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Touch: An integrative review of a somatosensory approach to the treatment of adults with symptoms of post-traumatic stress disorder

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Introduction post-traumatic stress disorder (PTSD) is a complex experience which can adversely affect a person's health and engagement in daily life. Some evidence-based treatments for PTSD, including pharmacological and psychological interventions, reduce the severity of some of the associated symptoms, although they have shown limited efficacy. Somatosensory approaches can be used to assist a person to regulate their autonomic nervous system. This review identifies touch-based interventions in the treatment of PTSD and examines the role of touch with this population. Methods An integrative literature review was conducted to examine touch-based interventions which addressed the symptoms of PTSD in adults. Quantitative, qualitative and conceptual data were identified on eight databases, findings were appraised and synthesised using thematic analysis strategies, the Mixed Methods Appraisal Tool (MMAT) and the Critical Appraisal Skill Program (CASP). Results A total of 39 articles were included, describing eleven different touch-based interventions. Three key themes were identified: (i) catalogue of touch-based interventions being utilised in the treatment of PTSD; (ii) proposed mechanisms explaining the effects of touch-based interventions with PTSD; (iii) touch-based interventions which may reduce the symptoms of PTSD. Conclusion Touch can play an important role in emotional regulation and the reduction of symptoms of PTSD. With a growing evidence base for the efficacy of these interventions, one intervention, Emotional Freedom Technique, prevailed. Methodological diversity and a paucity of conceptual frameworks mean that findings should be interpreted with caution. Developing a theoretical understanding for the underlying mechanisms of why touch-based treatments may be effective is required.
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European Journal of Integrative Medicine 54 (2022) 102168
Available online 23 July 2022
1876-3820/© 2022 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Systematic review
Touch: An integrative review of a somatosensory approach to the treatment
of adults with symptoms of post-traumatic stress disorder
Suzie McGreevy
*
, Pauline Boland
Department of Clinical Therapies, Faculty of Education and Health Sciences, University of Limerick, Limerick, V94 T9PX Ireland
ARTICLE INFO
Keywords:
Touch
Posttraumatic stress disorder
Somatosensensory
Integrative review
ABSTRACT
Introduction: Post-traumatic stress disorder (PTSD) is a complex experience which can adversely affect a persons
health and engagement in daily life. Some evidence-based treatments for PTSD, including pharmacological and
psychological interventions, reduce the severity of some of the associated symptoms, although they have shown
limited efcacy. Somatosensory approaches can be used to assist a person to regulate their autonomic nervous
system. This review identies touch-based interventions in the treatment of PTSD and examines the role of touch
with this population.
Methods: An integrative literature review was conducted to examine touch-based interventions which addressed
the symptoms of PTSD in adults. Quantitative, qualitative and conceptual data were identied from eight da-
tabases, ndings were appraised and synthesised using thematic analysis strategies, the Mixed Methods Appraisal
Tool (MMAT) and the Critical Appraisal Skill Program (CASP).
Results: A total of 39 articles were included, describing eleven different touch-based interventions. Three key
themes were identied: (i) catalogue of touch-based interventions being utilised in the treatment of PTSD; (ii)
proposed mechanisms explaining the effects of touch-based interventions with PTSD; (iii) touch-based in-
terventions which may reduce the symptoms of PTSD.
Conclusion: Touch can play an important role in emotional regulation and the reduction of symptoms of PTSD.
With a growing evidence base for the efcacy of these interventions, one intervention, Emotional Freedom
Technique, prevailed. Methodological diversity and a paucity of conceptual frameworks mean that ndings
should be interpreted with caution. Developing a theoretical understanding for the underlying mechanisms of
why touch-based treatments may be effective is required.
1. Introduction
Post-traumatic stress disorder (PTSD) has been described as the
complex cognitive, emotional, somatic and behavioural response [1]
which can occur after exposure to a traumatic event [2]. A traumatic
event can leave an individual feeling overwhelmed, having experienced
intense fear and helplessness [3] and may develop into PTSD in some
individuals. Events which can trigger PTSD and its associated symptoms,
may include violent crime, war, an accident or medical procedure, or
experiences of trauma, such as sexual, physical and emotional abuse and
neglect in childhood, which are often referred to as complex trauma [4].
PTSD prevalence can range from 0.5-9% of the general adult popu-
lation worldwide [2]. Traumas involving interpersonal violence showed
the highest risk for developing PTSD, including rape (13%), other sexual
assault (15%), and the unexpected death of a loved one (11.6%) [5].
Prior trauma history predicts both future trauma exposure and future
PTSD risk [5]. A formal diagnosis of PTSD requires the person to be
6-months symptomatic post-traumatic event, with this assessment being
undertaken by a registered healthcare provider [6]. Table 1, outlines the
symptoms and current criteria for PTSD and complex trauma (CPTSD)
Abbreviations: ANS, Autonomic Nervous System; BOT, Body Oriented Therapy (later renamed MABT); CAM, Complementary and Alternative Medicine; CMT,
Complex Manual Therapy; CSA, Childhood Sexual Abuse; CPTSD, Complex Post-traumatic Stress Disorder; CT, Tactile Afferent Nerve Fibres; EFT, Emotional Freedom
Technique; HPAT, Hypothalamus Pituitary Adrenal Touch; RMB, Rosen Method Bodywork; LTMT, Light Touch Manual Therapies; MABT, Mindful Awareness in Body
Oriented Therapy; MT, Massage Therapy; PvT, Polyvagal Theory; SES, Social Engagement System; SUD, Substance Use Disorder; UCST, Upledger CranioSacral
Therapy; ZB, Zero Balancing.
* Corresponding author.
E-mail addresses: suziemcgreevy@hotmail.com (S. McGreevy), pauline.boland@ul.ie (P. Boland).
Contents lists available at ScienceDirect
European Journal of Integrative Medicine
journal homepage: www.sciencedirect.com/journal/european-journal-of-integrative-medicine
https://doi.org/10.1016/j.eujim.2022.102168
Received 7 December 2021; Received in revised form 20 July 2022; Accepted 22 July 2022
European Journal of Integrative Medicine 54 (2022) 102168
2
according to the Diagnostic and Statistical Manual of Disorders (DSM-V)
[6] and the International Classication of Diseases (ICD-11) [7].
Although often referred to as a mental disorder [6], PTSD and its
associated symptoms were originally and directly linked with war
experience [8] and described as a ‘physio-neurosis; the persons body
was observed to continue reacting to the trauma experienced [9]. There
is growing neuro-biological evidence that the fragmentary way in which
trauma memory is stored in the body, permits such memories and so-
matic symptoms to persist long after the trauma has occurred [10,11,
12]. Indeed, even after signicant progress has been made utilising the
current evidence-based treatments of PTSD, a range of issues and
symptoms including chronic pain, diminished immune function, auto-
immune disorder, cardiac problems, mental and emotional health issues
remain linked to living with PTSD [13,14,15]. Attempts to cope with
these symptoms and the intense physical sensations in the body such as
hyperarousal (Table 1a), may take the form of substance misuse,
addiction or dissociation [3,10,16] and can have far reaching effects on
an individuals engagement in daily living activities, social and intimate
relationships [13,16].
Interpersonal touch, or the experience of being touched by another,
appears to have a pivotal role in mammalian development and in
helping one cope with anxiety, stress and depression [17,18], pain and
physical illness [17,19,20] and the regulation of intense emotions; with
researchers [21,22] demonstrating how interpersonal touch can
diminish activity in brain regions implicated in emotional regulation.
Conversely, an increase in reactivity to emotional stimuli, with height-
ened autonomic arousal and associated poor emotional regulation in
touch deprived individuals has also been observed [23].
Although we know that touch is part of the everyday routine for
healthcare service users [24], with some professions such as physio-
therapy for example, performing a large part of their work through
touch-based modalities [25], it is unclear to what extent touch is being
used to explicitly treat persons with PTSD and, similarly, theory
underpinning touch interventions is multifarious [17]. It has been sup-
posed that moderate pressure massage increases activity in the para-
sympathetic nervous system, inducing the relaxation response, by
activating pressure receptors in the skin [17,26]. It has also been pro-
posed that the hormone oxytocin, released during touch, is what induces
the parasympathetic relaxation [27], and suppresses cortisol activity,
reducing reactivity to perceived stress [28], though this is contested
[29].
Finally, a recent possible explanation is that ‘pleasant-touch
responsive nerves, the c-tactile afferents (CT), account for the positive
effects of touch. Stimulation of the CTs in neuroimaging studies has been
shown to have an inuence on emotional regulation [30] and intero-
ceptive awareness [23,31,32]; the ability to perceive internal physio-
logical sensations such as hunger, thirst. Touch that activates these
bres is processed in the brain, mainly in the insula, which is connected
to several other brain structures involved in the processing of tactile
information [22].
A key brain structure of attention and vigilance to threat/danger, the
amygdala, responds to the integration of interoceptive cues and external
environmental stimuli across all the sensory systems, and is connected to
the insula via multiple feedback loops [22,33]. Further implicated in the
ability to regulate emotions in persons with PTSD [34], the amygdala
shows a temporary disengagement to ‘discrete incoming stimuli in
non-human primates, engaging in grooming behaviours [22]. Although
their hypothesis is yet to be validated, Gothard and Fuglevand argue that
the positive context of this grooming experience may signal to the rest of
the brain ‘safetyin the social environment. Thus, enhancing the activity
of the parasympathetic branch of the ANS and promoting an overall
relaxation response [22].
Current treatment options for PTSD and its related symptoms include
cognitive behavioural therapy (CBT), eye movement desensitization and
reprocessing (EMDR), and pharmaceutical medication [35,36].
Although these interventions have been effective for some [36], residual
symptoms, side-effects and therapeutic efcacy remain problematic for
many [8,12,35,37]. For these reasons, continued efforts are required to
nd interventions to meet the complex needs of people with PTSD [8,15,
33]. Optimising a persons somatosensory functioning is what some
clinicians and researchers claim as an essential ingredient in the treat-
ment of PTSD and its associated symptoms [8,11,12,33], with this
perspective continuing to gain empirical support [17,37,38].
A review of the literature examining the role of touch-based in-
terventions as a somatosensory approach to the treatment of adults with
PTSD, CPTSD and associated symptoms is required. For the purposes of
this paper, the term PTSD will be used to denote both formally diag-
nosed PTSD and CPTSD and informal PTSD responses and the term
practitioner will be used to denote clinician, healthcare professional or
other care provider delivering a touch-based treatment. Touch will refer
to interpersonal touch unless otherwise described.
The objectives of this review are:
1 To identify touch-based interventions in the treatment of adults with
symptoms of PTSD.
2 To examine and summarise key concepts that explain the role of
touch as a somatosensory approach to the treatment of PTSD
symptoms in adults.
2. Methods
2.1. Study design
An integrative literature review approach was chosen to allow for the
inclusion of research from diverse contexts, which is particularly useful
when mapping the depth and breadth of an area of emerging practice
[39,40].
The stages of an integrative review which we followed are as out-
lined by Whittmore and Kna: clearly identifying the problem, purpose
Table 1
Summary of key PTSD symptoms as per the DSM V and complex PTSD as per the
ICD-11.
Intrusion including upsetting memories, nightmares;
Avoidance including thoughts, feelings, external reminders of the trauma;
Altered Cognitions or Mood including negative thoughts about oneself, negative
affect, blame, decreased interest in activities;
Impaired Arousal Levels or Reactivity including irritability, aggression, difculty
sleeping, hypervigilance;
Functional, social or occupational impairment;
Dissociative specication such as depersonalisation, the experience of being an
outside observer or feeling detached from oneself, and derealisation, an experience
of unreality; a full diagnosis requires 6-months after traumatic event experienced
[6].
‘Self Organisationissues including severe and pervasive problems in emotional
regulation, persistent beliefs about oneself as diminished, or worthless,
accompanied by feelings of shame, guilt or failure related to the traumatic event and
persistent difculties in sustaining relationships and in feeling close to others
(ICD-11) [7].
TABLE 1a: Denitions of terms used in describing PTSD symptoms
Somatosensation refers to all aspects of touch and proprioception that contribute to a
persons awareness of his or her body parts and the direct interface of these with
objects and the environment [11,13,38].
Interoception is the sensing of the internal state of ones body and is distinct from the
processing of sensory information concerning external (non-self) stimuli (e.g. vision,
hearing, smell) [49,30].
Emotional Regulation is the awareness of emotional states which is associated with
awareness of bodily signals (interoceptive awareness) [10,49].
Affect is the outward expression of feelings and emotion. Affect regulation includes
emotion- and mood-regulation and refers to the modulation of feeling states,
including the valence and the energy level of those states [1].
Dissociation, a process that keeps different mental states and body experiences
disconnected from one another [12,60].
Hypervigilance is the increased state of vigilance and awareness of ones environment
and may be caused by fear and an attempt to avoid danger [10,38].
Arousal refers to the physiological state of readiness or general state of excitation of
ones nervous system [4].
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
3
or phenomenon, conducting a thorough systematic literature search,
evaluating, analysing and presenting the synthesised ndings and lim-
itations of the studies selected, with conclusions [39].
2.2. Search strategy
A literature search was conducted in Medline in Ebsco, EMBASE and
AMED, PsychINFO, CINAHL, Scopus, and the Cochrane Register of
Controlled Trials (CENTRAL). These databases were selected as they
cover the majority of peer-reviewed allied health literature. In the in-
terests of comprehensiveness, an additional search on the general search
engine Google, sought to identify any studies that met the inclusion
criteria, which were not reected in the key database search. Reference
lists of included papers were reviewed and forward citations searched
for the most recent possible studies. Boolean operators were used and
the initial list of terms was added to iteratively as new keywords were
identied (See Table 2 for list of key words).
2.3. Type of intervention
The primary intervention of interest was touch as treatment for the
symptoms of PTSD with an adult population. This study does not focus
on specic professions which include touch in their day-to-day delivery
of care. Rather, we are interested in interventions i.e. treatment tech-
niques that are touch-based.
Touch-based interventions are diverse and for the purposes of this
review could be dened as any manual, hands-on application delivered
interpersonally by a touch practitioner or caregiver or a self-applied
touch practice (touching the self, such as self-massage or acupressure).
Touch-based interventions which were administered using needles,
brushes or other non-human appliances were excluded, given the focus
of contact is on the practitioners hand touching the recipients body
rather than via any other medium.
2.4. Study selection and type of intervention
Articles published between January 1995 and May 2021 were
considered for inclusion, as this period largely maps the developing eld
of traumatic stress study. The search did not include books, book
chapters, book reviews and only peer-reviewed English language articles
were considered. Titles and/or abstracts of studies were retrieved and
screened against the inclusion criteria which were:
Empirical studies (all designs), qualitative studies, theoretical liter-
ature, reports, reviews and expert opinions on a specic touch-based
intervention with adults with symptoms of PTSD or CPTSD or have
included primary or secondary outcome measures for PTSD;
Interventions including either interpersonal touch and self-applied
touch interventions as described above, review papers and expert
opinion reporting on the role of touch and/or the mechanism of
touch as a somatosensory intervention;
Populations focused on adults aged 18 years or older, who experi-
enced either
Single event trauma (e.g. road trafc accident, surgical/medical
procedure) and have PTSD symptoms which may or may not be
determined by the application of the DSM-VI or V criteria for
trauma exposure (6) and/or
Complex interpersonal trauma in childhood, also known as
developmental trauma or multi-event trauma, also known as
complex PTSD or CPTSD. This included adults exposed to child-
hood physical and/or sexual abuse, domestic violence, neglect,
forcibly displaced persons (refugees, asylum seekers), torture sur-
vivors, recruitment into armed conict as a child, on-going armed
conict and combat, and relocation through human trafcking.
A distinction was drawn between PTSD and CPTSD. However, both
terms were included as it was not until most recent that this distinction
was made diagnostically [6,7] and the majority of the research in this
study was carried out before this time.
Exclusion criteria consisted of studies where: 1) Participants had
secondary or vicarious trauma, professional burnout, compassion fa-
tigue, or work stress, as the focus was on direct exposure to personal
trauma and/or traumatic events with reference to PTSD and 2) Children
and adolescents (under 18 years), due to their ongoing psychological
and neurophysiological developmental growth process. These exclusion
criteria were used to ensure focus of the review on people aged 18 years
or more with a history of PTSD or CPTSD.
The full text of potentially eligible studies was assessed. All articles
were saved in an EndNote library. Any article where the touch compo-
nent of an intervention was not easily extractable from the data, was not
included in this study.
2.5. Data extraction and synthesis
An extraction table detailed the included articles regarding study
quality and key research characteristics including, author(s) and coun-
try of origin, study participants, age, details on the touch-based inter-
vention and any control conditions, study methodology and outcome
measures used, ndings/outcomes (including the mean +/- SD for
quantitative data and core themes for qualitative data), and limitations/
conclusions. See Table 3
2.6. Quality assessment
Studied which met the inclusion criteria were critically appraised
through the online 2018 version of the Mixed Methods Appraisal Tool,
(MMAT) [42,43]. The efciency of this tool has been validated for the
appraisal of both qualitative and quantitative data [43,44] and reli-
ability of the tool is rated as moderate [45]. The critical appraisal skill
program [46] on line version for systematic review was utilised to
appraise any systematic review papers retrieved, as the MMAT is not
applicable for this methodology. Two evaluation tools are often required
in an integrative review, due to the diversity of primary data under
critical appraisal [39].
The rst author (SMG) screened all articles for inclusion and
completed quality appraisal in regular discussion with the second author
(PB). The second author completed a quality cross appraisal on 4 articles
and results were compared to promote consistency in the appraisal
process. Although argued a non-essential component to the integrative
review process [39], with no consensus on how best to implement [40],
the quality appraisal performed in this study supported the analysis and
synthesis of the data in terms of design, sample and statistical ndings of
the papers reviewed.
2.7. Data analysis
Thematic synthesis was performed involving a 6-phase approach
[46] which included the coding of text, and the development of
descriptive themes (including touch-based interventions identied in
Table 2
Literature search terms including Boolean operators used.
Keywords relating to trauma exposure:
trauma* OR post traumaticOR posttraumatic OR post-traumatic OR PTSD OR
"psychological trauma" OR emotional traumaOR shock OR traumatic stressOR
developmental traumaOR complex traumaOR childhood abuseOR adverse
childhood experienceAND
Keywords relating to touch-based interventions:
Touch* OR tactile OR touch therapyOR touch-based intervention OR touch
interventionOR affective touch OR somatosensory OR body workOR body
therapyOR massage OR manual therapyOR craniosacral therapyOR healing
touchOR therapeutic touch OR trauma touch therapyOR TTT OR tapping
OR emotional freedom techniqueOR EFT OR acupressure OR reiki
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
4
Table 3a
Summary of quantitative and qualitative studies reviewed.
Author and
Country
Aim of Study and
Participants
Touch-based Intervention Study design, outcome
measures and statistical analysis
Findings Conclusions/Limitations
Bernard,
2016
USA [74]
To describe Rosen Method
Bodywork (RMB) with
trauma survivors;
practitioner and survivor
perspectives. N=8 female.
RMB Qualitative Study.
1-1 interviews & projective
drawing using interpretive
phenomenological analysis
(IPA) & focus group with
practitioners.
Core Themes included: RMB touch is a valid tool in
trauma treatment in
conjunction with
psychotherapy. It offers a bridge
for body/mind split of
traditional trauma treatment.
1 Relational somatic presence
2 Somatic resonance and
creating safety
3 Interoceptive awareness &
embodiment
4 Nervous system regulation
5 Relational and sexual
healing
6 Integration of soma and
psyche
7 Meaning making and
spiritual insights
8 Transcending trauma
9 Practitioner attitude/skills
No participant or practitioner
data available.
Boath et al.,
2014
UK [54]
To establish feasibility &
effectiveness of Matrix
Reimprinting (MR) for
treatment of PTSD in civilian
survivors of war in Bosnia.
N=18, 10 female, 8 male.
EFT & MR including
heart-focused breathing
techniques; home EFT
practice.
MR includes ‘inner child
focus.
Mixed methods pilot study.
Measures at baseline, post-EFT,
4-week f/u.
PCL-C; Participant
Questionnaire.
Qualitative data analysed using
a Framework Approach.
Shapiro-Wilk test; t-test
(p<.05).
Mean score baseline PCL
82.71 (SD=18.72), post-test
53.77 (SD=27.20),
statistically sig. result
(p=.009); 4-week f/u score
53.38 (SD=24.58),
statistically sig. (p=.005).
No change post-test scores &
f/u gains maintained. N=4
did not complete study.
Themes identied:
Signicant improvements in the
reduction of PTSD symptoms.
Qualitative data show EFT/MR
is an effective & acceptable
intervention for survivors of the
Bosnian war.
More longitudinal data
required, larger sample &
controls.
1 Physical and psychological
changes
2 The strength to move on
and self-care
3 Rapport with practitioners
4 Recommending the
intervention to others
Church 2010
USA [79]
To test effectiveness of EFT
for veterans with combat
trauma.
N=11, 9 veterans & 2 family
members (female), 4 male, 7
female.
Range 26 61 years.
EFT (The EFT Manual) 5-
day intensive treatment
between 2-3 sessions
daily 1-hour duration.
Included DVD take home
practice.
Quantitative, time-series,
within subjects repeated
measures design.
Measures at baseline (30 days
before intervention), pre-test,
post-test, 30-days, 90-days &
1year f/u.
SA-45, PCL-M
Seven-day sleep diary.
Blind Analysis.
t-test, paired t-test, GLM,
RMAV, Multivariate Wilks
Lambada, Post hoc Tukey tests.
PCL scores pre-test in clinical
range for PTSD (mean 62.3,
SD±15.13).
Statistically sig. improvement
SA-45, PCL-M scores post-test
(p<.01).
Gains maintained SA-45 f/u,
except for ‘somatisation
scores (p<.001).
Scores remained subclinical
& maintained at the 90-day f/
u (mean 32.6, SD±16.7) &
1year f/u (mean 33.43, SD±
16.6).
Improvement in sleep (F
(3,4) =26.4, p<.83).
EFT can reduce symptoms of
PTSD & severity of
psychological distress. Gains
maintained over time. No
control group; small sample
size. Inclusion/exclusion
criteria not claried.
Church 2014
USA [47]
To examine pain, anxiety,
depression following EFT
treatment for PTSD in
Church et al., 2013, an RCT.
EFT RCT repeated measures design
with waitlist control see Church
et al., 2013.
Data available for n=49.
Data from EFT intervention
combined for nal analysis.
See Church et al., 2013
No change waitlist group
over time on any measure.
Sig. changes EFT group as per
SA-45 depression, anxiety
(p<.0001), perceived pain
over time. Gains maintained
3 & 6-month f/u (p<.0001).
EFT may be used to address a
complex of co-morbid
psychological & physiological
conditions; PTSD symptoms
decrease, mental health
improves & pain levels drop.
Gains maintained f/u. EFT may
be cost-effective treatment for
veteran mental health disorders.
Church
et al.,
2018
USA [76]
To assess the feasibility of
measuring changes in gene
expression associated PTSD
using EFT.
N=16 war veterans;
11 male, 5 female
Mean 59.5years.
10 one-hour sessions over
10-weeks EFT.
RCT pilot, waitlist control.
Messenger RNA levels for 93
genes related to PTSD;
BPI; ISS; SA-45; SF-12; PCL-M;
Hospital Anxiety and
Depression Scale; RPQ.
t-test (p<.15);
ANOVA; Log transformed ratios
(gene expression); Lilliefors test;
2 sample F-test (mean 37.06).
Sig. reduction PTSD
symptoms EFT group (53%,
p<.00001) as per PCL-M.
Gains maintained on f/u 10
weeks, 3, 6-months.
Statistically signicant
difference
α
=.05 in all
parameters except for SF-12-
PCS (p=0.411) & RPQ-3
(p=.489).
Signicant differential
expression of 6 genes (p<.05)
pre-& post test.
Candidate gene expression
correlate with successful PTSD
treatment. EFT is an effective
treatment for PTSD; therapeutic
gains maintained at f/u. More
research into the physiological
mechanisms, epigenetic effects
of EFT and the
phenomenological experiences
of participants required. Small
sample size; high usage of
analgesic medication in
participants.
(continued on next page)
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
5
Table 3a (continued )
Author and
Country
Aim of Study and
Participants
Touch-based Intervention Study design, outcome
measures and statistical analysis
Findings Conclusions/Limitations
Church
et al.,
2017
USA & UK
[64]
To develop clinical best
practice guidelines for EFT
in treating PTSD.
N =448 EFT practitioners
N =2 male combat veterans
with PTSD.
EFT based on The EFT
Manual.
Quantitative descriptive; cross-
sectional survey study, case
studies, questionnaire
37.7% of EFT practitioners
mental health professionals;
31.6% CAM practitioners.
63% of EFT practitioners
reported complex PTSD can
be remediated in <10 EFT
sessions.
65% stated >60% of PTSD
clients are fully rehabilitated.
89% stated <10% of clients
make little or no progress.
A stepped care model based on
the NICE guidelines with 5 EFT
session for subclinical PTSD &
10 sessions for clinical PTSD in
addition to group therapy
recommended; online self-help
resources & ongoing social
support & treatment with EFT.
Referral of clients to appropriate
care if no response to EFT
treatment.
Church
et al.,
2013
USA [99]
To examine effect of EFT on
PTSD & psychological
distress in veterans receiving
mental health services.
N=59, veteransclinical
levels of PTSD (50 PCL-
M). 90% male, mean 52
years (age range 24-86
years).
‘peer to peercoaching,
6 one-hour EFT
concurrent with mental
health standard care.
EFT group n=30; waitlist
group n=29. Tx Fidelity
measures.
RCT repeated measures design,
waitlist control.
Measurements 6 time points,
pre-test 30 days, baseline, after
3 sessions, post-intervention, 3-
months and 6-months f/u.
SA-45, PCL-M, ISI.
t-tests, Chi-square analyses,
Bonferroni Correction, Linear
Mixed Effects Models.
EFT group sig. reduction in
psychological distress
(p<.0012), & PTSD symptom
levels (p<.0001) post-test.
Combined treatment results
for both groups include 86%
participants subclinical PTSD
after treatment ((p<.0001);
change maintained 6-month
f/u as per PCL-M, statistically
signicant main effect for
time (p<.0005). Complete
data available for n=49.
EFT applied by trained life
coaches led to sig. reductions in
PTSD symptoms. Brief EFT can
improve PTSD & co-occurring
conditions; gains maintained
over time. EFT is effective where
applied by life coaches with
basic levels of clinical training.
A 6-session protocol as adjunct
to standard mental health
treatment is recommended. No
demographics available for
participants or esearch
practitioners.
Church
et al.,
2009
USA &
Canada
[77]
To explore the effectiveness
of EFT.
N=7 combat veterans
3 female, 4 males.
6 sessions EFT delivered
by life coach & clinical
psychologist.
Home practice included.
Quantitative non-randomised;
repeated measures pilot study,
within-subjects time-series
design. Measures taken pre-test,
post-test, 90-day f/u.
PCL-M, SA-45, SCL-90.
t-tests, GLM, RMAV, Bonferroni
Correction at p<.16.
Statistically sig. reduction
post-test PCL score; not
maintained 90-day f/u. PCL
scores available for n=4;
mean clinical PTSD score pre-
test 66.
N=3 sub clinical PTSD score
(p<.016).
Symptom severity sig.
decreases (SA-45) 40%
(p<.001), anxiety 46%
(p<.001), depression 49%
(p<.001).
EFT is effective in reducing
PTSD symptoms &
psychological distress in
veterans. A 6-session protocol
may be an effective for this
group. Session duration not
clear. Limited demographics
available for practitioners. Not
generalizable due to small
sample size.
Church &
House,
2017
USA [58]
To elucidate relationship
between PTSD, depression
and anxiety.
N=81; 68 female, 13 male
Mean 54.3 years
Non-clinical sample.
EFT 5, 2-day workshops,
group treatment
‘Borrowing Benets.
Quantitative non-randomised;
repeated measures with waitlist
control.
PCL-C, SA-45, ISI, Pain VAS.
Mean, SD, ANOVA, Chi-Square
Analysis.
Statistically sig. time effects
found for all variables
(p<0.05);
Sig. reductions all measures
(p<0.03); maintained at 6-
month f/u (p<0.02);
moderate treatment effect for
PTSD (Cohens d=0.54).
N=49 completed f/u at 6-
months.
Important clinical relationship
established between PTSD and
other psychological conditions.
EFT is a simple, cost-effective,
evidence-based self-help
technique for complex co-
occurring symptoms. N=32, no
f/u data at 6-months. No
controls.
Davis et al.,
2016
USA [75]
To examine effects of mixed
light touch manual therapies
(LTMT) with active duty
soldiers with chronic PTSD
& self-reported injury to
head.
N=10 male active-duty
soldiers with PTSD & a self-
reported injury to the head
acquired at least 2 years
earlier.
range 27-45 yrs
LTMT including massage,
UCST.
2 one-hour sessions over
2 weeks, provided by
same practitioner.
Quantitative non-randomised
pilot study, pre/post-test single
cohort design. Measures taken
pre-test, 4 days post-test.
PROMIS, Neuro-QoL, PCL-M,
MYMOP2,
t-test, Wilcoxon signed rank
test, Cohens d.
Headache, anxiety sig.
reduced (p<.04), & pain
(p<.039). PTSD symptoms
not clinically or statistically
sig.
LTMT may be helpful in
reducing some of the symptoms
of PTSD including headache.
Further research required to
determine if LTMT is an
effective non-pharmacological
treatment for headache, anxiety
& PTSD. Small sample size; no
control group.
Dinter 2008
USA [78]
To describe the EFT process
with veterans with PTS.
N=4 veterans PTSD
Range 43-62 years
3 male,1 female.
‘EFT 4Vets training
program
Quantitative descriptive;
including opinion piece and 4
individual case reports.
PCL-M, SA-45.
Themes identied and topics
covered include:
Supporting veterans in their
healing from trauma is a deeply
personal, spiritual and
transformative process for both
the individual and the
practitioner. Opinion piece with
no clear case study presentation
formatting or research question.
Follow-up support groups with
EFT recommended.
1 An overview of EFT
2 Importance of self-care in
healing trauma
3 PTSD a humanitarian
catastrophe
4 Assessing & releasing PTSD
symptoms with EFT
5 PTSD, the soul &
forgiveness
6 Follow-up, continued
healing.
Edmunds
and
To report on hypnotic ego
strengthening & zero
ZB combined treatment
performed by a mental
2 case reports; descriptive. Both case reports had
multiple physical and mental
To meet the diverse somatic &
psychological needs of
(continued on next page)
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
6
Table 3a (continued )
Author and
Country
Aim of Study and
Participants
Touch-based Intervention Study design, outcome
measures and statistical analysis
Findings Conclusions/Limitations
Gafner
2003
USA [57]
balancing (ZB), a combined
treatment method for
refugee survivors of torture.
N=2, 1 female, 1 male
history of torture, PTSD.
health practitioner and a
physiotherapist in a
refugee clinic.
health issues; PTSD before
treatment. Life very difcult,
suicide attempts.
Improvements noted over
several months of treatment.
Resolution of physical
symptoms, improved mental
health, relationships, ability
to manage life following
treatment.
survivors, practitioners
combined ZB body with
hypnotic ego strengthening
therapy & TAU.
Integrating both therapies
address body, mind & energy of
person, which supports &
hastens recovery. No empirical
data available.
Geronilla
et al.,
2016
USA, UK,
Israel [98]
To replicate an earlier study
by Church et al., 2013.
58 combat veterans (score >
50 on the PCL-M) clinical
PTSD levels.
51 male, 7 female
Mean 50-51 years.
EFT, The EFT Manual, 6
sessions.
N=32, EFT group
N=26, TAU
43 completed treatments;
30 at 3-month f/u; 24 at
6-month f/u.
RCT waitlist/TAU control
Based on study by Church et al.,
2013.
PCL-M, SA-45, ISI, HHQ
t-tests, Bonferroni Correction,
Cohens Coefcient.
Wait list TAU and EFT groups
combined results for nal
analysis.
Mean pre-treatment PCL-M
score 66±7.4 no sig.
difference between groups.
EFT group sig. reduction in
PCL-M score from 65±8.1 to
34±10.3 (p<.001). No
change in TAU group.
Linear mixed effects
modelling combined post-
EFT PCL-M scores declined to
mean of 34
(-54%, p<.001). Gains
maintained at 3 & 6-month f/
u.
Sig. decline in anxiety,
depression, insomnia and
pain and PTSD. Large
treatment effect (Cohens d
=3.44).
Results replicate those obtained
in an earlier investigation
(Church et al., 2013). EFT is an
evidence-based practice; highly
effective at reducing symptom
severity in veterans with PTSD.
High attrition. No practitioner
demographics available.
Jain et al.,
2012
USA [70]
To determine if Healing
Touch (HT) & guided
imagery (GI) can reduce the
symptoms of PTSD in active-
duty military.
N=123, Range 20-48 years,
mean 27.5 years. 90% male
HT including GI.
N=68, HT/GI & TAU 6
sessions over 3-weeks.
N=55, TAU control
group, including CBT,
medication and
biofeedback training.
RCT repeated-measures design.
PCL-M, BDI-II, SF-36, C-MHI.
Bonferroni Correction, Cohens
d, RMANCOVA.
Sig. reduction PTSD
symptoms (P<.0005, Cohens
d =0.85), depression
(p<0.0005, Cohens d =
0.70), mental quality of life
(p=0.002, Cohens d =0.58),
cynicism (p=0.001, Cohens
d =0.49) for HT/GI vs TAU.
Participation in HT/GI resulted
in statistically sig. reduction in
PTSD & related symptoms in
combat veterans. Further
investigation of CAM treatment
for PTSD in military warranted.
An overall 20.25% attrition rate
with 12.2% attrition in the HT/
GI/TAU group compared to
28.3% in the TAU group.
Karatzias
et al.,
2011
UK [100]
To report on the rst
controlled comparison
between EFT & EMDR for
treatment of PTSD.
N=46, 26 female, 20 male.
Stable dose medication for 6
weeks.
EFT. N=23, EFT group,
mean of 3.8 sessions (The
EFT Manual & ‘minimovie
technique)
OR
N=23, mean of 3.7
sessions EMDR.
Fidelity measures in
place.
A controlled comparative RCT,
repeated measures design.
Measures baseline, after 8-week
wait period/pre-test, with 2
further blind assessments
conducted at post-test & 3-
month f/u.
CAPS, PCL-C, Hospital Anxiety
and Depression Scale,
Satisfaction with Life Scale.
t-tests, Chi-squared Analysis,
Mann-Whitney U-test, ANOVA.
Treatment effect sizes large
(d .80) both interventions
across measures & time (p
.001).
Pre- post-test CAPS total
score effect sizes d =1.1
EMDR & d =1.0 EFT group.
Pre- post-test PCL total scores
effect sizes
d =1.00 EMDR & d =1.1 EFT
group.
No statistically sig.
interaction effects found in
any outcome measure
indicating lack of superiority
of either group.
Similar treatment effect sizes
observed in both groups.
Considering the speculative
nature of EFT, a dismantling
study on the active ingredients
of EFT should be subject to
future research. A replication
study is recommended. High
attrition rate (N=23). No
absolute control groups.
Kim and Yu
2015
Republic
of Korea
[55]
To identify impact of
physiotherapy/ complex
manual therapy (CMT) as
part of an integrated
treatment for the
musculoskeletal system of
torture survivors.
N=30 male torture
survivors, chronic LBP.
Mean age 59.2 years study
group; 62.6 years control
group.
CMT including
myofascial release &
exercise.
N=15 CMT group
N=15 self-exercise
control group.
90 mins CMT, 3 times a
week for 8-weeks.
A quantitative randomised pre-
and post-test control group
design.
PDS-K, VAS for Pain, KODI,
Balance System-SD.
Paired t-test, t-test.
All outcome measures sig.
improvements post-test for
study group, no change
control group (p<.001).
CMT can contribute to
functional recovery, reducing
low back pain & PTSD
symptoms in torture survivors.
Can improve dynamic balance &
may support falls prevention in
aging torture survivor
populations in Korea.
Current healthcare resources
cannot meet needs for this
population. Small sample size;
No denition of torture; No
demographics for survivors or
practitioners; limited reporting
on results.
Minewiser
2017
USA [87]
To describe EFT process with
single case report.
N=1 male, veteran 27 years
old. 9 and half years in
service.
EFT
Refer to Geronilla et al.,
2016.
A mixed methods case study.
One of 58 veterans who took
part in the Geronilla et al., 2016
study.
PCL-M, ISI, SA-45, The Health
Continued use EFT 3 years
post study to support
emotional regulation.
Post-test mean PCL-M
score=40; mean group score
6 sessions of EFT reduced PTSD
scores to below clinical
threshold. EFT reduced
hyperarousal, supported
reframing of limiting self-
(continued on next page)
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
7
Table 3a (continued )
Author and
Country
Aim of Study and
Participants
Touch-based Intervention Study design, outcome
measures and statistical analysis
Findings Conclusions/Limitations
History Questionnaire,
1-1 Interview
=34 (non-clinical PTSD score
<50). At 6 months PCL-M
score =22 (p<.001).
SA-45 sig. reduction in
symptoms (p<.001), ISI score
pre-treatment to 6 months f/
u (p<.001).
beliefs. EFT appears highly
effective for PTSD in combat
veterans. No clear methods.
Single case study: part of larger
study.
Nicosia
et al.,
2019
USA
[101]
To evaluate the effectiveness
of EMDR and EFT in treating
PTSD following Sept 11.
N=1 male; 43 years
EFT 6 sessions followed
by 15combined EFT/
EMDR sessions
Quantitative, descriptive case
study
PAI, TSI
A single session of EFT
treatment facilitated a
reduction of anxiety and
PTSD symptoms such as
ashbacks, autonomic
hyperarousal, phobia and
depression.
EFT effective in reducing
symptoms of PTSD. Following
extended combination
treatment with EFT/EMDR,
client enabled to return to work.
Single case study, with no
qualitative data available.
Larger studies with non-veteran
populations needed.
Price 2002
USA [61]
To illustrate potential
benets of Body Oriented
Therapy (BOT) as an adjunct
to psychotherapy for
survivors if CSA
N=1 female, mid forties.
8 sessions of BOT with
psychotherapy TAU
Mixed Methods. Quantitative,
descriptive case study PSC,
POMS, SCL-90, CR-PTSD
Qualitative open-ended
questionnaire
Scores improved on all scales
utilised pre and post test
except fatigue. CR-PTSD
scores improved indicating
shift from active PTSD to non-
PTSD status. Questionnaire 3
themes: -
BOT as an adjunct to
psychotherapy is benecial for
CSA survivor and promotes
feelings of inner safety and may
be related to the reduction of
psychological symptoms and
PTSD symptoms.
Single case study. Larger study
samples required..
1 Ability to reach a ‘safe inner
place
2 ‘Listening to ones body
promotes selfcare.
3 Accessing and experiencing
deep emotions come easily
through relaxation and
feeling safe.
Price 2004
USA [28]
To examine the
psychological & somatic
prole of women who seek
touch therapy as an adjunct
to psychotherapy in
recovery from CSA.
N=8 (28 52years)
BOT 8, 1-hour sessions
over 8 weeks. Women
paid 50% of the cost for
their BOT session.
Mixed methods design.
SCL-90, CR-PTSD, DES, The
Brief Condential Medical
History Form, The Symptom
Checklist, POMS,
questionnaire, 1-1 interview.
High levels of psychological
distress indicated on SCL- 90;
6/8 scored above the cut off
on the CR-PTSD & DES
indicating active PTSD &
dissociative symptoms.
4 key characteristics of the
women in this study:
Data gathered before BOT
experience, highlighted highly
motivated and professional
women of predominantly
Caucasian race, with high levels
of PTSD and physical symptoms
seeking BOT.
Identied need for body
therapist to have additional
training for to work with this
population.
Participants contributed
nancially to treatment; only
those who could nance could
participate.
1 7/8 had many years of
psychotherapy, professional
occupations, Caucasian race.
2 Highly motivated;
prioritised health & healing
in their lives.
3 Physical symptoms chronic
rather than acute, associated
with psychological distress &
h/o abuse.
4 7/8 in sexual relationships
found intimacy problematic
& connected to CSA &
somato-psychosexual health.
Price 2005
USA [59]
To examine the efcacy &
perceived inuence on CSA
survivors of BOT with
women in psychotherapy
treatment. n=22,
mean 41 years (26-56 years).
BOT n=11. Comparative
massage group n=11.
8 one-hour sessions over
10 weeks. Both
techniques applied over
clothes.
Fidelity protocol in place.
Exploratory, randomised two
group repeated measures, mixed
methods design.
Measures baseline, prior to 3rd
& 5th sessions, post-
intervention, 1-month & 3-
month f/u.
BSI, DES-T, CR-PTSD, Medical
Symptoms Checklist, SCL-90,
SBC, BIS, Bowerman Touch
Empathy Scale, Questionnaire.
ANOVA
P<.10 due to small sample size
Sig. change on all outcome
measures both groups
(p<.00). PTSD reductions
maintained at f/u; Post
intervention 5 participants
scores reecting active PTSD
(Massage, SD=.42; BOT,
SD=.34) compared to
baseline of 15 participants
(Massage, SD =.40; BOT,
SD=.61).
Results maintained f/u 3-
months.
3 Core themes/2 subthemes:
1. Efcacy of touch therapy
with CSA, improvements,
maintained 3-month period;
2. BOT and massage
contributes to health
outcomes
- motivation to address
recovery through attention to
Signicant reduction in body
dissociation experiences. BOT &
massage therapy are effective
interventions in recovery from
CSA.
Touch-based therapy can make
important contribution through
enhanced somatic experience &
support engagement with
concurrent psychotherapeutic
process.
Important role of the
therapeutic relationship in
creating safety. Recommend
additional training for
bodywork therapists.
Larger sample size is warranted.
(continued on next page)
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
8
Table 3a (continued )
Author and
Country
Aim of Study and
Participants
Touch-based Intervention Study design, outcome
measures and statistical analysis
Findings Conclusions/Limitations
the body, yielding positive
outcomes
3. The inuence of a sense of
safety;
- the use of self-directed
therapeutic activity and
learned body awareness skills
in the BOT group.
Price 2007
USA [60]
To describe dissociation
with respect to BOT in sexual
abuse recovery.
As part of a larger study
to test the efcacy of BOT
in comparison to
standard massage in CSA
recovery in women. See
Price 2005.
See Price 2005. Combined results for both
massage & BOT groups: mean
score for dissociation (DES)
12.2 compared to general
population mean range of
4.4-7.8. N=15, (50%) score
range 13-27. Decreases in
dissociation across time sig.
for both groups (F=33,
p<.001). Dissociation highly
& positively correlated with
psychological measures
(range .64 and .71)
moderately positively
associated with physical
wellbeing (.40 -.50) & highly
negatively associated with
body connection (.52 - .63).
Sig. differences from baseline
to post intervention (3-
month) for PTSD symptoms
(p<.02).
Persons with the highest
dissociation experience prior to
study participation had greatest
reduction in psychological,
physical & PTSD symptoms &
greatest increase in body
awareness over time.
First study of dissociation & the
role of body therapy for women
in recovery from CSA & PTSD.
Larger sample size is warranted.
Price et al.,
2007
USA [48]
To examine the feasibility &
acceptability of Mindful
Awareness Body Therapy
(MABT) for female veterans
with PTSD & chronic pain,
taking prescription
analgesics.
N=14, female 47years (28-
56 years).
8 sessions MABT 10
weeks & home practice,
n=7 TAU (individual &
group therapy for mental
health, chronic pain
management group).
Randomised repeated measures,
mixed methods design.
Pre- post-test, 6weeks post-test.
Written questionnaire, 1-1
interviews
PCL-C, BSI, DES, Medical
Symptoms Checklist, SBC.
Fidelity measures in place.
3 core themes identied
included:
learning tools for pain
relief/relaxation
increased body/mind
connection
increased trust/safety
3 primary elements of
intervention identied
included: Massage, inner
body awareness, dialogue
with the therapist.No
statistics reported.
Reduction in dissociation is key
factor in trauma recovery.
MABT is an acceptable
treatment to female veterans
with PTSD & chronic pain; a
feasible treatment, worthy of
further efcacy testing. Longer
session duration indicated.
Only 3/7 participants in the
study group completed the
questionnaire at 6weeks reason
unclear. Participants paid $25
for postal questionnaire return.
Small sample size; limited
baseline quantitative data
reported in study results, non-
tabulated.
Price et al.,
2012
USA [62]
To examine MABT feasibility
as a novel adjunct to
womens SUD treatment.
N=52 female, range
1858 years; mean 38.83
years.
MABT. N=31 MABT/TAU
N=15 TAU.
Baseline n=46
A 2-group RCT repeated
measures design. Baseline, 3,6,9
months measures taken and
include BSI, EDE-Q, BD, DERS,
MPSS.
Chi-square Analysis, Bayesian
Information Criterion (BIC),
Comparative Fit Index.
42% attended between 1& 4
MABT sessions.
At 9-months, 82% MABT
continuing regular ‘body
connectionhome practice,
average 5.4 times/wk. N=18
completed MABT treatment.
Primary outcome - no. of days
on substance use sig. fewer
(p<0.02); secondary
outcomes PTS, eating
disorder symptoms,
depression, anxiety,
dissociation, perceived stress,
physical symptom frequency
all sig. improvement in
comparison to TAU (p<0.02).
MABT group clinically
greater reductions in PTS
symptoms (MPSS) than TAU,
not statistically signicant.
MABT is a feasible treatment,
worthy of further efcacy
testing with this population.
Small sample size with high
attrition (due to early discharge
from TAU program) n=13.
Price et al.,
2019
USA [63]
To examine the immediate
pre-post effects of MABT as
an adjunct to womens SUD
treatment.
N=217 accepted, mean age
not available.
MABT (n=93) /TAU
(n=68), Womens Health
Education (WHE)
(n=56)/TAU, TAU.
N=187 at baseline
measurement.
Mixed Methods; 3 group,
randomised pre-post-test
measures RCT
TLEQ, FMI, DERS, RSA, BDI-II,
PSS-SR, TLEB, MAIA
Analysis using intent to treat
(ITT) for MABT and WHE
All participants had
experienced interpersonal
trauma exposure; 68%
participants above cut-off for
PTSD =active PTSD.
Reduction in PTSD symptoms
across all groups; MABT
Interoceptive training with
MABT, which is linked to
emotional regulation is
associated with health outcomes
for women in SUD treatment.
RSA data showed improved
regulatory capacity under
(continued on next page)
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
9
Table 3a (continued )
Author and
Country
Aim of Study and
Participants
Touch-based Intervention Study design, outcome
measures and statistical analysis
Findings Conclusions/Limitations
groups and Intervention Dose
for all 3 groups 6 sessions;
p.05
Chi Square, mean, standard
deviation, multilevel mixed-
effects linear regression.
Qualitative written
questionnaire post intervention.
group largest reduction in
trauma related symptoms at
post-test (44%), (WHE 29%;
TAU 39%). No sig differences
between groups in ITT
analysis. Signicant
improvements in
interoceptive awareness,
mindfulness skills, emotion
dysregulation, depressive
symptoms, substance craving
and days abstinent.Primary
theme from qualitative data:
-The importance of self-care.
Themes emerging from
MABT group included: -
1 new physical body and
emotional awareness
2 new or enhanced body-
mind connection
3 increased awareness is
critical for self-care
4 Better able to cope with
stressors
5 Increased interoceptive
awareness facilitated better
physical symptom
management.
conditions of negative affect for
MABT group. Clinically
signicant reduction in PTS
symptoms for MABT group in
comparison to other groups
proportionally. Attrition rate
27%.
Price et al.,
2019
USA [50]
To examine the longitudinal
effects of MABT, an
interoceptive awareness
training as an adjunct to
womens SUD treatment.
Data extracted from Price
et al., 2019. 3, 6, 12-
month comparisons
Pre-post test, 3, 6, 12 months. As
per Price et al., 2019
Substance use decreased
signicantly for MABT vs.
TAU at 6, 12 months. Positive
longitudinal effects on
secondary outcomes for
MABT including RSA, a
physiological index of
emotion regulation.; craving
and interoceptive awareness
skills. Analyses based on
>75% of MABT sessions
completed revealed
signicant improvement for
depressive symptoms and
emotion regulation
difculties, mindfulness
skills. PTS not statistically
signicant over time or
between groups. MABT group
showed largest drop in PTS
symptoms clinically at 3
(44%) and 6 (50%) months,
compared to WHE (29% and
39%) and TAU (39% and
45%)
MABT shows efcacy for
longitudinal health outcomes to
support womens recovery as an
adjunct to community-based
SUD treatment. Whilst no
statistically signicant
reductions in PTS symptoms for
the MABT group, ndings are
clinically valuable and point to
all groups in the program of
benet to the women.
Interoceptive skills learning are
important for emotion
regulation and relapse
prevention, with full completion
of MABT intervention
supporting SUD treatment
outcomes.
Price et al
2019 [51]
USA
To test hypothesis that RSA
would be sig. and positively
associated with
interoceptive awareness and
mindfulness skills in group
of women in SUD treatment.
Data extracted from Price
et al., 2019.
Pre-post test, 3, 6, 12 months. As
per Price et al., 2019. An
exploratory, within-subjects,
cross-sectional study.
Interoceptive awareness
positively and sig. associated
with resting RSA. RSA was
not sig. associated with
trauma, depression
mindfulness skills.
Correlations on all self-
reported measures were sig.
and moderate. Exception for
trauma symptoms/
interoceptive awareness and
substance use/health
outcome measures (trauma,
depression, interoceptive,
mindfulness skills).
Interoceptive awareness is
important for emotion
regulation. RSA rarely been
shown in the literature to be
associated with
psychopathology or disorders.
The higher RSA is associated
with the active behavioural
process of using interoceptive
awareness skills to promote
emotion regulation. Study
lacking healthy controls for
comparative data, which is used
in majority of RSA studies.
Price and
Herting,
2013
USA [49]
To examine the role of body
dissociation & emotion
regulation on PTS symptoms
in women in substance use
disorder (SUD) treatment.
See Price et al., 2012 Data based on a prior study, See
Price et al., 2012.
Bodily dissociation &
emotion regulation have sig.
direct effects on PTSD
symptoms from baseline to 6-
month f/u (b =0.461, std B=
0.468, p<.01).
Body dissociation may
See Price et al., 2012.
Preliminary evidence
supporting importance of
addressing bodily dissociation,
emotion regulation difculties
& PTSD symptoms in womens
SUD treatment.
(continued on next page)
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
10
Table 3a (continued )
Author and
Country
Aim of Study and
Participants
Touch-based Intervention Study design, outcome
measures and statistical analysis
Findings Conclusions/Limitations
indirectly operate to reduce
PTSD symptoms through its
effect on emotion regulation
difculties (indirect effect =
14.3, std indirect effect =
0.347, p<.01).
All temporal variable
correlations statistically
signicant (p.05).
Reeve et al.,
2020
USA [53]
To examine the use of HT as
an intervention in treating
PTSD. Veterans n=40. Mean
age 62 years.
HT. 10 weekly 1hour
sessions
Mixed Methods; a 2-armed
randomised crossover waitlist-
controlled trial and open-ended
questionnaire (1 question). PCL-
5
t-test and paired t-test
Phase 1 post test t=3.164,
p<.01, HT and standard care
more effective at reducing
PTSD symptom severity than
standard care alone. Paired t-
test t=4.3, p<.001 results
were sustained over time (3
months). Results compared
with waitlist control group.
Response to open ended
question; most notable area
of improvements were
improved mood and
relaxation N=28, reduced
pain levels n=19.
HT is a low-risk, low-cost
intervention for PTSD that can
be implemented as a treatment
option. Larger sample sizes are
warranted. Very limited
discussion.
Stub et al.,
2020
Norway
[71]
To investigate and describe
the indications for the used
of CST within trauma
therapy. N=8 trauma
therapists. N=6 female, n=2
male
CST Qualitative; Semi-structured
interviews and 1 focus group.
Content analysis and coding.
5 Themes: -
1 Rationale for using CST
2 A holistic treatment
approach
3 Aims of treatment
4 Signs of improvement
5 Handling adverse effects of
and the benet of teamwork
Patients with PTSD benet from
a multimodal treatment
approach and holistic treatment
philosophy including CST.
Recommend CST to be provided
for ‘severely traumatised
patientsin cooperation with
psychotherapists and/or
working in specialised
institutions.
Lacking clarity on the CST
therapist(s) background who
had been providing therapy at
the centre.
Sumpton &
Baskwill,
2019
Canada
[73]
To explore the use and
effects of massage therapy
(MT) on sleep quality with
individuals with PTSD. N=3.
N=2 veterans and n=1 rst
responder. 2 male and 1
female.
MT. 10, 1hour weekly
sessions.
Quantitative Descriptive, Case
series. Sleep diary, PSQI, LSEQ
All completed intervention
and well tolerated. Data
collected showed
inconsistent improvements
and worsening of symptoms.
N=1 consistent and
signicant improvement with
all LSEQ scores.
MT did not predictably impact
sleep quality contrary to
previous research ndings.
Further investigation of how MT
affects sleep in required, with
larger sample sizes.
Upledger
et al.,
2000
USA [72]
To investigate effect of UCST
in reducing PTSD symptoms
in Vietnam war veterans
with PTSD.
N=22, 1 female, 21 male,
mean age not available.
12-day UCST Program, 2-
day weekend rest;
psychotherapy, body/
touch therapies available.
Applied over clothes.
Quantitative non randomised
repeated measures pre- post-test
design.
BSI, BHS, CSE, QOL, Mississippi,
TSI.
t-test analysis.
Reduction in BSI, BHS & CSE
scores after UCST program,
statistically sig. (p<.01).
Importance of the therapeutic
relationship.
UCST can be effective for
reducing psychological &
physical medical symptoms &
promoting hopefulness in
Vietnam veterans with PTSD.
Small sample size; no control
group.
No demographics available for
participants.
Yachi et al.,
2018
Japan
[52]
To examine the
psychological and
physiological effects of
touch on healthy and
traumatised individuals. N=
24 female. Mean age 24
years.
HPA Touch Quantitative non-randomised.
TDMS-t, ACEQ, DTS, RSA, heart
rate, BP. Measurements taken
for both groups at baseline pre
touch, post arm touching (10
mins) and post HPA touching
(10 mins). T-test, ANOVA, holm
method of multi comparison.
RSA increased and was
statistically signicant in
both healthy and trauma
groups, p<.01. Trauma group
had sig. lower RSA at
baseline. No signicant
changes in TDMS-t scores.
Touching the HPA axis found to
positively affect the social
engagement system as observed
through changes in RSA and
heart rate. No change in
psychological wellbeing.
Age difference between healthy
and trauma group not
statistically considered. Trauma
group already known to touch
therapist (clients) and had
received between 5-50 sessions
of 50 mins.
KEY: ACEQ Adverse Childhood Experiences Questionnaire; APA American Psychological Association; BD The Bodily Dissociation Scale; BDI Beck Depression
Inventory; BPI Brief Pain Inventory; BSI Brief Symptom Inventory; BHS Beck Hopelessness Scale; BIS Scale of Body Investment; CAM Complementary and
Alternative Medicine; CAPS Clinician-Administered PTSD Scale; CBT Cognitive Behavioural Therapy; CES-D C-MHI Cook-Medley Hostility Inventory; CR-PTSD
Crime Related Post-Traumatic Stress Disorder; CSA Child Sexual Abuse; CSE CranioSacral Evaluation; CST Craniosacral Therapy; DERS Difculties with
Emotional Regulation Scale; DES Dissociative Experiences Scale; DTS Davidson Trauma Scale; EDE-Q Eating Disorder Examination Questionnaire; EMDR Eye
Movement Desensitisation and Reprocessing; EQ-5D European Quality of Life; FMI Freiburg Mindfulness Inventory; HPA Hypothalamus Pituitary Adrenal IES-R
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
11
the treatment of adults with symptoms of PTSD). Data from the different
study types, conceptual papers and reviews were then synthesised to
identify overarching analytical themes that explained how touch-based
interventions may inuence recovery from PTSD and its associated
symptoms in adults. Intervention aims, descriptions, theoretical basis
and results were examined and compared to identify similarities and
differences and grouped together to form themes, as is consistent with
this analysis approach [39,40]. Review ndings were arranged around
these themes using a constant comparative method to enable conclusion
drawing. This approach to the data supported the creativity and critical
analysis of the broad evidence base under review, which is necessary for
this type of study [40].
3. Results
3.1. Searching and screening
A total of 1,044 articles were initially identied and a further 26
papers were retrieved through reference listings and hand searches,
including the Google search engine. Thirty-nine articles remained after
full text screening. Five of the articles remaining [47,49,50,51,60] were
based on larger research studies which are included in this review
(Fig. 1).
Impact of Event Scale; ISI Insomnia Severity Index; ISS Insomnia Severity Scale; KODI Korean Oswestry Disability Index; LBP Low Back Pain; LSEQ - Leeds Sleep
Evaluation Questionnaire; MABT Mindful Awareness Body Therapy; MAIA Multidimensional Assessment of Interoceptive Awareness; Mississippi Mississippi Scale
for Combat Related PTSD; MPSS Modied PTSD Symptom Scale; MYMOP2 Measure Yourself Medical Outcome Prole 2; Neuro-QoL Quality of Life in Neuro-
logical Diseases; PCL-C Post-traumatic Checklist-Civilian; PCL-M Post-traumatic Checklist-Military; PDS-K Post-Traumatic Stress Disorder Symptoms-Korea;
POMS Prole of Mood State; PSC Physical Symptom Checklist; PSQI Pittsburgh Sleep Quality Indicator; PTSD Post-traumatic Stress Disorder; PROMIS
Patient-Reported Outcomes Measurement Information System; QOL Quality of Life Questionnaire; RMANOVA Repeated Measures Analysis of Covariance; RNA
Ribonucleic Acid; RPQ Rivermead Post-Concussion Questionnaire; RSA Respiratory Sinus Arrhythmia; SA-45 Symptom Assessment 45; SCL-90 The Psycho-
logical Symptom Checklist; SF -12 physical symptom checklist; SF-36 Quality of Life measure; SBC Scale of Body Connection; Sig. Signicant; SOC Sense of
Coherence; STAI State Trait Anxiety Inventory; TDMS-t Two Dimension Mood Scale test; TFT Thought Field Therapy; TLEQ Traumatic Life Events Questionnaire;
TSI Trauma Symptom Inventory; UCST Upledger CranioSacral Therapy; VAS Visual Analogue Scale.
Records identified through database
searching
(n = 1,044)
gnineercS
dedulcnI
ytilibigil
E
noitacifitnedI
Additional records identified through
other sources including hand searching
(n = 26)
Records after duplicates removed
(n =1,002)
Records screened: title,
keywords
(n =1,002)
Records excluded
(n = 949)
Full-text articles assessed
for eligibility
(n = 53)
Total articles included
n=39
Quantitative (n= 31)
Qualitative (n = 2)
Conceptual/review (n=6)
Fig. 1. Prisma Flowchart of Literature Search [41].
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
12
3.2. Study characteristics and participants
Broad variations were found in study setting, participants and
design. Most studies took place in either a clinical treatment room (n=7)
or an ofce (n=7), and one study took place in a university classroom
[52]. The study setting was not clear for 13 studies. The majority of the
research took place in the USA (n=31).
A total of 886 persons took part across all the studies, with 346 male
and 500 female participants; one study [53] did not report on gender
(n=40). The age range for participants was 18 86 years with the mean
age 45 years. 369 participants across studies, approximately 40% of
combined population, were war veterans, with four studies focusing on
the civilian survivors of war in Bosnia (n=18) [54] or torture [55,56,
57]. The participants of one study (n=81) were involved in a group
intervention which implemented a self-administered touch known as
Emotional Freedom Technique (EFT) [58]. The remaining population
included childhood sexual abuse (CSA) survivors (n=31) [28,59,60,61]
women with substance use disorder (n=269) (SUD) [62,63] of which
65% had a history of physical abuse and CSA.
One paper [64] included a survey of practitioners who used EFT
(n=448) in the treatment of people with PTSD. These practitioners
consisted of licensed mental health practitioners (n=168), medical
professionals (n=29), alternative medicine practitioners (n=141), life
coaches (n=86) and others (n=91). The majority (n=375) were in pri-
vate practice with others practicing in mental health facilities (n=43)
and medical centres (n=30).
Generally, information regarding practitioner gender, education,
race was limited, although there appeared a diversity of professionals
working in this area, most with additional training in whichever touch
modality was under study. A summary of the studies reviewed can be
found in Table 3.
3.3. Design of studies included
Study designs included 11 randomised controlled trials (RCT) and
eight mixed methods studies, four of which included a RCT. Three non-
randomised repeated measures single group design studies, one single
group pre and post-test design and one pre- post-test design with control
group were included, with an additional ve descriptive studies based
on either case study or case series designs. Six papers presented quan-
titative ndings based on ve larger studies and two qualitative papers
were retrieved.
Six papers were either a review or based on conceptual information
on the topic and included one meta-analysis [65] three mixed review
papers [66, 67,68] related to the key touch-based interventions of in-
terest, a new treatment approach proposal [56] and one expert opinion
[69]. Four articles, including a meta-analysis specically on EFT, all
concluded that EFT may be an efcacious clinical treatment for PTSD
and its associated symptoms [66,67,68,65]. One paper presented an
exploration of the autonomic nervous system (ANS) in the aftermath of
shock and trauma and biodynamic massage [69], another explored the
chronic pain literature relating to survivors of torture [56] and
described, with the help of case studies, an interdisciplinary treatment
protocol utilising complementary and alternative medicine (CAM) touch
techniques. All six review and conceptual papers, advocated the somatic
component in the treatment of PTSD.
3.4. Quality analysis
The methodological rigour as assessed by the MMAT varied across
the studies. All studies retrieved, which met inclusion criteria for this
study, were subsequently appraised in an attempt to map the breadth of
research in this area.
3.5. Key themes identied
Three key themes were identied from the research studies
reviewed: (i) catalogue of touch-based interventions being utilised in the
treatment of symptoms of PTSD; (ii) proposed mechanisms explaining
the efcacy of touch-based interventions with PTSD and its associated
symptoms; (iii) touch-based interventions can reduce the associated
symptoms of PTSD.
3.5.1. Touch-based interventions being utilised in the treatment of
symptoms of PTSD
Eleven touch-based interventions were described, with one paper
including multiple CAM utilising touch techniques as part of a wider
interdisciplinary treatment programme [56]. EFT, was the focus of 17
articles, with body-oriented therapy/Mindful Awareness in
Body-oriented Therapy (BOT/MABT) described in 10 of the total papers
reviewed. The remaining interventions were diverse in nature and
included Upledger CranioSacral Therapy (UCST) [71,72] Zero Balancing
(ZB) [57], biodynamic massage [69], massage therapy [73], Healing
Touch (HT) [53,70], Complex Manual Therapy (CMT) [55], Rosen
Method Bodywork (RMB) [74], Hypothalamus Pituitary Adrenal Touch
(HPAT) [52] and Light Touch Manual Therapies (LTMT) [75].
Developed in the early 1990s, EFT has been described as a psy-
chophysiological intervention which draws from two established ther-
apies CBT and exposure therapy and adds the touch component as light
touch applied to acupuncture points or acupoints,which are specic
areas on the human body [67,68]. The somatic stimulation, mostly
delivered as a tapping touch [64], can be applied interpersonally, be-
tween therapist and client or may be self-applied.
All of the 17 EFT [47,54,58,64-68,76-79,87,98-101] studies in this
review reported impact on key outcomes, including PTSD symptom
reduction, with no adverse effects reported. With 9/17 papers on EFT
focused on war veterans, the majority of the research was generated by
one organisation in the USA [64]. In addition to practitioner led sessions
guiding EFT, participants also used self-applied EFT/tapping touch.
However, it was not clear from the majority of the studies, if practitioner
or self-applied EFT touch was utilised. None of the studies evaluated the
self-applied touch take home practice when prescribed. One study,
demonstrated that remotely guided telephone group sessions produced
signicant outcomes; although the in-person practitioner led sessions
produced signicantly greater reductions in PTSD symptoms as per the
PTSD Checklist when compared to the remote sessions [64].
BOT/MABT [28,48-51,59-63] combines mindfulness, touch, and the
emotional processing of traumatic experience, with home-based prac-
tices [48]. All studies reported PTSD symptom reduction and accept-
ability of the intervention amongst users and the approach was
comparable in its effects to massage therapy [59]. Seven of the ten ar-
ticles were RCTs, with four of these papers [49,50,51,60] reporting the
ndings of the three larger mixed method studies [59,62,63]. The mixed
methods studies provided thin qualitative data, lending to the partici-
pants perceived experience and data diversity. The research highlighted
the importance of this therapy in its effects on reducing bodily dissoci-
ation experiences and promoting interoceptive awareness, through the
development of emotional regulation in women with PTSD and associ-
ated symptoms and a history of CSA.
ZB [57], LTMT [75] HT [53,70] HPAT [52] and UCST [71,72] are
based on the principle of applying a gentle touch technique over
clothing. Applying HT, researchers [70], presented data to support re-
ductions in PTSD symptoms (p<0.0005), depression (0.0005), cynicism
(p=0.001) and an improvement in mental quality of life (p=0.002) for
participants with PTSD. Effect sizes were comparable to typical phar-
macological and psychological treatments, with notably lower attrition
rates [70]. One article on LTMT, a blend of modalities including mas-
sage, UCST and light touch therapy on the cranium, studied its effects on
PTSD symptoms, headache, anxiety and pain interference with
active-duty soldiers. Headache symptoms (p<0.04), anxiety (p<0.04)
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
13
and pain interference (p<0.039) were signicantly reduced during this
pilot study over two weeks. PTSD symptoms showed no statistically
signicant change but an overall decrease in clinical PTSD symptoms
was observed [75].
One study exploring CMT [55] reported a reduction in the symptoms
of PTSD (p<0.001) and an increase in function (p<0.001) [55]. Biody-
namic massage [69], a combination of massage and psychotherapy was
comparable to other studies [56,57,59,70,74] in recognising how
touch-based interventions can assist survivors re-establish a sense of
‘feeling safe, following traumatic experience. None of these studies
explored the concept or meaning of ‘feeling safein any depth, or why it
may be important for persons living with PTSD and its symptoms.
Of the eleven touch interventions reported, EFT and MABT were the
most prolic, with MABT offering both qualitative and quantitative data
to this eld of research. All interventions claimed to have value in the
treatment of persons with symptoms of PTSD.
3.5.2. Proposed mechanisms explaining the effects of touch-based
interventions with PTSD and its associated symptoms
Several mechanisms were suggested by various authors as potential
explanations for the effects of the touch-based interventions with per-
sons with symptoms of PTSD with three core mechanisms identied: the
importance of touch in the therapeutic relationship; the effects of touch
on regulating the touch receivers nervous system; specic locations
where touch results in key change in the nervous system for participants.
The importance of the therapeutic relationship in supporting persons
to ‘feel safe through touch, was an acknowledged factor in 12 studies
[48,52,53,56,57,59,61,69,70,71,72,75]. Bernard [74] explained how a
client with symptoms of PTSD may need to relearn ‘feeling safeafter an
experience of prolonged terror, referring to this therapeutic process in
RMB as ‘relational somatic presence. Bernard [74] further emphasised
how the therapeutic relationship allows for the ‘corrective experience
of touch, that may have become interrupted due to traumatic circum-
stance and led to disruption in the early attachment process [52,61]. The
safe therapeutic exchange can assist the person restore balance to a
dysregulated Autonomic Nervous System (ANS); an area that has been
identied as problematic for most survivors of trauma [49,52,56,63,67,
69,74,77].
Therapeutic skill on behalf of practitioners of touch-based therapies
was identied as a requirement to assist a person restore balance to their
ANS [48,50,51,52,63,64,74]. This was also emphasised by some study
participants, referring to the practitioners touch as ‘nurturing,
‘compassionate, supporting them to ‘feel safe and ‘calmly connected
with their bodies. Interoceptive awareness was noted as an important
channel for increasing somatosensory or body-awareness in trauma
survivors [48,49,50,51,59,62,63,74], through the discovery of the
ability to notice and stay present to uncomfortable feelings in the ‘here
and now. The skilled, safe, therapeutic support offering touch-based
intervention was identied as a key for allowing the recipient to stay
present with challenging sensations, rather than develop hyperarousal
and dissociate from the experience [48,49,50,51,56,62,63,74]. Growing
empirical evidence for developing interoceptive awareness, through
recognition of bodily dissociation and emotion regulation difculties,
has been shown to partially mediate PTSD symptoms among a female
SUD group [62]. Recent ndings recognised that interoceptive skills
training utilising MABT, improved health outcomes, critical for sup-
porting women with a history of post-traumatic stress [50,51,63]. See
Table 3.
Feinstein [67] provided a theoretical exploration of why acupoint
tapping in EFT may be effective with PTSD, and emphasised how certain
‘acupointson the body appear to have distinctive electrical properties
as contrasted with other areas of the skin. When stimulated through
touch tapping or rubbing, these acupoints are proposed to send deacti-
vating signals to the amygdala, a key brain structure associated with the
fear response [66]; an explanation shared in HPAT [52], though based
on the neural response of the CT afferents; which are primarily received
and processed via the insula [22,52]. Explorative data on the fMRI im-
aging, back up claims that the acupoints are connected to energy
channels or ‘meridiansin fascia, according to acupuncture theory [67];
although, most of the EFT research reviewed focused on the efcacy of
the intervention rather than the underlying mechanisms of effect.
Re-establishing balance between the sympathetic and para-
sympathetic ANS was identied as a priority in the treatment of symp-
toms of PTSD, with the therapeutic relationship playing an important
role in the process of re-establishing safety and interoceptive awareness
through touch mechanisms.
3.5.3. Touch-based interventions can reduce the symptoms of PTSD
Most of studies in this review (Table 3a) made use of the PTSD
Checklist (PCL) [97] as a baseline diagnostic and measure of PTSD and
its associated symptoms. Based on the DSM-IV criteria for diagnosing
and identifying the associated symptoms of PTSD (Table 1), the PCL was
utilised in both civilian (PCL-C) and military (PCL-M) forms. Nine
studies included other validated instruments of self-assessed PTSD based
on the DSM VI [28,50,52,55,59,61,62,72,101]. Three studies did not
utilise a validated tool to measure PTSD symptoms; these were quali-
tative [74] or descriptive papers in design [64,73]. Bernards qualitative
study [74] which included complex trauma survivors, were required to
be no longer experiencing active PTSD symptoms. The researcher
argued that this was necessary due to the potential retraumatisation of
the retrospective interview situation [74]. Four studies identied the
main criteria for participant inclusion, as a diagnosis of PTSD made by
the associated care facility in which the research was being conducted
[48,53,71,73]. However, only one study reported the gold standard
psychological interview for the diagnosis of PTSD, alongside the PCL as a
symptom measure [100].
Most of the studies measured the efcacy of the touch-based treat-
ment being delivered to some extent, and all but four studies [48,62,63,
75] reported statistically signicant reductions in the symptoms of PTSD
on validated measures. Although, PTSD symptom reduction was clini-
cally noted in all four of these studies.
PTSD symptoms were measured in six MABT studies conducted by
Price et al. who found that dissociation may indirectly inuence PTSD
symptoms through its effect on emotional regulation [49,62]. Most re-
searchers in this area acknowledged the likelihood of touch in promot-
ing emotional regulation in persons with PTSD.
Other common co-morbid symptoms of PTSD including anxiety,
depression and chronic pain, pain interference, headaches, and
insomnia were specically measured with self-rated validated tools in
some studies and demonstrated statistically signicant improvement in
those domains as a result of touch-based intervention. Findings relating
to symptom reduction were also claimed in the qualitative and
descriptive data, which reported inter-personal relational improvements
(reductions in relational conict) and more motivation to engage with
life [48,54,59,61,74,87]. These positive improvements were not inves-
tigated in the quantitative ndings reported.
Touch-based interventions were shown to play an important role in
reducing the symptoms of PTSD and the co-morbid symptoms associated
with PTSD, as demonstrated utilising validated outcome measures in the
majority of studies. Other changes were offered by participants quali-
tatively, as areas of life improvement, including interpersonal relation-
ships, and engagement in everyday living.
4. Discussion
The three themes identied in this review, offer a framework for the
current evidence on the role of touch-based interventions as a somato-
sensory approach to treating symptoms of PTSD. This review identied a
catalogue of touch-based interventions that are currently being utilised
in the treatment of PTSD symptoms, proposed mechanisms of effect for
these interventions and recognised the measurable reduction of symp-
toms of PTSD as a result of such treatments. The ndings illustrate the
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
14
diversity of touch-based interventions being utilised, along with several
possible mechanisms to support the efcacy and the role of touch with
PTSD.
The most common group who had been the focus of studies on touch-
based interventions are combat veterans with PTSD. This is consistent
with the historical origins of PTSD diagnosis which rst appeared in the
DSM in 1980 [8]. However, this review also highlighted research on a
broader range of people living with PTSD symptoms and how childhood
trauma can also develop into PTSD in later life [48,52,62,63]. Different
populations have also been more likely to be exposed to different
touch-based interventions; for example, the EFT literature focused on
veterans [66] in contrast to MABT research which included women,
predominantly with SUD and history of CSA [28,49,59,62,63]. Whether
either group is more suited to a certain type of touch-based intervention
is not known. Although, it is clear that the styles of touch used in EFT for
example ‘tapping touch and in BOT/MABT, for example, a slower,
gentle, stroking touch over clothing, are contrastingly different and can
promote different responses in the tactile nerve bres stimulated [17,
31].
A take-home practice is common in treatments utilising touch, to
support the goals of the individualised therapy [48,63,77,78,79] and
facilitate self-management strategies between therapy sessions and into
the future. One of the key components in home practice programmes,
was the reported ability of participants to manage their somatic re-
sponses and self-regulate emotional experiences as a result of
touch-based interventions. Phenomenological studies with trauma sur-
vivors [80,81] describe how the somatosensory tools learned, supported
emotional regulation and provided a sense of empowerment when no
further treatment is available [63]; with research further demonstrating
the analgesic effect of self-touch through EEG evoked potentials within
the somatosensory cortex [82] and the emotional regulation offered by
such practices [83]. None of the studies in this review examined the
effects of participants take-home/self-touch practice on PTSD outcome
measures. However, two studies, both by Price et al. [50,62], included
questionnaires regarding post-intervention body awareness/MABT
practices utilised by participants. Both studies comment on the potential
of these take-home practices, mostly interoceptive skills practices [62],
to contribute to health outcomes up to 9-months post MABT interven-
tion, in a SUD program [50,62].
Price et al., [48,62,63], in recognising the importance of touch in
emotional regulation, have developed an explanatory model to explore
the development of interoceptive capacities related to touch [84].
Applying interoceptive awareness practices to somatosensory treatment
approaches, specically touch, continues to be advocated by both re-
searchers and clinicians in the areas of mental health and PTSD [4,23,
38] and the recent evidence is supportive [62,63]. An awareness of these
applications, including the physiological mechanisms of the touch de-
livery, and the evidence underpinning them, can inform and support
options to augment traditional treatment for people with PTSD and its
associated symptoms.
According to seminal practitioners and researchers in this area,
supporting people to manage their ANS, and to thereby enhance
emotional regulation, could be ‘the single most important pre-requisite
to dealing with PTSD[8, p520]. Ones physiological arousal needs to be
calmed and regulated before one can access the executive skills required
to process traumatic memory in psychological ‘talktherapies [4,85,86]
and touch-based interventions can support people with symptoms of
PTSD to do this. Touch has been described by several study participants
as ‘soothing, ‘calming, ‘relaxing and ‘safe[28,74,87], with some re-
searchers noting how the somatic soothing component of treatment feels
like restoration of equilibrium to the nervous system, through contact
with specic areas of the body; ‘acupointsin EFT [64] or through the CT
afferent nerve bres on non-glabrous skin as described in HPAT [52] or
the activation of the Messiner or Pacinan corpuscles and the A-beta af-
ferents in light to moderate pressure massage respectively [17]. How, or
indeed if, this equilibrium is actually achieved is not clear from the
studies reviewed, which used mainly self-reported measures, and only
one EFT paper [67] offered a thorough discussion of the neurophysio-
logical mechanisms that may be responsible for this change. BOT/MABT
offers a comprehensive exploration of how an individuals physiology
may respond to this treatment modality [84] and this can be observed in
the evolving BOT/MABT research presented over this last 20 years;
although the evidence to date excludes male populations.
For persons living with PTSD and its associated symptoms, re-
establishing a sense of safety and promoting a primary human need to
manage fear and hypervigilance may be in part be fullled by touch
proximity in the overall context of the therapeutic relationship. Along-
side the reported soothing experience of touch, it was the presence of a
skilled practitioner delivering the touch-based treatment who played an
important function on outcomes. By expanding on the evolutionary and
developmental role of the CT bres, also known as the social touch
system in mammals, McGlone and colleagues [31] explore why this
relationship may be important. They argue that the role of the CTs is
reected in an infants behaviour as they are led to seek physical
proximity to their caregiver [31]. The caregivers presence, demon-
strating social empathy, expressed through touch, may act as the pri-
mary signal to the developing ANS that they are safe and secure (96),
supporting healthy child development. It is possible that this early
mammalian care-taking strategy, conveying social empathy and sup-
porting emotional regulation may be also recreated in the therapeutic
relationship. In offering individuals with symptoms of PTSD touch-based
treatment in a safe, trauma-responsive environment, there arises an
opportunity to experience a fundamental mammalian requirement:
safety and security in relationship.
Theory which may support the important role of this relationship is
the polyvagal theory (PvT) [88,89,90] which relates to the development
of the social engagement system (SES) in mammals. The PvT views the
physiological state as a neuralplatform upon which different classes of
adaptative behaviours manifest [88] and claims to account for not only
‘ght/ightautonomic responses to danger cues but also a second re-
action tendency, resulting in immobilisation and dissociation [88]. A
PvT informed therapist will aim to promote autonomic regulation in her
clients through her own autonomic awareness, and understands the
development and functions of the SES; touch being one of these func-
tions. Through attuned relational presence, she or he reassures their
client, supporting interoceptive awareness, self-soothing behaviours and
knowledge of the ANS [91]. In the safety of this relationship, the
adaptive self-protective responses once learned, for example dissocia-
tion, so prevalent in survivors of trauma is difcult to recruit [91].
The evidence that touch performs much more than a discriminatory
function [17,23], and the rewarding value of touch in nurturing and
social interactions [92], reects the presence of these evolutionary
systems which does not diminish with age [88,93]. It appears from the
research that both of these systems, the CT and SES, serve humans for
example in times of illness, distress or perceived threat of danger to help
manage fear responses [23,88,91] and remain emotionally regulated.
Although contested by some researchers [94,95] the PvT theory con-
tinues to be supported by many clinicians and researchers in the trauma
eld [91,96].
4.1. Limitations and strengths
The ndings highlight eleven touch-based interventions in the
treatment of PTSD symptoms and presents the breadth of evidence un-
derpinning these modalities. However, the limited number of published
peer reviewed experimental studies evaluated were only in the English
language, which can mean restrictions in respect of comparison and
analysis of all available data in the eld. Across the studies, methodo-
logical drawbacks included small sample sizes, a shortage of randomised
control studies and qualitative data.
There was a strong reliance on self-rated measures throughout the
studies. And whilst the PTSD Checklist provided comparability of the
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
15
Table 3b
Summary of conceptual papers and reviews.
Author and
Country
Aim of Study and Population Touch Intervention Methodology Findings Limitations, Conclusions
Church and
Feinstein
2017
USA [66]
To provide an overview of EFT
treatment with veterans with
PTSD.
To outline cautions and
obstacles related to its
implementation.
EFT with clear clinical
illustrated treatment
protocol.
A literature review. Main themes identied in
literature:
1 Few sessions needed to reduce
symptoms of PTSD
2 Improvements are substantial
and lasting
3 Safe with low risk of adverse
events
4 Minimal training is needed to use
and can be integrated into any
clinical framework
5 Effective in both individual and
group sessions
6 Can remediate both psychologic
and physiologic symptoms
Can be delivered via electronic
communication media
Does not discuss any of the
methodological drawbacks of the
studies reviewed.
EFT is an Energy Psychology (EP)
treatment modality.
Despite the high level of evidence
supporting EFT for PTSD, there
still remains a systematic
oppositionto the use of EFT in
mainstream healthcare, which
may be due to its unconventional
origin.
Sebastian
and
Nelms,
2017
USA [65]
To assess the efcacy of EFT in
treating PTSD: A Meta-
Analysis.
EFT based on The EFT
Manual.
A Meta- Analysis.
Applied Quality
indicator the APA
Division 12 Task Force
on Empirically
Validated Therapies.
7 RCTs met the quality criteria.
A large treatment effect found with
weighted Cohens d =2.96 (95%
Cl: 1.96-3.97, p<.001) for the
studies that compared EFT to usual
care or a waitlist.
No treatment effect differences
were found in studies comparing
EFT to EMDR (1 study) and CBT (1
study).
No critical appraisal of RCTs
discussed.
Analysis shows a series of 4-10
EFT sessions is an efcacious
treatment PTSD with mostly
veteran populations.
No adverse effects reported.
EFT can be used as a self-help tool
and as a primary evidence-based
treatment for PTSD.
Feinstein
2010
USA [67]
A review of the literature,
anecdotal evidence and
possible mechanisms of action
for EFT in the treatment of
persons with PTSD.
EFT A literature review,
theoretical and
treatment protocol
discussion.
All treatments are required to be
applied in the context of
establishing a therapeutic rapport,
identifying treatment goals, any
resistance or ambivalence towards
achieving these goals.
Conventional psychological &
exposure treatments have some
success in treating PTSD, although
substantial portion, of persons do
not respond.
A conceptual paper with data
update.
Although EFT has been considered
controversial by convention,
results so far are promising for
survivors of trauma and their
families.
Additional RCTs are required and
more research on the suggested
mechanisms for action and
dismantling studies are needed.
Flint et al.,
2008
USA [68]
To provide instruction and
guidelines for using EFT in
disaster situations and with
traumatic stress responses
including PTSD.
EFT treatment
protocols including 12-
step tapping and 9-
Gamut with eye
movements.
Education and literature
review including 2 case
studies and group
intervention to illustrate
intervention.
Themes covered include:
1 Background and history of EFT
and TFT
2 Literature review
3 EFT practical treatment method
4 Instructions for using EFT
5 Group vs individual treatment
Group EFT protocol to help with
the traumatic death of a work
colleague. Successful outcome
described.N=1 case report, male.
Successful ‘processing of traumatic
experienceusing EFT, after 6 years
of living with PTSD symptoms.
Education piece with limited
information provided in case
reports.
EFT can help to process traumatic
stress.
Can be practised at home as a self-
help tool.
Does not require a trained mental
health professional except for
more complex trauma issues,
where it is used as an adjunct to
psychotherapy and mental health
treatment.
Stauffer,
2000
UK [69]
To identify the role of massage
with persons in a state of shock
or with post-traumatic stress.
Biodynamic Massage Educational/expert
opinion piece
shock and trauma
the ANS
massage techniques
the importance of
creating safety and the
therapeutic relationship.
n/a Expert Opinion piece with limited
data to back up rationale.
Massage is a resource to help
clients reduce the fear in response
to shock and trauma. Through
creating a safe & contained
environment, clients can connect
with what can be a ‘pleasurable
experience a/c researcher.
Vargas
et al.,
2004
Canada
[56]
To propose an integrated
approach to the treatment of
survivors of torture, as
practised at the Vancouver
Association for the Survivors of
Torture (VAST).
An integrated
treatment combining
psychotherapy,
physiotherapy, CAM -
includes reiki, RMB,
UCST, TuiNa,
kinesiology & massage
Proposal treatment
approach based on
research on PTSD, pain
& clinical observations
illustrated through case
reports.
Main issues identied:
1 Current research ndings on
pain are relevant for those
experiencing PTSD & chronic
pain.
2 A treatment approach for
‘speechless terrorin survivors
who hold trauma in the body is
required.
3 Case reports demonstrate how
with close client/therapist
collaboration, skilled therapists
Rehabilitation programs with this
group require cross-disciplinary
knowledge & expertise, including
CAM; a new model of care,
addressing the complex nature of
PTSD.
CAM can advance the
psychological & physical healing
process as demonstrated at VAST;
can improve recovery rate when
practised with psychological
(continued on next page)
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
16
overall data, some researchers argue that treatments in which PTSD
scores drop on a symptom rating scale may not necessarily be effective
treatments [8]. Such treatments may have helped change symptom
presentation and reduce distress; however, it is important to inquire if
the remediation of the symptoms of PTSD are enough to claim efcacy
and success. The utilisation of objective physiological measures such as
respiratory sinus arrythmia (RSA), heart rate and salivary cortisol to
assess ANS function was limited [52,63], although provided some
valuable information regarding physiological changes as a response to
treatment. Furthermore, only one study clearly referred to the diag-
nostic assessment for PTSD [100], the gold standard psychological
assessment, as inclusion criterion; most studies preferred the PTSD
checklist to assess symptoms and diagnosis for participant inclusion.
A further limitation, to this integrative review was the restricted
blind screening quality appraisal for this study; the second author (PB)
blind screened and both authors cross checked the rst 4 studies only.
The recommendations for this process, although not necessary, include
at least 2 persons performing quality appraisal [40]. The heterogeneity
of the research in this eld was unsurprising and with no quality ratings
available for the reader, comparisons are difcult and recommendations
must be viewed cautiously. Furthermore, while this review includes only
studies in which PTSD symptoms were addressed and/or measured,
some study samples included participants with and without a trauma
history [58,62] or PTSD symptoms [58,62,74] such that interpretation
of these ndings is limited.
Notwithstanding the limitations, all the studies that explored the
effectiveness of their intervention reported efcacy, the majority of
some statistical signicance (see Table 3a). The ndings of this review
can advance understanding of the role of touch in the treatment of
symptoms of PTSD, the importance of therapeutic relationship in touch
delivery and can help inform clinical practitioners in decision making
regarding when touch-based treatment may be an important consider-
ation. Similarly, this information may be helpful in highlighting areas of
conceptual development of touch-based treatments and be supportive of
healthcare management in realigning services towards a more person-
focused and integrative model of healthcare.
4.2. Recommendations
With the exceptions of EFT and BOT/MABT, the other touch-based
interventions had a limited evidence base, therefore more rigorous
research designs with larger sample sizes are required in future studies.
EFT appears to have the majority number of studies indicating efcacy
of this modality, however, expanding the participant populations to non-
military and including more mixed methodologies, would support this
touch-based intervention. The scarcity of qualitative studies is notable,
more of this kind of data could help inform researchers, practitioners
and policy makers from a person-centred perspective as well as under-
stand those not interested in this approach. It would also support the
clinical therapies, which utilise touch as part of their therapy practice;
physiotherapy, occupational therapy, osteopathy, chiropractic for
example, to address the needs of their clients with symptoms of PTSD,
through specic touch intervention, where assessed as appropriate. The
extent to which this may be already happening is not clear and may be
an avenue worthy of future research.
Although, none of the studies reviewed presented any adverse re-
actions to touch-based interventions, one study, through case review,
commented on the participants preference for a deep pressure touch
application having previously experienced and further declined a ligh-
ter, slower touch treatment [56]. The type of trauma experienced, for
example either complex PTSD or combat PTSD, may prefer a different
touch technique and why this may be so requires investigation. Further
research of touch-based treatment would also do well to include
self-touch techniques and explore the different underlying neuro phys-
iological mechanisms effected by the different styles and context of
touch delivery.
Finally, in going forward, researchers would do well to clarify their
choice of PTSD diagnostic assessment tools and why, if not utilised, a
formal diagnostic interview of a complex disorder such as PTSD is not
required.
5. Conclusion
This integrative review identied touch-based interventions
currently utilised in the treatment of adults with symptoms of PTSD and
the evidence in this area indicates that touch-based treatment can play
an important role in supporting emotional regulation and reducing the
symptoms of PTSD. Although methodological rigour across all the
studies varied, the ndings are promising for advocating for touch as a
somatosensory approach to treatment of symptoms of PTSD in adults.
More research is necessary to establish a stronger theoretical basis and to
explore the mechanisms of why touch as a somatosensory approach may
Table 3b (continued )
Author and
Country
Aim of Study and Population Touch Intervention Methodology Findings Limitations, Conclusions
& choice of most appropriate
body therapy, individuals can
begin to reclaim their lives and
heal their bodies; can lead to
faster recovery when concurrent
with psychological therapy.
therapy. More research is
warranted.
KEY: ACEQ Adverse Childhood Experiences Questionnaire; APA American Psychological Association; BD The Bodily Dissociation Scale; BDI Beck Depression
Inventory; BPI Brief Pain Inventory; BSI Brief Symptom Inventory; BHS Beck Hopelessness Scale; BIS Scale of Body Investment; CAM Complementary and
Alternative Medicine; CAPS Clinician-Administered PTSD Scale; CBT Cognitive Behavioural Therapy; CES-D C-MHI Cook-Medley Hostility Inventory; CR-PTSD
Crime Related Post-Traumatic Stress Disorder; CSA Child Sexual Abuse; CSE CranioSacral Evaluation; CST Craniosacral Therapy; DERS Difculties with
Emotional Regulation Scale; DES Dissociative Experiences Scale; DTS Davidson Trauma Scale; EMDR Eye Movement Desensitisation and Reprocessing; EQ-5D
European Quality of Life; FMI Freiburg Mindfulness Inventory; HPA Hypothalamus Pituitary Adrenal IES-R Impact of Event Scale; ISI Insomnia Severity Index;
ISS Insomnia Severity Scale; KODI Korean Oswestry Disability Index; LBP Low Back Pain; LSEQ - Leeds Sleep Evaluation Questionnaire; MABT Mindful
Awareness Body Therapy; MAIA Multidimensional Assessment of Interoceptive Awareness; Mississippi Mississippi Scale for Combat Related PTSD; MPSS Modied
PTSD Symptom Scale; MYMOP2 Measure Yourself Medical Outcome Prole 2; Neuro-QoL Quality of Life in Neurological Diseases; PCL-C Post-traumatic
Checklist-Civilian; PCL-M Post-traumatic Checklist-Military; PDS-K Post-Traumatic Stress Disorder Symptoms-Korea; POMS Prole of Mood State; PSC
Physical Symptom Checklist; PSQI Pittsburgh Sleep Quality Indicator; PTSD Post-traumatic Stress Disorder; PROMIS Patient-Reported Outcomes Measurement
Information System; QOL Quality of Life Questionnaire; RMANOVA Repeated Measures Analysis of Covariance; RNA Ribonucleic Acid; RPQ Rivermead Post-
Concussion Questionnaire; RSA Respiratory Sinus Arrhythmia; SA-45 Symptom Assessment 45; SCL-90 The Psychological Symptom Checklist; SF -12 physical
symptom checklist; SF-36 Quality of Life measure; SBC Scale of Body Connection; Sig. Signicant; SOC Sense of Coherence; STAI State Trait Anxiety Inventory;
TDMS-t Two Dimension Mood Scale test; TFT Thought Field Therapy; TLEQ Traumatic Life Events Questionnaire; TSI Trauma Symptom Inventory; UCST
Upledger CranioSacral Therapy; VAS Visual Analogue Scale.
S. McGreevy and P. Boland
European Journal of Integrative Medicine 54 (2022) 102168
17
be an important intervention for persons with symptoms of PTSD and
CPTSD.
Financial support
No funding was obtained for this research project.
CRediT authorship contribution statement
Suzie McGreevy: Conceptualization, Methodology, Validation,
Investigation, Resources, Data curation, Formal analysis, Writing
original draft, Writing review & editing, Visualization. Pauline
Boland: Methodology, Validation, Investigation, Data curation, Formal
analysis, Writing review & editing, Supervision.
Declaration of Competing Interests
Suzie McGreevy is an integrative occupational therapist and utilises
somatosensory approaches in clinical private practice. Pauline Boland
has no competing interests.
Acknowledgements
This project was in part fullment of the Masters of Science in
Advanced Healthcare Practice at the University of Limerick, Ireland.
Data availability
Not applicable. All studies reviewed are contained in the reference
list.
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