Complementary Therapies in Clinical Practice 22 (2016) 64e68

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

Therapeutic touch for nausea in breast cancer patients receiving

chemotherapy: Composing a treatment
Zohreh Vanaki a, Pegah Matourypour b, Roya Gholami c, *, Zahra Zare d,
Valiolah Mehrzad e, Mojtaba Dehghan f
a
Tarbiat Modares University, Tehran, Iran
b
Department of Nursing, School of Nursing and Midwife, Arak University of Medical Sciences, Arak, Iran
c
Department of Midwifery and Reproductive Health, School of Nursing and Midwife, Islamic Azad University Tehran Medical Branch, Tehran, Iran
d
Tehran University of Medical Sciences, Tehran, Iran
e
Department of Oncology, Isfahan University of Medical Sciences, Isfahan, Iran
f
Isfahan University of Medical Sciences, Isfahan, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Background and Objective: Therapeutic touch (TT) is independent nursing intervention which is effective
Received 24 August 2015 on nausea induced by chemotherapy but technique, steps and variables affected by this therapy are not
Received in revised form yet well known. The aim of this study was to elicit descriptions of how TT is used with cancer patients,
28 November 2015
providing a basis for the systematic use and evaluation of TT with patients.
Accepted 3 December 2015
Materials and Method: In this research, 108 patients were examined with intentional sampling and
random allocation in 3 groups (control, placebo and intervention) in 2013 (each group 36). Intervention
Keywords:
received therapeutic touch (touching of first energy layer) and demographic form, visual analog scale
Therapeutic touch
Nausea
(VAS) for intensity of nausea, check list for duration and times of nausea in the morning, noon, afternoon
Chemotherapy and night at acute phase were used. Data were analyzed by Kruskal Wallis, c2 and analysis of variance
Breast cancer (ANOVA).
Results: Duration, frequency and intensity of nausea were significantly lower in the test group (P < 0.001,
P < 0.001 and P < 0.001). The mean duration of intervention (whole process) was 21.38 min [SD 6.04]. In
69.4% of women there was a need for re-intervention after reassessment phase.
Conclusion: Results of this randomized control trial showed that TT is effective on duration, times and
intensity of nausea; therefore, TT can be used as an alternative method for patients who are willing to use
this technique.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction Given the limited effectiveness and serious side effects of

Chemotherapy is one of the oldest and most common cancer
treatments [1,2]. Chemotherapy induced Nausea and vomiting is
among the most severe and feared collateral effects of chemo-
therapy that is experienced by 70e80% of patients [2,3]. This side
effect causes a significant reduction in quality of life and decline in
patients' ability to perform activities of daily living; that can in-
fluence the patient's willingness to continue with and successfully
complete cancer treatment. Therefore, it is essential to treat these
side effects to encourage patient compliance [4].
* Corresponding author.
E-mail address: gholami.roya680@gmail.com (R. Gholami).
common antiemetic drugs; the use of complementary and alter-
native medicine is one of the basic and safety measures. Over the
past decade, these treatments have been taken into account by
patients and their families, and professionals around the world [5].
The incidence of this treatment use in adults and children with
cancer is 50e84% [6,7]. Breast cancer has the highest rates of
complementary and alternative medicine use among other cancers
[8,9].
Therapeutic touch (TT) is a low-cost and non-invasive comple-
mentary medicine form that can be performed at any time and any
place, it has no contraindications and only need a pair of hands
[10e12]. It needs formal training [13] and everyone that has the
ability and desire to help others (even family members of patients),
can do it after training courses [14]. Unlike other haptic or touch

http://dx.doi.org/10.1016/j.ctcp.2015.12.004
1744-3881/© 2015 Elsevier Ltd. All rights reserved.

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 Z. Vanaki et al. / Complementary Therapies in Clinical Practice 22 (2016) 64e68
based modalities such as massage therapy, TT does not require the
practitioner to physically touch patient. Instead, the practitioner
uses a form of focused attention and his/her hands as the center for
creating balance and coordination in the field of bilateral energy of
the patient and environment [15,16].
In different studies, at RCT framework, beside all limitations, TT
has been shown to decrease stress and anxiety in adult patients
[15]. Data has revealed that TT alleviates pain [17], controls ar-
rhythmias and blood pressure [15], increases the hemoglobin level,
improves immune system, speeds up the healing process of
wounds and fractured bones and improves mobility in patients
with arthritis [10,18]. The best-known outcomes of TT with cancer
patients are the decrease in nausea and vomiting [13,16,19].
Yet, with increased research on the use of TT with adults and
children, little work has emerged on the use of TT with nausea and
vomiting; particularly in cancer patients. This may be due, in part,
to the lack of descriptive investigations on the use of TT with nausea
and vomiting in cancer patients. The aim of this descriptive and
clinical trial study was to elicit descriptions of how TT is used with
cancer patients, providing a basis for the systematic use and eval-
uation of TT with patients.
2. Materials & methods
2.1. Therapeutic touch
The basic assumptions of therapeutic touch are that human
beings (recipients and practitioners) are complex systems of
patterned energy in continual process with the energy of their
environments. More specifically, a person's (and in this instance,
the breast cancer patient's) energy is a vital life force that perme-
ates the individual and interpenetrates the energy of the universe
[20]. The bisymmetrical structures and energy patterns in the hu-
man body, mind, and spirit reflect a mutual balance, strength,
function and direction in a healthy person. When an individual is ill,
changes in his or her energy patterns are perceived as energy field
imbalances that may be associated with symptoms of the illness.
Based on the perceived, altered characteristics of the ill person's
energy patterns and symmetry, the TT practitioner moves his or her
hands and uses mental imaging to intentionally modulate the en-
ergy field to facilitate the person's endogenous capacity to heal
[15,21,22]. TT has a remarkable and strong history of clinical
research that prove the safety and positive impact of this inter-
vention [10,18].
2.2. Study population
This descriptive and clinical trial study was conducted to elicit
descriptions of how TT is used with breast cancer patients,
providing a basis for the systematic use and evaluation of TT with
patients among 108 women aged 18e65 years (36 with, 36 without
TT and 36 placebo group). The sample size was determined based
on Altman's nomogram. This nomogram is a method for deter-
mining the sample size for the intervention study using test power
and standard deviation of the considered variable in a similar study
[23] and calculating the parameter called clinical differences. The
women undergoing chemotherapy for breast cancer were admitted
to Seyedalshohada Hospital, Isfahan 2012e2013. The sampling
technique was purposive and the samples randomly divided into
three groups. The inclusion criteria were as follows: patient with or
without metastases (excluding central nervous system (CNS) me-
tastases and metastases to the gastrointestinal (GI) tract, which can
cause nausea and vomiting), having the same drug regimen in all
three groups (Cyclophosphamide, Epirubicin and antiemetic drugs:
Dexamethasone, Plasil, Kitril and Emend), no concurrent
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65
radiotherapy and having experienced at least one course of
chemotherapy and chemotherapy-induced nausea and vomiting.
Exclusion criteria were not completed questionnaires within 24 h
after completion of chemotherapy and patient's unwillingness to
cooperate.
2.3. Data collection tools
Data were collected using a questionnaire including de-
mographic characteristics, a 100-mm visual analog scale (VAS) [24]
that patients rated their nausea severity on it and a chart to record
duration and frequency of nausea at 4 times (morning, noon, eve-
ning and night) during the acute phase. Content validity was used
to determine the validity of this chart.
2.4. Data collection procedures
After university internal review board approval was obtained, TT
practitioner who used TT with patients began her intervention at
the hospital. The researcher described the project and obtained
written consent to participate in the study during the initial con-
tact. The subjects who agreed to participate in the research were
randomly divided into 3 groups (test, placebo and control). Then
the participants filed out the questionnaires and VAS. The inter-
vention for two groups (test and placebo) was carried out prior to
their first chemotherapy appointment (once for about 15e20 min).
The procedure is described in detail in Box 1. History of any un-
derlying disease, especially gastrointestinal disease was considered
and the time spent on those cases was much higher. In the placebo
group, the repeated procedure was exactly the same as the test
group (Box 1) and was performed on the same day, but the prac-
titioner's hands-to-patient's body distance was different (more
than 20 cm) and in fact there was no energy transfer. The control
group received no intervention. At the end the nausea chart of
acute phase (during 24 h after chemotherapy) was given to them (3
groups) (Fig. 1).
2.5. Analysis
We used descriptive statistics to describe the demographic
characteristics of the sample, KruskaleWallis test, Chi-squared test
and Analysis of variance test. Statistical analysis was performed
using SPSS version 17. P < 0.05 was considered as statistically sig-
nificant. Also, narrative inquiry was used to explore the use of TT
with cancer patients and provided the themes to compose a TT
process for breast cancer patients.
3. Results
The mean age in three groups was 49.7 years [standard devia-
tion (SD) 9.2]. The maximum number of patients in three groups
was belonging to the 40e49 year age category. Most subjects in
these groups were married, housewife with no independent in-
come and did not have a high school diploma. Most of them did not
have a history of past gastrointestinal diseases and metastatic
breast cancer (Table 1). The demographic characteristics (education
level, income, occupation, marital status and age) were similar
between three groups.
Analysis of variance test showed that average time of nausea
differed between the groups; Tukey's test in comparing each of the
two groups showed that duration of nausea in the intervention
group was significantly lower than the placebo and control groups.
The mean duration of nausea in the three groups are presented in
[Table 2].
Also, KruskaleWallis test showed that frequency and intensity
66 Z. Vanaki et al. / Complementary Therapies in Clinical Practice 22 (2016) 64e68

Box 1
. Therapeutic touch process for breast cancer patients receiving assessed for
chemotherapy eligibility(n=108)

Initiation Phase (Preparing the environment): We should

provide a relatively quiet and solitude environment [16]
even if the patients receive treatment in a hospital or
clinic. It is not necessary to remove a patient's clothing
(energy can pass through all their clothes [17]).
Second phase (Evaluating and preparing the patient): At
first, the patient is asking for history of any underlying
disease (except breast cancer) to investigate TT contrain-
dication (head trauma, pregnancy and psychosis) and pay
special attention to the involved area during the evaluation
process [15]. Then, the patient is asked to sit up straight on a
comfy chair without handle. She should close her eyes,
relax, don't think about any things and take slow deep
breaths [16]. Practitioner prepares to treat the patient during
this time.
Third phase (Practitioner preparation): The practitioner
quiets the mind, uses thoughts or images of peace and
wholeness, breathes to physically relax, acknowledges the
patient's unique wholeness, establishes the intent to pro-
vide support and comfort to the patient, requests permis-
sion from the patient, mentally, to perform TT and observes
the patient's response; and if the practitioner perceives the
patient is accepting or receptive to TT, proceeds to assess-
ment [16].
Fourth phase (Assessment): after preparation, the practi-
tioner passes the hands, beginning at the patient's head and
moving to the feet and then beginning at the patient's head
and moving to the sacrum, 12e15 cm above the body, palm
facing down, one time to become familiar with the character
of the patient's energy field [16] and then makes a second
pass to assess for specific disruptions in the patient's hu-
man energy field, including imbalances, congestions, or
deficits [15,16].
Fifth phase (intervention): The practitioner makes a single
pass with two hands through the patient's field in quiet
brushing motions, from head to sacrum and directs energy
purposefully toward or away from a particular area of the
patient's field to release congestion, fill in areas of perceived
energy deficit, or facilitate flow of energy in a healthy
pattern throughout the patient's field, from the head
through the feet [15]. History of any underlying disease,
especially gastrointestinal disease was considered and the
time spent on those cases was much higher.
Sixth Phase (reassessment): At the end the practitioner
makes a final pass through the patient's field with two
hands to assess the patient's field [15]. She compares any
differences or similarities in the patient's final field pattern
assessment with the initial assessment and makes an
additional intervention and reassessment pass through the
field, if necessary.
of nausea differed between the groups, pairwise comparisons of the
groups (post hoc) showed that frequency and intensity of nausea
were significantly lower in the test group (P < 0.001 and P < 0.001)
[Table 3].
The mean duration of intervention (whole process) was
randomized (n=108)
test group(n=36) placebo group(n=36) control group (n=36)
filed out the filed out the filed out the
questionnaires and VAS questionnaires and VAS questionnaires and VAS
The intervention was
carried out prior to their
first chemotherapy
appointment
filed out the nausea chart
of acute phase (during 24
hours after
chemotherapy)
Fig. 1. Flow diagram of the study group.
21.38 min [SD 6.04]. The mean duration of intervention in patient
without history of gastrointestinal disease was lower than patient
with (20 and 25 min respectively). Also in 69.4% of women there
was a need for re-intervention after reassessment phase. Table 2
outlines the TT process for breast cancer patients.
4. Discussion
Due to the effects of TT on chemotherapy-induced nausea in
breast cancer patients receiving chemotherapy, the results can be
used to introduce some parts of the operational program. It should
be noted, however, that training is essential to gain expertise in this
field.
Complementary therapies is a nursing intervention and do not
require a doctor's prescription. TT is also one of the branches of
complementary therapies that is effective in a wide range of
symptoms [25,26]. TT can reduce stress, anxiety [15] and pain [17]
and has positive effects on the cardiovascular and immune systems
[15]. It also promotes wound and broken bones healing and facili-
tates improved joint mobility in arthritis patients [10,18]. In this
study we observed that TT decreases the chemotherapy-induced
nausea in breast cancer patients receiving chemotherapy. Since
nausea that occurs with cancer and its treatment can also occur
with other diseases, the findings of this study are usable in other
parts of the hospital in addition to oncology department.
Our study showed a significant effect of TT on the average time
and frequency of nausea during acute phase. As we said, the
average time and frequency of nausea was significantly lower in the
test group. Also, hypnosis reduced the frequency of nausea in pla-
cebo group. Molassiotis et al. demonstrated that acupressure is
effective in the control and management of chemotherapy-related
acute nausea in the test group in comparison with the placebo and
control groups [27]. In this regard, Suzanne et al., in a study on
some women with breast cancer undergoing chemotherapy [28]
and Shen and Glaspy in a study on some patients with gastric

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Table 1
Comparison of demographic characteristics among three groups (test, placebo and control) using the chi-squared test.

Variable Test group Placebo group Control group P-value

(n ¼ 36) (n ¼ 36) (n ¼ 36)
No. (%) No. (%) No. (%)

Educational level
Illiterate 8 (22.2) 10 (27.8) 9 (25) 0.85
without a high school diploma 15 (14.7) 16 (44.4) 14 (38.9)
High school diploma 7 (19.4) 7 (19.4) 10 (27.8)
Bachelor's degree or higher 6 (16.7) 3 (8.3) 3 (3.83)
Occupation
Housewife 28 (32.2) 30 (83.3) 29 (80.6) 0.8
Office worker 3 (8.3) 3 (8.3) 2 (5.6)
Manual worker 2 (5.6) 2 (5.6) 4 (11.1)
Retired 3 (8.3) 1 (2.8) 1 (2.8)
Income
No income 26 (72.2) 31 (86.1) 30 (83.3) 0.53
Less than 500.000 Tomans/month 4 (711.1) 3 (8.3) 2 (5.6)
More than 500.000 Tomans/month 6 (16.7) 2 (5.6) 1 (2.8)
Marital status
Single 1 (2.8) 1 (2.8) 1 (2.8) 0.99
Married 30 (83.3) 30 (83.3) 31 (86.1)
Divorced or widowed 5 (13.9) 5 (13.9) 4 (11.1)

Table 2 association was seen between TT and the nausea intensity during
Comparison of the duration of nausea in the three groups-experimental, placebo the acute phase, the nausea intensity was lower in the test group in
and control-during the acute phase. comparison with the placebo group. Basak et al. showed the nausea
Groups Duration of nausea (h) ANOVA intensity-lowering effect of foot massaging in the test group in
Mean Standard deviation Homogeneity of f P
comparison with the control group (P < 0.001) [31]. This was
variance consistent with the findings of the present study.
Since most of the patients were referred from the surrounding
Sig Leven statistic
cities to Isfahan and received only one medication dose, there was
Experiment 5.36 2.17 0.1 2.34 57.88 <0.001
no possibility of intervention for several days in a row; as a result,
Placebo 10.81 1.77
control 10.01 2.88 there was no possibility of measuring the nausea intensity in the
delayed phase (delayed Chemotherapy-Induced Nausea and Vom-
iting, which occurs more than 24 h after chemotherapy [32]) and it
was the limitation of our study. Also, fatigue and weakness were
Table 3
Comparison of frequency of nausea in the three groups-experimental, placebo and
other reasons. To prevent sample loss as a result of occurrence of
control-during the acute phase. bias in this phase, intervention and review was avoided in this
phase.
Groups Frequency of nausea KruskaleWallis
Despite these limitations, there are certain important aspects of
Mean rank Chi-square P the design of this study that may have enhanced the accuracy of the
Experiment 50.29 51.08 <0.001 study. These include having a placebo group that reduce the bias to
Placebo 31.44 the extent possible and having a control group that enabled us to
control 81.76
find out if the TT really had effect. Our study had some other
strengths including having one practitioner, as we know; the
varying degrees of experience of the practitioners influenced the
cancer [29] demonstrated that acupressure leads to a significant degree of detail.
reduction in delayed nausea in these patients and reached similar
results.
In explaining these findings of the research, nausea and vom- 5. Conclusions
iting are due to the disruption in energy balance in one of the body
orbits and with touch therapy, the therapist is trying to restore the In conclusion we found TT decreases the chemotherapy-induced
energy balance [24]. Researchers believe that touch therapy can nausea in breast cancer patients receiving chemotherapy. Consid-
relieve physical tension and create relaxation, and has a significant ering chemotherapy causes numerous complications, due to sys-
impact on reducing nausea in the subjects. Touch therapy delays temic treatment including nausea and vomiting (the most common
the onset of nausea [24], while the majority of patients in the and troublesome complication); health providers in this field can
control group were nauseated from morning or afternoon. This, design a training program to teach TT technique as one of the main
itself, is a milestone in controlling nausea because the absence of courses in nursing schools and facilitate treatment process during
nausea immediately after completion of chemotherapy, as the pa- this particular stage. The research processes applied here may be
tient expects it, could be promising for the patients. used to design education programs and standards of practice for TT
A number of patients reported being very anxious as they practitioners. It is also suggested that future research be performed
entered the clinic. Anxiety it-self can cause nausea in some people; on the effect of therapeutic touch on the delayed phase of nausea
also, some studies have linked anxiety to the development of caused by chemotherapy and on other disturbing factors in cancer
nausea. TT is an effective approach for managing anxiety [15,30] so, patients, such as insomnia, or compare therapeutic touch with
a possible mechanism that can explains the role of TT in reducing other complementary therapies on chemotherapy-induced nausea
nausea is its anxiety-reducing effect. In this study, a significant and vomiting. The findings of the present study should be

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considered together with the limitations of the study. The number
of breast cancer patients participating in the study reduces the
coefficient of generalizability of the study results.
Conflicts of interest
The authors report no declaration of Interests.
Acknowledgments
We express our deep gratitude toward all dear colleagues and
subjects taking part in this study, especially officials and staff of
outpatients' chemotherapy unit of Seyed Al-Shohada hospital,
Isfahan for their sincerely cooperation. We are also thankful of
Deputy of Research and Technology of Tarbiat Modares University
for providing facilities and opportunities to conduct this study. This
study was approved by the Ethical Committee of the university. The
registered article number in IRCT is 2013080311136N2.
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