-
back, include your own relevant research but remain objective and stay up to date. In
this integrative literature review, the information regarding the searching for the data-
base, keywords and time of publication served as inclusion and exclusion criteria, with
resemblance to a systematic literature review. (Pautasso 2013, 1-3).

In addition, an integrative literature review synthesizes information using quantitative

methods as well as critical analysis, synthesis of new knowledge on the topic, logical
and conceptual reasoning and serves as a catalyst for further research. The integrative
review tells a story by critically analysis of the literature. This involves the history and
origins of the topic along with main concepts while examining the relationships of an
issue and providing critique. Critical analysis allows for reconceptualization of infor-
mation that has been overlooked, using the concept of critique; which is used to iden-
tify knowledge that should be created or improved in the current literature. (Whitte-
more et al. 2013, 549-551).

The synthesis of new knowledge includes old and new ideas to create a better under-
standing of the topic in question. It is a creative process that produces a new model or
 19

conceptual framework or other concept informed by the author of the review. There
are a few strategies to form the synthesis; among them are research agenda or concep-
tual framework that present a new perspective on the topic and metatheory explaining
a body of theory. (Torraco 2005, 363). The importance of logical and conceptual rea-
soning is the basis of the arguments and explanations used in an integrative review.
The aforementioned relies on a description of how it was developed from the literature
review, including the interrelationships and the reasoning process used to present the
theoretical framework. (Torraco 2005, 363).

7.2 A checklist for writing an integrative literature review

There are several questions to be answered before conducting an integrative literature

review and questions to be asked while writing an integrative review:

a. What type of review article will be written?

b. Is there a need for the integrative review?

Organizing an integrative review requires a coherent conceptual structuring of the

topic as well as sufficiently describing the methods used in the literature review.

Producing an integrative literature review:

c. Does the article critically analyze existing literature on the topic?
d. Does the article synthesize knowledge from the literature into a significant,
value added contribution to new knowledge on the topic?
e. What forms of synthesis are used to stimulate further research on the topic?
f. Does the article describe the logical and conceptual reasoning used by the au-
thor to synthesize the model or framework from the review and critique of the
literature?
g. Are provocative questions for further research presented to capture the interest
of scholars?
 20

7.3 The checklist report

This review article will be an integrative literature review with characteristics remind-
ing of a systematic analysis. As such, it includes an inclusion and exclusion criteria
and a presentation of the searching process. The integrative review provides an oppor-
tunity to answer a qualitative question with both a quantitative and qualitative answer.
Without the structure of the integrative review, critical information on the topic would
have been left out due to the uncompromising requirements of a systematic literature
review. This review thesis is organized and presented using topics related to the re-
search question. The investigation of contributing factors provided a broad understand-
ing of the topic.

The methods used in this integrative literature review have been described in a flow
chart presenting a literature searching process with the goal of providing better trans-
parency. This review deals with critical evaluation of existing literature on the effect
of touch in manual therapy. It is written from a prospective physiotherapist’s viewpoint
and summarizes the up-to-date information regarding the topic, in addition to consid-
ering the clinical implication of the research. The review synthesizes knowledge from
3 different databases and objectively reaches a conclusion that may affect physiother-
apy practice if utilized. Moreover, this article integrates the newest research about the
topic and synthesizes it with the old.

This form of research agenda was chosen for making this review as to provide the
relevant clinical information for the reader. Furthermore, the reader is encouraged to
continue the research regarding the topic in question, with the goal of clarifying the
role of touch in manual therapy. Finally, the text itself is provocative and calls for a
re-evaluation of age old premises in the world of manual therapy as well as beckons
new research in the topic.
 21

8 RESULTS

8.1 Searching strategy

The manual searching process was conducted on the 11th of November (2015), in-
cluded the material that had already been gathered by (Website of Diane Jacobs 2016)
(Table 2) and PubMed literature review using Mesh Terms; these terms included man-
ual therapy AND skin, manual therapy AND therapeutic touch, chronic pain AND
therapeutic touch, neuropathic pain AND the skin (Table 3). The choice of mesh terms
correlated with the thesis topic in an equivalent manner so that both the skin and touch
are assessed in relation with manual therapy. In addition, on the 4th of September 2016,
the database of Science direct was included in the search process, only for the terms
manual therapy AND therapeutic touch. The content of the abstracts had to contain
relevant information regarding the therapeutic qualities of touch or the skin and publi-
cation year did not exceed that of 10 years for all of the articles searched.

On a final note, the searching process considered the database of Diane Jacobs, Science
direct and PubMed (Figure 5); this in turn provided a wider perspective on the topic,
to provide greater reliability and contradictory evidence.
 22

Table 2. Preliminary inclusion and exclusion criteria from DNM references based ar-
ticles

Manual • 3 results • Scientific articles published within the last 10 years

therapy

• 27 results • Keywords such as “manual therapy”, “skin”, “touch”, “chronic

Skin
pain”, “neuropathic pain”

• 39 results
Touch

• 10 results
Chronic pain

Neuropathic • 16 results
pain

Table 3. Inclusion and exclusion criteria from (a) PubMed and (b) Science Direct
based articles

Manual • (a) 22 results

therapy & • This search was repeated on the 9.4.16
skin
• Scientific articles published within the last 10 years.
Manual • (a) 43 results
therapy & • Mesh Term combinations such as “Manual therapy” AND
therapeutic • (b) 62 results
“skin”, “manual therapy” and “therapeutic touch”, “therapeutic
touch
touch” AND “chronic pain”, “Neuropathic pain” AND “skin”
Chronic pain • (a) 4 results
• Only “manual therapy” and “therapeutic touch” was searched in
& therapeutic
touch Science Direct.

• (a) 101 results

Neuropathic
pain & skin

The integration of information using 3 databases displayed in a transparent manner

including the process of this integrative literature review:
 23

DNM References Science direct PubMed

95 articles
Terms selection

Keyword selection

Mesh terms selection

62 articles
published
27 articles excluded,
68 articles published in within 10
based on publishing 170 arti-
the last 10 years years
date exceeding that of cles pub-
10 years lished
within 10
1 article selected based on
years
abstract and full text avail-
ability

151 articles excluded, 19 articles selected,

32 articles selected,
based on title based on title
based on title

14 articles excluded,
based on abstract
24 articles excluded, 8 articles selected 5 articles selected
based on abstract and based on abstract and based on abstract and
full text availability full text availability full text availability
A total of 14 articles se-
Exclusion of titles or abstracts: lected for the making of
1. Not about the topic this thesis
2. Full text availability
3. Other

Figure 6. Selection of literature

 24

8.2 The role of touch in manual therapy

The role of touch in manual therapy is intertwined with that of the skin, offering an
opportunity to promote or inhibits pain; it is then the therapists understanding regard-
ing the neurophysiological effects of touch on client populations which consequently
should guide the choice of manual intervention. Moreover, touch can be used to acti-
vate the somatosensory map effectively when applied and should be integrated in the
early stages of the physiotherapy sessions due to its trust building effect. Evidently,
the areas of the brain associated with placebo and reward pathways are activated when
affective touch is being used in conjunction with promising verbal presentation of a
manual therapy intervention.

In practice, touch can be utilized in manual therapy to release a variety of hormones

associated with pleasure. These hormones temporarily decrease chronic pain as well
as alleviate symptoms of stress, anxiety and depression in as little as 5 minutes of an
intervention. Nevertheless, touch has its limitations as an intervention, where certain
neuropathies such as hereditary autonomic neuropathy type V (HANTV) perceive
touch as unpleasant.

9 CONCLUSION AND DISCUSSION

The personal limitations of this literature review may have impacted the quality and
results of the thesis. For example, the knowledge of biochemistry required for the un-
derstanding of the articles surpassed that of my proficiency level which may have left
out relevant information regarding the transferability of the study’s results. Secondly,
the use of a premade database of references in conjunction with PubMed and Science
direct does not imply the highest level of methodological quality and should be ethi-
cally considered. Lastly, the mesh terms did not include acute pain as part of this thesis
and should be included in future studies.
 25

On another note, the quantitative assessment of affective touch was difficult to muster
from the databases searched as it is relatively an understudied research topic. Further-
more, PubMed search did not yield many manual therapy interventions using the cho-
sen keywords and one should critically interpret the transferability of the results of K-
tape study, since 78% of the participants were women in their 50. Unfortunately, in
the case of neuropathic pain alleviation through manual therapy, research regarding
other neuropathies than HANTV was not found in this literature review, thus warrant-
ing further research.

Initially, the idea of the thesis was to perform a literature review about a manual ther-
apy intervention of light touch named “DermoNeuroModulation” which integrates the
database used in this thesis. Fortunately, the opportunity to participate in a professional
course concerning the aforementioned intervention was made possible in May of 2016.
Nevertheless, specific research regarding the intervention in specific is nonexistent and
required a change of topic. Therefore, a questionnaire regarding the importance of the
skin, sent to manual therapists working in Finland and Israel was another proposition;
however, this did not ensue after consultation with the authors tutor. Finally, the role
of touch and the skin in manual therapy was brought up as a relevant and applicable
topic of research.
 26

REFERENCES

Bahram. ‘a new Paradigm in Manual Therapy: Abandoning Segmental Motion Pal-

pation’. Aptei Weblog. 15.7.2016. Referred 9.4.16. http://www.aptei.ca/wp-con-
tent/uploads/Manual-Therapy-Paradigm-Shift-2016.pdf

Bigliardi, P.L., Tobin, D.J., Gaveriaux-Ruff, C. and Bigliardi-QI, M., 2009. Opioids
and the skin – where do we stand?. Experimental Dermatology, vol. 18, no. 5, pp.
424-430. Available from: http://dx.doi.org/10.1111/j.1600-0625.2009.00844.x ISSN
1600-0625. DOI 10.1111/j.1600-0625.2009.00844.x.

Carr, D.B. and Goudas, L.C., 1999. Acute pain. Lancet (London, England), Jun 12,
vol. 353, no. 9169, pp. 2051-2058 ISSN 0140-6736; 0140-6736. DOI S0140-
6736(99)03313-9 [pii].

Fillingim, R.B., Bruehl, S., Dworkin, R.H., Dworkin, S.F., Loeser, J.D., Turk, D.C.,
Widerstrom-Noga, E., Arnold, L., Bennett, R., Edwards, R.R., Freeman, R.,
Gewandter, J., Hertz, S., Hochberg, M., Krane, E., Mantyh, P.W., Markman, J., Ne-
ogi, T., Ohrbach, R., Paice, J.A., Porreca, F., Rappaport, B.A., Smith, S.M., Smith,
T.J., Sullivan, M.D., Verne, G.N., Wasan, A.D. and Wesselmann, U., 2014. The
ACTTION-American Pain Society Pain Taxonomy (AAPT): an evidence-based and
multidimensional approach to classifying chronic pain conditions. The Journal of
Pain: Official Journal of the American Pain Society, Mar, vol. 15, no. 3, pp. 241-249
ISSN 1528-8447; 1526-5900. DOI 10.1016/j.jpain.2014.01.004 [doi].

Garrison, S.R., Dietrich, A. and Stucky, C.L., 2012. TRPC1 contributes to light-
touch sensation and mechanical responses in low-threshold cutaneous sensory neu-
rons. Journal of Neurophysiology, 20111109, Feb, vol. 107, no. 3, pp. 913-922 ISSN
1522-1598; 0022-3077. DOI 10.1152/jn.00658.2011 [doi].

Gifford, L. 2014. Aches and pains. Swanpool: CNS Press.

Jesse. ‘IFOMPT 2016 conference summary‘. Physiopedia Weblog. 18.7.2016. Re-

ferred 7.31.2016. http://www.physio-pedia.com/conferences/ifompt/

Jones, T. and Glover, L., 2014. Exploring the psychological processes underlying
touch: lessons from the Alexander Technique. Clinical Psychology & Psychotherapy,
20121106, Mar-Apr, vol. 21, no. 2, pp. 140-153 ISSN 1099-0879; 1063-3995. DOI
10.1002/cpp.1824 [doi].

Lindgren, L., Rundgren, S., Winso, O., Lehtipalo, S., Wiklund, U., Karlsson, M.,
StenlunD, H., Jacobsson, C. and Brulin, C., 2010. Physiological responses to touch
massage in healthy volunteers. Autonomic Neuroscience : Basic & Clinical, Dec 8,
vol. 158, no. 1-2, pp. 105-110 ISSN 1872-7484; 1566-0702. DOI 10.1016/j.aut-
neu.2010.06.011 [doi].

Lloyd, D.M., Mcglone, F.P. and Yosipovitch, G., 2015. Somatosensory pleasure cir-
cuit: from skin to brain and back. Experimental Dermatology, 20150309, May, vol.
24, no. 5, pp. 321-324 ISSN 1600-0625; 0906-6705. DOI 10.1111/exd.12639 [doi].
Loken, L.,S., Wessberg, ,Johan, Morrison, ,India, Mcglone, ,Francis and Olausson,
,Hakan, 2009. Coding of pleasant touch by unmyelinated afferents in humans ISSN
5.

Lorimer. 'Reconceptualising pain according to modern pain science'. Body in mind

Weblog. 19.7.2013. Referred 30.8.16. http://www.bodyinmind.org/resources/journal-
articles/full-text-articles/reconceptualising-pain-according-to-modern-pain-science/

Lumpkin, E.A., Marshall, K.L. and Nelson, A.M., 2010. The cell biology of touch.
The Journal of Cell Biology, Oct 18, vol. 191, no. 2, pp. 237-248 ISSN 0021-9525;
1540-8140. DOI 201006074 [pii].

Mccabe, C., Rolls, E.T., Bilderbeck, A. and Mcglone, F., 2008. Cognitive influences
on the affective representation of touch and the sight of touch in the human brain.
Social Cognitive and Affective Neuroscience, June 01, vol. 3, no. 2, pp. 97-108.
Available from: http://scan.oxfordjournals.org/content/3/2/97.abstract DOI
10.1093/scan/nsn005.

Melzack, R., 2001. Pain and the neuromatrix in the brain. Journal of Dental Educa-
tion, Dec, vol. 65, no. 12, pp. 1378-1382 ISSN 0022-0337; 0022-0337.

Morrison, I., Loken LS FAU - Olausson, Hakanand Olausson, H., 2010. The skin as
a social organ. .

Morrison, I., Loken, L.S., Minde, J., Wessberg, J., Perini, I., Nennesmo, I. and
Olausson, H., 2011. Reduced C-afferent fibre density affects perceived pleasantness
and empathy for touch. Brain : A Journal of Neurology, 20110304, Apr, vol. 134, no.
Pt 4, pp. 1116-1126 ISSN 1460-2156; 0006-8950. DOI 10.1093/brain/awr011 [doi].

Parreira PDO, C., Costa LDA, C., Takahashi, R., Hespanhol Junior, L.C., Luz Junior,
M.A., Silva, T.M. and Costa, L.O., 2014. Kinesio taping to generate skin convolu-
tions is not better than sham taping for people with chronic non-speci fi c low back
pain: a randomised trial. Journal of Physiotherapy, 20140610, Jun, vol. 60, no. 2, pp.
90-96 ISSN 1836-9561; 1836-9561. DOI 10.1016/j.jphys.2014.05.003 [doi].

Pautasso, M., 2013. Ten Simple Rules for Writing a Literature Review. PLoS Com-
putational Biology, 20130718, Jul, vol. 9, no. 7, pp. e1003149. Epub 2013 Jul 18
doi:10.1371/journal.pcbi.1003149 ISSN 1553-734X; 1553-7358. DOI
PCOMPBIOL-D-12-01817 [pii].

Sayers, A., 2008. Tips and tricks in performing a systematic review. The British
Journal of General Practice, Feb 1, vol. 58, no. 547, pp. 136 ISSN 0960-1643; 1478-
5242. DOI 10.3399/bjgp08X277168 [doi].

Schley, M., Bayram, A., Rukwied, R., Dusch, M., Konrad, C., Benrath, J., Geber, C.,
Birklein, F., Hagglof, B., Sjogren, N., Gee, L., Albrecht, P.J., Rice, F.L. and
Schmelz, M., 2012. Skin innervation at different depths correlates with small fibre
function but not with pain in neuropathic pain patients. European Journal of Pain
(London, England), 20120503, Nov, vol. 16, no. 10, pp. 1414-1425 ISSN 1532-2149;
1090-3801. DOI 10.1002/j.1532-2149.2012.00157.x [doi].
Sommer, C., 2012. Are there biological markers of neuropathic pain?. European
Journal of Pain, vol. 16, no. 10, pp. 1345-1346. Available from:
http://dx.doi.org/10.1002/j.1532-2149.2012.00179.x ISSN 1532-2149. DOI
10.1002/j.1532-2149.2012.00179.x.

Testa, M. and Rossettini, G., 2016. Enhance placebo, avoid nocebo: How contextual
factors affect physiotherapy outcomes. Manual Therapy, 8, vol. 24, pp. 65-74. Avail-
able from: http://www.sciencedirect.com/science/article/pii/S1356689X1630008X
ISSN 1356-689X. DOI http://dx.doi.org/10.1016/j.math.2016.04.006.

Tobin, D.J., 2006. Biochemistry of human skin-our brain on the outside. Chemical
Society Reviews; Chem.Soc.Rev., vol. 35, no. 1, pp. 52-67 ISSN 0306-0012.

Torraco, R.J., 2005. Writing integrative literature reviews: guidelines and examples.
Human resource development review, September 01, vol. 4, no. 3, pp. 356-367.
Available from: http://hrd.sagepub.com/content/4/3/356.abstract DOI
10.1177/1534484305278283.

Vardeh, D. and J.Mannion, R. J. and Woolf, C., 2016. Toward a Mechanism-Based

Approach to Pain Diagnosis. - Elsevier Available from: -
http://dx.doi.org/10.1016/j.jpain.2016.03.001 ISBN - 1526-5900. DOI -
10.1016/j.jpain.2016.03.001.

Wall, P.D., 1991. Neuropathic pain and injured nerve: central mechanisms. British
Medical Bulletin, Jul, vol. 47, no. 3, pp. 631-643 ISSN 0007-1420; 0007-1420.

Website of Diane Jacobs. Referred 9.8.2016. https://docs.google.com/docu-

ment/d/1FJ9jWwUIcEr7kJ07DJMitYW3C0nLHJU_cJoO_U2Rx28/edit

Website of Openstax. Referred 10.8.2016 www.cnx.org.

Whittemore, R. and Knafl, K., 2005. The integrative review: updated methodology.
Journal of Advanced Nursing, vol. 52, no. 5, pp. 546-553. Available from:
http://dx.doi.org/10.1111/j.1365-2648.2005.03621.x ISSN 1365-2648. DOI
10.1111/j.1365-2648.2005.03621. x.

Williams, A.C. and Craig, K.D., 2016. Updating the definition of pain. Pain, Nov,
vol. 157, no. 11, pp. 2420-2423 ISSN 1872-6623; 0304-3959. DOI
10.1097/j.pain.0000000000000613 [doi].