On the effects of tactile touch in Parkinson's disease patients

Abstract: Background: Tactile Touch as a treatment modality is, in broad terms, scientifically unexplored. Patients use Complementary and Alternative Medicine (CAM) forms of treatment outside the area of pharmaceuticals to a great extent, particularly patients suffering from chronic diseases. Delineating and evaluating patients’ own experiences of alleviation using different treatment forms are important tasks for modern health services. The search for humoral substrates that reflect bodily experiences of stress is an area that is attracting scientific curiosity. Diseases affecting the brain appear to be thoroughly investigated using modern imaging and laboratory techniques, but uncertainty remains concerning how degenerative processes affect hormonal secretion patterns mediated by glands located in or near the central nervous system. An elevated cortisol concentration is commonly used as a biomarker of stress. This hormone is secreted and is measurable in saliva, and there is much evidence concerning its usefulness as a non invasive test of the Hypothalamic-Pituitary-Axis (HPA) function, of which it is a part. Aims: Much knowledge is lacking with respect to the effects of complementary treatment forms on non motor symptoms in Parkinson´s Disease (PD). Based on patients’ reports, we know that symptoms such as chronic pain, disruption of sleep and a negative impact on mood affect Health Related Quality of Life (HRQoL). This thesis aims to describe, compare and evaluate short- and long-term effects of two different forms of complementary treatments, Tactile Touch (TT) and Rest To Music (RTM) in PD patients with chronic pain. Chronic pain is defined as the occurrence of pain related to PD for three days or more per week during at least three months prior to inclusion in the study. Outcome measures are the impact of TT and RTM on non motor symptoms such as subjective pain experiences and disturbed sleeping pattern, as well as the effects of interventions on HRQoL. Other aims are to describe the HPA-axis function in PD with and without longstanding pain and to study the effects of interventions on salivary cortisol concentrations as a surrogate marker for stress. Methods: Forty-five patients with stable and well defined PD for more than two years and with chronic pain during at least three months were recruited from routine health care visits at sites in Southern Sweden. They were blindly randomized to TT (n=29) or RTM (n=16). Salivary cortisol was sampled in a cotton swab four times during 24 hours (at 8am, 1pm, 8pm and 8am the next morning) at five occasions during the 34-week-long study. In addition, samples were taken immediately before, immediately after, and 30´after the end of the interventions at two occasions, at the first and at the eighth occasion. The cortisol concentrations were analyzed at the same time and at the same laboratory with a well established radioimmunological technique (Cortisol RIA I125). Visual Analogue Scales (VAS), Questionnaires for pain evaluation (Patient Evaluation Analysis, PEA), the Parkinson Disease Sleep Scale (PDSS), and the SF-36 (Swe.ver.1) for evaluation of HRQoL were repeatedly used during the intervention and follow-up periods. To measure severity of PD, the Unified Parkinson Disease Rating Scale I – IV, (UPDRS I-IV) and the Hoehn&Yahr (H&Y) scales were used, and to follow participants’ medications, drug lists were completed at several occasions during the study. Results: The main findings of the study are: 1. The diurnal pattern of cortisol secretion indicates a normal HPA-axis function in PD with and without chronic PD-related pain. 2. Significantly elevated morning cortisol concentrations, compared to those in a healthy reference group from the same area matched by age and gender, are detected. 3. No effects on diurnal salivary cortisol concentrations are seen that are due to the severity of PD measured by the Unified Parkinson Disease Rating Scale (UPDRS I-IV). 4. Significantly decreased salivary cortisol concentrations are found after intervention with TT and to a lesser extent after RTM, no significant differences between groups. 5. PD-related pain precedes the diagnosis of PD in one third of the participants and in half of the patients it is present during all their waking hours. 6. Polypharmacy is common; One quarter of all participants are prescribed analgesics of which paracetamol is the most common. Only 1/3 report pain relief with analgesics. Almost all (9/10), use medication for anxiety/insomnia and one of five use antidepressants. 7. Different pain parameters are positively affected in the short term follow up in TT and RTM. A significant decrease in pain experience (VAS) is registered in the TT-group but not in the RTM-group at week 3. In total there was a significant decrease in pain measured by the VAS scale in both TT and RTM from screening to the last follow-up, at week 34. 8. Sleep, measured by the Parkinson Disease Sleep Scale (PDSS) improves significantly within the TT group after the initial treatments; differences between groups do not reach significance at the 0.05 level. 9. HRQoL, compared to a Swedish healthy reference population ( SF-36,Swe ver.) improves in both groups but normal values of HRQoL are only achieved in the short-term follow-up in the TT group. Discussion: CAM treatments with TT and RTM have positive effects in several respects, especially in the short-term follow-up. It is more difficult to find significant differences between two groups when the positive “within group” effects are substantial in many areas. Absolute effects are replaced by relative effects, as the control group is active. There is a lack of longstanding effects. Very few published CAM studies in general, and especially in PD, are performed with a follow-up time as long as in the Parkitouch study. Consideration of more treatment arms, including "no treatment at all," and the use of recurrent brief treatment periods to facilitate the demonstrated short-term effects should be taken into account in future studies. Conclusions: The HPA-axis function in PD with and without chronic pain seems to be intact. Increased morning salivary cortisol is shown. PD with chronic PD-related pain has negative effects on HRQoL. Benefits from both treatment forms with TT and RTM are shown and in different respects concerning pain, sleep and HRQoL. The positive short term effects in both groups are not significantly better in TT compared to RTM. Long-term effects are sparse.