Research Protocol
 

By Dr. Deepak Gupta , Dr. Sarwan Kumar , Dr. Arvind Srirajakalidindi
Corresponding Author Dr. Deepak Gupta
Wayne State University, - United States of America 48201
Submitting Author Dr. Deepak Gupta
Other Authors Dr. Sarwan Kumar
Internal Medicine, Wayne State University, - United States of America

Dr. Arvind Srirajakalidindi
Detroit Medical Center, - United States of America

ANAESTHESIA

Seizure, Migraine, Anxiety, Panic Attack, Cesarean Section, Emergence Agitation, ICU Delirium

Gupta D, Kumar S, Srirajakalidindi A. Hand On Forehead: Can It Calm Our Perioperative And Critical Care Patients? A Worth Exploring Non-Pharmacological Intervention's Efficacy. WebmedCentral ANAESTHESIA 2019;10(4):WMC005562

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
No
Submitted on: 13 Apr 2019 09:55:48 PM GMT
Published on: 25 Apr 2019 06:44:54 AM GMT

Abstract


In regards to soothing and healing hands on our foreheads, we as medical scientists have begun to wonder and question whether human touch soothes and how maternal touch heals. Thus, we as anesthesiologists and perioperative physicians and critical care specialists have envisaged a protocol which can be used to seek the proof in colloquial terms and the evidence in scientific terms whether the age-old human touch with its caring maternal innuendos needs to prove itself to be acceptable as a comforting and may be a healing strategy in perioperative scenarios and in critical care settings. Essentially, results can be expected from the envisaged protocol to deduce that instead of asking whether the benefits of skin-to-skin contact are lost once humans outgrow their infancy, it is important to recognize that, as time passes by, the knowledge of these benefits may be getting lost instead of the benefits themselves getting lost. Therefore, there may not be a better way than the calming caring cooler hands pressed on the foreheads of agitated/combative perioperative and critically ill patients to scientifically explore calming and may be healing power of human touch.

Origin of Hypothesis


As children we have always been pacified [1] and comforted by our elders’ hands over heads [2-5] and especially our mothers’ hands on our foreheads. There is never a time that comes to our memories when our mothers’ hands on our foreheads did not calm us down whether we were crying or agitating or nauseating or vomiting. But as we grew older, we got/became lost and forgot the importance of human touch [6-13], especially caring maternal touch because we as medical scientists began to wonder and question how come human touch soothes and why so maternal touch heals. Do we have proof? Are the questions reliable? Are the results reproducible? Will evidence be valid? Essentially, we as anesthesiologists and perioperative physicians and critical care specialists have envisaged the hereafter presented protocol which can be used to seek the proof in colloquial terms and the evidence in scientific terms whether the age-old human touch with its caring maternal innuendos needs to prove itself to be acceptable as a comforting and may be a healing strategy in perioperative scenarios and in critical care settings.  

Envisaged Materials and Methods


After institutional review board approval for waived patient consent from patients aged 18 years or more, waived parental consent from parents of wards aged less than 18 years and waived oral assent from patients aged 7 years and less than 18 years, all patients presenting to the perioperative and critical care settings can be included in this randomized controlled prospective study. In case if mastering the intervention of hand on forehead is turning out to be difficult, then patients aged less than 7 years can be excluded from inclusion into this study considering that the head size of such pediatric patients may be too small and the hand pressure on their foreheads may unintentionally become too high. The difficulty in mastering the intervention can be the simple fact that the hand pressure over forehead must not restrict patient’s head movement wherein it will have to be envisaged how much pressure on the forehead of an adult or a child or a young one is not being perceived by the adult or the child or the young one as if being held down forcefully. As the objective amounts of hand pressure on forehead for various age groups are still unknown and non-quantified, the efficacy and safety of subjective mastering of this non-pharmacological intervention is an uncharted domain yet. However, instead of constant hand-force pressing the forehead, hand-pressure being released every few moments intermittently and rhythmically may make this intervention’s perception as a supportive hand-hold instead of forceful hold-down. The envisaged intervention has been schematically shown in Figure 1.

 

For now, the envisaged investigation can be limited to tabulated avenues only which can be further expanded if the results appear promising on the expected lines. Therefore, for now, the patients demonstrating any of the tabulated six symptoms can be correspondingly randomized into three groups and thus there can be patients distributed into eighteen groups with 30 patients in each group (total 540 patients; see Table 1). Simple scoring can be modified from Richmond Agitation-Sedation Scale (RASS) [14] wherein patients can be scored at the start of 10-minute period and at the end of 10-minute period by the abbreviated newly-envisaged-and-named “CRAC” score:

  • Calm with absent non-purposeful movements
  • Restless with infrequent non-purposeful movements, controllable by patient
  • Agitated with frequent non-purposeful movements, controllable by caregiver
  • Combative with aggressive non-purposeful movements, uncontrollable by caregiver  

 

This non-pharmaceutical intervention may most likely be utilized when patients are Agitated or Combative because utilizing this technique may not produce appreciable differences and reproducible results when patients are just Restless. Moreover, when utilizing this non-pharmaceutical intervention, it is automatically implied that none of the study patients can be scored as Calm at the start of 10-minute period. Similarly, presuming that almost all study patients may become Calm at the end of 10-minute period, it may be better, for comparative analysis among groups, to record the time when the patients first become Calm during the 10-minute period. In terms of migraines, seizures and panic attacks, their comparative incidence among the three types of interventions can be recorded for analysis. Additionally, the following standardized rescue medications can be used as corresponding to the row in Table 1 for comparison among the three types of interventions accordingly:

  • In perioperative seizure aura patients, comparison of anti-seizure rescue medication as midazolam’s dose given during 10-minute period.
  • In perioperative migraine aura patients, comparison of headache rescue medication as fentanyl’s dose given during 10-minute period.
  • In preoperative severe anxiety patients, comparison of anti-anxiety rescue medication as midazolam’s dose given during 10-minute period.
  • In intraoperative anxiety Cesarean section patients, comparison of rescue medications’ doses may not be done because anti-anxiety medications may have to be avoided to prevent their placental transfer to fetuses
  • In emergence agitation patients, comparison of anti-agitation rescue medication as dexmedetomidine’s dose given during 10-minute period.
  • In ICU delirium patients, comparison of anti-delirium rescue medication as dexmedetomidine’s dose given during 10-minute period.

 

Besides the above-mentioned, standard baseline demographics can be recorded like patients’ age, sex, height and weight, and body mass index. Patients’ co-morbidities can be recorded but, considering the absence of any exclusion criteria for this waived consent randomized controlled prospective study, they may not serve towards being analyzable as confounding factors especially when the intervention is simple non-pharmacological placement of hand on forehead for 10-minute period or less.

 

Statistical analysis

The primary outcome can be difference in proportions of calmed patients after 10-minute interventions with either non-gloved hands or gloved hands as compared to after 10-minute interventions with non-pressing non-touching hands over the foreheads of agitated or combative patients. The secondary outcome can be (a) difference in doses of rescue medications for calming agitated or combative patients during 10-minute interventions with either non-gloved hands or gloved hands as compared to during 10-minute interventions with non-pressing non-touching hands over their foreheads, and (b) difference in time to achieve Calm state in Agitated or Combative patients during 10-minute interventions with either non-gloved hands or gloved hands as compared to during 10-minute interventions with non-pressing non-touching hands over their foreheads. The supplementary outcomes can be differences for the above-mentioned primary and secondary outcomes even between the patients receiving 10-minute interventions with non-gloved hands and the patients receiving 10-minute interventions with gloved hands. The proportions can be compared by Chi square analysis while means can be compared by analysis of variance (ANOVA). The statistical significance level can be ascertained to have been achieved when analyzed p< 0.05.

Expected Line of Results


Assuming that hand on forehead has calming effect, the expected line of results can be (a) significantly increased proportions of calmed patients after 10-minute interventions with either non-gloved hands or gloved hands as compared to after 10-minute interventions with non-pressing non-touching hands over the foreheads of agitated or combative patients, (b) significantly decreased doses of rescue medications for calming agitated or combative patients during 10-minute interventions with either non-gloved hands or gloved hands as compared to during 10-minute interventions with non-pressing non-touching hands over their foreheads, (c) significantly decreased time to achieve Calm state in Agitated or Combative patients during 10-minute interventions with either non-gloved hands or gloved hands as compared to during 10-minute interventions with non-pressing non-touching hands over their foreheads, and (d) significant differences for the above-mentioned primary and secondary outcomes even when the patients receiving 10-minute interventions with non-gloved hands are compared with the patients receiving 10-minute interventions with gloved hands.

 

The explanation may be simply that the hand pressure on forehead may be breaking the feedback loop to the brain wherein the hand pressure on forehead by physically relieving or preventing the creation of “cardiovascular mortality risk-signaling and risk-enhancing forehead wrinkles” [15-17] may be “misleading” brain to assume that “everything must be alright” considering there are no wrinkles on forehead [2]. Moreover, assuming that compared to gloved hands, non-gloved hands can be considered as transgressions when healthcare workers examine patients’ anatomically “private” areas [18-19], it ironically signifies that human skin’s touch has a different feedback loop in the touched person’s brain as compared to when gloves are interfering with skin-to-skin touch by being a plastic barrier between the two skins [20]. Therefore, it may be worthwhile to not only explore if there is calming effect with hand on forehead but also going further to explore if the calming effect is enhanced by non-gloved hand “pressing and touching” on forehead as compared to gloved hand “only pressing” on forehead. Essentially, the focus may be to decipher if the feedback loop to brain secondary to appropriate gloved hand pressure on forehead is accentuated by the feedback loop to brain secondary to warm non-gloved hand touch on forehead. It can be further explored in futuristic times to confirm that it is not a pressure band on forehead but rather a caring hand on forehead when futuristically invented robotic hands with futuristically designed electronic skins [21] are designated to work long hours for pressing and touching foreheads of critically ill patients demonstrating ICU delirium so as to abort-or-shorten their cycles of agitations. These robotic hands with temperature-controlled electronic skins and pressure-controlled self-inflating cushions may have to decipher over time which temperature range and which pressure range may serve best for calming the agitated and delirious patients in ICUs. Only time may tell if the potential physiology behind the calming effect of hand on forehead may be much more beyond than just the light pressure on the forehead muscles or the light touch of human skin-on-skin because the human skin-to-skin touch may be actually allowing heat transfer from agitated/combative patients' warmer foreheads into the cooler calming hands on their foreheads. It may be further interesting to explore if healthcare workers’ hands on foreheads behave differently than caregivers’ (kin’s) hands on foreheads [18] in regarding to breaking the cycles of agitation and combativeness, considering that there may be clinical instances when kin may be there to help with their hands on patients’ foreheads (a) during emergence agitation in pediatric patients recovering in post-anesthesia care units or (b) while acting as support persons for patients during their cesarean sections under awake regional anesthesia or (c) while acting as caregivers during critically ill patients’ stay in ICUs.

 

Summarily, instead of asking whether the benefits of skin-to-skin contact are lost once humans outgrow their infancy, it is important to recognize that, as time passes by, the knowledge of these benefits may be getting lost instead of the benefits themselves getting lost. Therefore, there may not be a better way than the calming caring cooler hands pressed on the foreheads of agitated/combative perioperative and critically ill patients to scientifically explore the calming and may be the healing power of human touch.

References


  1. Phillips R. The Sacred Hour: Uninterrupted Skin-to-Skin Contact Immediately After Birth. Newborn Infant Nurs Rev 2013;13: 67-72. https://doi.org/10.1053/j.nainr.2013.04.001 Last updated on June 06, 2013. Last accessed on February 04, 2019.
  2. Korb A: Psychology Today: Sussex Publishers, LLC. Calm your face, calm your mind: A quick tip for improving tranquility. https://www.psychologytoday.com/us/blog/prefrontal-nudity/201208/calm-your-face-calm-your-mind Last updated on August 21, 2012. Last accessed on February 04, 2019.
  3. Das PR: ScoopWhoop Media. You won’t believe what pressing your forehead for 45 seconds a day does to your body. https://www.scoopwhoop. com/what-happens-if-you-press-forehead-45-secs Last updated on April 29, 2016. Last accessed on February 04, 2019.
  4. Levine P: The Art of Healing Trauma. Peter Levine’s Self Holding Exercises for sufferers of PTSD – Part 2. http://www.new-synapse.com/aps/wordpress/?p=2 34 Last updated on September 29, 2013. Last accessed on February 04, 2019.
  5. Brian Esty. Emotional Stress Release. http://www.brianesty.com/ bodywork/2011/03/emotional-stress-release/ Last updated on March 25, 2011. Last accessed on February 04, 2019.
  6. Murphy MLM, Janicki-Deverts D, Cohen S. Receiving a hug is associated with the attenuation of negative mood that occurs on days with interpersonal conflict. PLoS One 2018;13:e0203522.https://doi.org/10.1371/journal.pone.0203522 Last updated on October 03, 2018. Last accessed on February 04, 2019.
  7. Mueller G, Palli C, Schumacher P. The effect of Therapeutic Touch on Back Pain in Adults on a Neurological Unit: An Experimental Pilot Study. Pain Manag Nurs 2018;pii: S1524-9042(17)30510-6. https://doi.org/10.1016/j.pmn.2018.09.002 Last updated on November 10, 2018. Last accessed on February 04, 2019.
  8. Tabatabaee A, Tafreshi MZ, Rassouli M, Aledavood SA, AlaviMajd H, Farahmand SK. Effect of Therapeutic Touch in Patients with Cancer: a Literature Review. Med Arch 2016;70:142-7. https://doi.org/10.5455/medarh.2016.70.142-147 Last updated in April 2016. Last accessed on February 04, 2019.
  9. Senderovich H, Ip ML, Berall A, et al. Therapeutic Touch(®) in a geriatric Palliative Care Unit - A retrospective review. Complement Ther Clin Pract 2016;24:134-8. https://doi.org/10.1016/j.ctcp.2016.06.002 Last updated on June 21, 2016. Last accessed on February 04, 2019.
  10. Vanaki Z, Matourypour P, Gholami R, Zare Z, Mehrzad V, Dehghan M. Therapeutic touch for nausea in breast cancer patients receiving chemotherapy: Composing a treatment. Complement Ther Clin Pract 2016;22:64-8. https://doi.org/10.1016/j.ctcp.2015.12.004 Last updated on December 11, 2015. Last accessed on February 04, 2019.
  11. Kumarappah A, Senderovich H. Therapeutic Touch in the Management of Responsive Behavior in Patients With Dementia. Adv Mind Body Med 2016;30:8-13. https://www.ncbi.nlm.nih.gov/pubmed/27925607 Last updated in Fall 2016. Last accessed on February 04, 2019.
  12. Woods DL, Beck C, Sinha K. The effect of therapeutic touch on behavioral symptoms and cortisol in persons with dementia. Forsch Komplementmed 2009;16:181-9. https://doi.org/10.1159/000220479 Last updated on June 10, 2009. Last accessed on February 04, 2019.
  13. Robinson J, Biley FC, Dolk H. Therapeutic touch for anxiety disorders. Cochrane Database Syst Rev 2007;(3):CD006240. https://doi.org/10.1002/14651858.CD006240.pub2 Last updated on July 18, 2007. Last accessed on February 04, 2019.
  14. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002;166:1338-44. https://doi.org/10.1164/rccm.2107138 Last updated November 15, 2002. Last accessed on February 04, 2019.
  15. Esquirol Y, Ferrieres J, Marquie JC, et al. Forehead wrinkles and risk of all-cause and cardiovascular mortality over 20- year follow-up in working population: VISAT study. Eur Heart J 2018;39(Suppl):ehy565.P1548. https://doi.org/10.1093/eurheartj/ehy565.P1548 Last updated on August 01, 2018. Last accessed on February 04, 2019.
  16. Esquirol Y, Ferrieres J, Marquie JC, et al. Wrinkles and risk of death (total and cardiovascular mortality) in a middle-aged working population. Archives of Cardiovascular Diseases Supplements 2018;10:125-6. https://doi.org/10.1016/j.acvdsp.2017.11.163 Last updated on January 18, 2018. Last accessed on February 04, 2019.
  17. ScienceDaily: European Society of Cardiology. Deep forehead wrinkles may signal a higher risk for cardiovascular mortality. www.sciencedaily.com/releases/2 018/08/180826120738.htm Last updated on August 26, 2018. Last accessed on February 04, 2019.
  18. Suvilehto JT, Glerean E, Dunbar RI, Hari R, Nummenmaa L. Topography of social touching depends on emotional bonds between humans. Proc Natl Acad Sci U S A 2015;112:13811-6. https://doi.org/10.1073/pnas.1519231112 Last updated on November 10, 2015. Last accessed on February 04, 2019.
  19. FSMB: Federation of State Medical Boards. Addressing sexual boundaries: Guidelines for State Medical Boards: Adopted as policy by the House of Delegates of the Federation of State Medical Boards. https://www.fsm b.org/siteassets/advocacy/policies/grpol_sexual-boundaries.pdf Last updated in May 2006. Last accessed on February 04, 2019.
  20. Sibert KS: aPennedPoint. Touch your patient. Don’t wear gloves. http://apennedpoint.com/touch-yo ur-patient-dont-wear-gloves/ Last updated on August 19, 2013. Last accessed on February 04, 2019.
  21. Lee BY: Forbes Media LLC. Scientists make electronic skin that can sense touch and temperature and heal itself. https://www.forbes.com/sites/brucelee/2018/02/11/electronic-s kin-that-can-sense-touch-and-temperature-and-heal-itself/#4e676783106e Last updated on February 11, 2018. Last accessed on February 04, 2019.

Table 1


Table 1: Envisaged Distribution of 540 Patients into Eighteen Groups

 

10-minute Intervention With Non-Gloved Hand (Pressure plus Touch)

10-minute Intervention With Gloved Hand (Pressure Only)

10-minute Intervention With Non-Pressing Non-Touching Hand (Control)

Perioperative Aura For Seizure

30 patients

30 patients

30 patients

Perioperative Aura For Migraine

30 patients

30 patients

30 patients

Preoperative Severe Anxiety or Panic Attack

30 patients

30 patients

30 patients

Intraoperative Anxiety In Post-Regional Anesthesia Awake Cesarean Section Patients

30 Females only

30 Females only

30 Females only

Emergence Agitation

30 Minors only

30 Minors only

30 Minors only

Intensive Care Unit (ICU) Delirium

30 Adults only

30 Adults only

30 Adults only

 

Figure 1


Figure 1: Schematic Diagram Showing Hand on Forehead

http://www.webmedcentral.com/images/g.jpg

Source(s) of Funding


None

Competing Interests


None

Reviews
0 reviews posted so far

Comments
0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.

 

Author Comments
0 comments posted so far

 

What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
Where
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)