HAND FUNCTION SERIES

TIPS FOR IMPROVING THERAPEUTIC HANDLING

Therapists' Hand Skills

* Editor's note: This is the final installment in a four-part series which examines hand development and function.

By Rhoda P. Erhardt

We are always trying to improve our clinical observations of the human hand during formal and informal evaluations, in order to plan and modify treatment programs appropriately.

A frequent and significant component of our treatment, of course, is our own hand function when we touch, guide, and move infants, children, and adults with compromised physical, mental, and emotional systems.

Like many of you, I have taken courses in NDT, SI, myofascial release, cranial-sacral therapy, joint mobilization, dynamic splinting, pediatric massage, Feldenkrais, and therapeutic touch. Their techniques have helped me learn how to grade my sensorimotor input to obtain predictable changes in my patients' movement patterns.

But there is more to touch than technique. I was an OT student more than 40 years ago at the University of Illinois, and I remember most clearly a concept that was drilled into us all--one which has become the core of my own professional philosophy: the therapeutic use of self.

We were taught the importance of the therapeutic relationship, and how to use that relationship as our most important tool, to communicate caring. A major component of therapeutic touch is the intent to help. Touch with intention is an energy exchange in which the caregiver, after becoming centered and quiet, transfers energy and makes it available to the other person, who needs to restore balance and harmony within.

In therapeutic adaptation of the environment, we attended to the patient's sensory as well as motor needs. We adjusted levels of sound and light, and adapted the size, shape, texture, weight, and temperature of materials. We considered what kind of proprioceptive, vestibular and tactile input was appropriate for a particular individual at a particular time, and we were alert to the patient's responses, which might indicate the need for further modifications.

Touch with intention includes the therapist's efforts to consciously focus on the patient, as well as to prepare a therapeutic environment. If successful, it empowers the patient to participate in his own natural healing process. We are only the guides, partners with the patient in this process toward wellness. It's truly a dynamic interaction, as touching keeps us connected and in tune with the changes taking place.

According to Eastern philosophies, a healthy organism with abundant energy is believed capable of consciously directing that vital energy. When touch is viewed as an organizer--as a method of restoring homeostasis--the central premise is that touch with compassionate intent somehow synchronizes our innate energies with those found in nature. We touch through our hands as well as with our hands to convey warmth, respect, and acceptance. This tangible form of caring creates a climate of trust particularly integrative for those who are ill and often feel a sense of disintegration.

The tactile sense (cutaneous sensations aroused by stimulation of skin receptor) is closely linked to the proprioceptive sense (receptors from muscles and joints) and the vestibular sense (the awareness of movement). Of course touch rarely occurs without the additional senses of vision, sound, smell, and taste.

All areas of development are dependent upon touch. The tactile system's influence on the central nervous system, on muscle tone, behavior, and organizational ability, is well documented in people with intact nervous systems. The nervous system always functions holistically, so tactile input affects the autonomic, reticular, and limbic systems. It has a particularly profound effect on emotions.

Individuals with tactile regulation issues have difficulty processing sensory information, especially from multiple channels simultaneously. Through our clinical experience, we have learned that all sensory input for them needs to be carefully graded, since they may be hypo- or hyper-responsive, overloading easily and reacting with fight-or-flight reactions.

Our challenge is to learn how to interpret and respond appropriately to their behavioral signals, so that our touch is sensitive, skilled, and therefore therapeutic.

The following tips for improving therapeutic handling can help facilitate healing through focused intention:

* Think about how you use touch in your personal and professional relationships. We all need touch and we need to touch.

* Develop your ability to center and become calm before intervening.

* Acknowledge rather than block your current emotions so you can communicate with touch in the context of your true feelings.

* Soften and steady your voice as you use it as an adjunct in therapy.

* Consider your touch as an equal component of communication. Your individual touching style usually reflects your general communication style.

* Realize that boundaries for touch vary widely in different cultures, societies, and at different ages. Respect individual variations. The type and amount of touching that soothes one person will make another bristle.

* Be sensitive to different energy levels. Children with central nervous system dysfunction must expend much more effort in thinking, talking, and moving than their normal peers. After mild exertion, people who are aging or chronically ill demonstrate decreased physical energy as exhaustion and the need for frequent rest periods. Distractibility or withdrawal may indicate problems maintaining personal interactions or intense emotion for any length of time, due to decreased psychological and emotional energy.

* Remember that problems with touch arise not only during touch itself, but also during the transitions from not touching to touching, and from touching to not touching. Your goal is to make those transitions smooth and unobtrusive rather than abrupt and aversive.

* Gather as much information as possible about the patient through your eyes, ears, and hands as you begin therapeutic handling. The visual data includes what you are watching as well as your unconscious observations of another part of the patient's body. The auditory sense picks up subtle changes in respiration, perhaps indicating the patient's discomfort. Kinesthetic and proprioceptive senses give you more qualitative information about the patient's responses.

* Try to balance intuition and thought. Wait for the patient's responses. Observe and analyze those responses. Continually modify what you are doing based on the patient's ongoing responses, both verbal and nonverbal (facial expressions, muscle tone changes) by changing location of your hand placement, firmness of pressure, direction of movement, and frequency/speed/duration of touch.

* Notice how your own breathing patterns change during movement. Stabilize with your hands and feet rather than holding your breath. Be aware of changes in your own emotions during or after therapy.

* Finally, adjust touch according to the feedback you are receiving.

Enjoy the results of your intuitive therapeutic handling, especially those magic moments that happen sometimes. Try to remember what you saw, heard, and felt, relating it to what you know about the human body, the state of the patient at the time, and your own mental and emotional state.

* About the author: Rhoda P. Erhardt, MS, OTR, FAOTA, is currently in private practice in the Minneapolis/St. Paul area, providing evaluation and consultation services to a variety of health agencies, educational systems, and national corporations. She is internationally known for her publications and workshops on topics such as prehension, vision, eye-hand coordination, and feeding in children with CP as well as perceptual problems in children with LD. You can reach Ms. Erhardt at (612) 730-9004 or online at rperhardtdp@worldnet.att.net.