RESEARCH: INVESTIGATING HUMAN TOUCH by William Evan Rivers–July 2002

Investigating Human Touch

By:
William Evan Rivers
Submitted in Partial Fulfillment
Of the Requirements for
Graduation with Honors from the
South Carolina Honors College

July 2002

Approved:
__________________________________
Dr. James Buggy
Director of Thesis
__________________________________
Dr. Kenneth Phillips
Second Reader
___________________________________
Peter C. Sederberg, James L. Stiver, or Douglas F. Williams
For South Carolina Honors College

Table of Contents:

Thesis Summary……………………………………………………………………………3
Abstract……………………………………………………………………………………5
Chapter 1: Introduction and Literature Review……………………….…………………..6
Chapter 2: Method………………………………………………….……………………20
Chapter 3: Results…………………………….………………….………………………27
Chapter 4: Discussion…………………………………………….………………………37
Acknowledgments……….……………………………………….………………………45
References.……………………………………………………….……………………….46
Appendix I…………………………………………………………………………….…54
Appendix II………………………………………………………………………………55
Appendix III………………………………………………………………………………56
Appendix IV………………………………………………………………………………57

List of Figures:
Figure 1. Change in State Anxiety Over Intervention Period……………………………29
Figure 2. Heart Rate vs Time..…………………..…………………………………….…31
Figure 3. LF Power vs Time……………………………………………………………..32
Figure 4. MF Power vs Time…………………………………………………………….33
Figure 5. HF Power vs Time……………………………………………………………..34
Figure 6. LF/HF Ratio vs Time……………………………………………………….….35
Figure 7. MF/(LF+HF) Ratio vs Time……………………………………………………36

List of Tables:
Table 1. Perceived Stress Scale Scores and Trait Anxiety Inventory Scores by Group..28
Table 2. State Anxiety Inventory Means by Group……………………………………..30
Table 3. Heart Rate Measured During the Experimental Periods…………………….…31
Table 4. LF Power Measured During the Experimental Periods..……………………….32
Table 5. MF Power Measured During the Experimental Periods..………………………33
Table 6. HF Power Measured During the Experimental Periods….….…………………34
Table 7. LF/HF Ratio Measured During the Experimental Periods……………………..35
Table 8. MF/(LF+HF) Ratio Measured During the Experimental Periods…………..….36

Thesis Summary

Everyone understands on some level that touch has the power to soothe pain and suffering, so it seems no surprise that touch has been practiced throughout human history to encourage a state of well-being, whether it be simple and intuitive like a mother’s caress, or elaborate and liturgical like a religious ritual. Recently, scientists began investigating the possible measurable effects such therapies may induce in the physiology of the body.

This study assesses the effectiveness of a touch healing technique, Bio-TouchTM, in inducing relaxation and engaging the body’s healing processes. Bio-TouchTM has been anecdotally and experimentally shown to relieve pain, reduce stress, and influence some biological indicators of wellness. Self-reported anxiety tests and a heart rate monitor were used to measure important factors in the healing process.

The experiment was set up with three groups – a Bio-TouchTM group, a touch group, and a time control group. The Bio-TouchTM group received a ten-minute Bio-TouchTM session. The touch group received a ten-minute touch intervention that resembled Bio-TouchTM, but that the Bio-TouchTM sets were not performed. The time control group received no interaction during the ten-minute intervention period. Each group filled out an anxiety survey before and after the ten-minute intervention period. Heart rate was monitored continuously for twenty minutes: five minutes pre-intervention, two five-minute blocks of the ten-minute intervention period, and five minutes post-intervention. The results of the various analyses were compared to find significant differences between pre- and post- measures and between all of the five-minute blocks of heart rate information.

This study reports that a ten-minute Bio-TouchTM intervention reduces anxiety, reduces heart rate, and changes the rhythm of the heart. The changes in the heart rate and rhythm indicate a shift in the body’s nervous system towards activation of healing processes, as well as a change in emotional state. The touch intervention also reduces anxiety, reduced heart rate, and changed heart rhythm. The changes reflect activation of healing processes, but not change in emotional state. The control group did not have any significant change in any of the measures.

These findings indicate that short-term applications of touch can immediately improve a person’s state of mind and body, and confirm the possibility that touch can positively affect health in a more global sense. They also suggest that there may be more to the Bio-TouchTM technique than can be experienced through casual touch. More research should be done to further explore these findings, and meanwhile, touch should continue to be enjoyed and appreciated for its comforting and healing benefits.

Abstract

Self-reported anxiety and analysis of heart rate variance were used in this study to evaluate the physiological response to the Bio-TouchTM touch healing intervention. This study reports that anxiety, heart rate, and the low-frequency/high-frequency (LF/HF) ratio derived from the power spectral density (PSD) of heart rate variance (HRV) in recipients of Bio-TouchTM decreased significantly during the ten-minute intervention. This study also found that light touch performed in the same manner as Bio-TouchTM, but without the Greeting or specific points outlined in the Bio-TouchTM manual, also resulted in reduced anxiety, heart rate, and LF/HF ratio. The Bio-TouchTM group, however, also showed reduced mid-frequency (MF) power activity and activity in the mid-frequency/(high-freqency + low-frequency) (MF/(HF+LF)) ratio, which may indicate activity on the emotional level.

These data indicate that a light touch administered for ten minutes directly to the skin in a controlled environment can have a profound short-term impact on human psychology and physiology, and also that there may be more to the technique of Bio-TouchTM than experienced through casual touch.

 

Introduction

And

Literature Review

Investigating Human Touch

There is wide consensus and much recent evidence that psychological distress is a prominent factor in the development of disease, especially cardiovascular disease (Mitka, 2002; May et al., 2002; Black & Garbutt, 2002). In addition to this information, there is evidence that stress management and mind-body interventions can reduce the risk of some kinds of heart disease (Blumenthal et al., 2002). When used as treatment for both mental and bodily disorder and disease ranging from cardiovascular disorders to chronic pain, there is evidence that mind-body interventions are effective – some even as effective as pharmaceutical treatment (Caudill, 1994; Benson, 1996). For some disorders, such as panic disorder, depression, and headaches, mind-body interventions are more effective treatments than pharmaceuticals, especially in the long-range maintenance of health (Jacobs 2001; Hermann, Kin, & Blanchard, 1995; DeRubeis et al., 1999). Research suggests that mind-body and relaxation interventions can enhance immune function (Kiecolt-Glaser & Glaser 1988).

In addition to the health benefits for the recipient, relaxation treatments have several other benefits: economic, biologic, and psychological. The economic benefits are reaped in reducing the amount of time patients spend directly in the health care system (from the reduced number of doctor’s visits and shortened hospital stays), reducing their dependence on pharmaceuticals so that long-term health care costs are reduced, and the instruction in and administration of these interventions can often be performed by non-professionals in group situations (Lorig, Mazonson, & Holman,1993). The biologic benefit (aside from the health benefits) is that dependence on pharmaceuticals with undesirable and toxic effects is decreased (Jacobs, 2001). Jacobs (2001) states that the psychological advantage of including mind-body approaches in health practices is that a patient’s sense of self-control and self-efficiency are developed, which are key to predicting improved health outcome.”

Bio-TouchTM is a touch intervention that has been used to address stress as well as disease symptoms. It can be described as a relaxation/mind-body intervention. Recipients of Bio-TouchTM report reductions in stress and pain, as well as increase in feeling “cared for.” (Bucky & Schwartz, 2000) These reports provide evidence that Bio-TouchTM can be used as an effective supplement to conventional medical practices to help in the prevention and treatment of disease states. Bio-TouchTM has been only recently scientifically assessed, though research into its effectiveness could provide insight into the benefits of the relaxation response and a better understanding of how Bio-TouchTM could be best used in health care.

Statement of the Problem

Medical research on touch therapies has historically been inconsistent and at times unscientifically performed (Eskinazi & Muehsam, 1999). The reviews of research on CAM therapies, whether well performed or not, have been divided and polarized between supportive CAM and nursing journals and opposing allopathic journals (Eskinazi & Muehsam, 1999). Controversy concerning the field of touch healing specifically has arisen questioning the scientific nature of the research and the validity of the concept of the “energy field.” (Rosa, Rosa, Sarner, & Barret, 1998) Some touch therapies use this framework to describe the effects of their technique (Krieger, 1979; Wardell, 2001). Western medicine doubts the existence of a “human energy field” and science’s ability to measure it if it does exist, since medical science has been rather exclusively biochemical (Eskinazi, 1999). Nevertheless, there continue to be reports of improvement in health that accompany such treatments. Despite the controversy that surrounds this research, CAM therapies can be scientifically studied to evaluate their efficacy and modus operandi through careful experiment design. This study will study the psycho-physiological effects of Bio-TouchTM, whose healing potential has been reported anecdotally, but studied minimally scientifically (Bucky & Schwartz, 2000). This study will sidestep some possible controversy because Bio-TouchTM is a touch healing modality wherein the associate does not purport to manipulate energy fields, though recipients do report positive “healing” effects after treatment.

Significance of the Problem

Recipients of the touch intervention Bio-TouchTM have anecdotally reported decreases in stress level, increased rate of healing, and increased feeling of being cared for. Some of these reports have been supported by data reported from the University of Arizona (Bucky & Schwartz, 2000). The accessibility of and ease with which Bio-TouchTM can be learned makes it a useful potential complementary health care practice if it is shown to significantly affect the mood and physiology of individuals to enhance the mechanisms of the healing process.

Background of the Problem

Introduction to CAM

Interest is growing within the medical field in what is called complementary and alternative medicine (CAM). Western medicine has not traditionally taught these therapies or made them available to patients in its hospitals (Eisenberg et al., 1993). Recently, however, in response to the burgeoning popularity of CAM interventions in the west (Paramore, 1997; Landmark Healthcare, 1997; Eisenberg et al., 1998), more and more attention has been directed to discovering why such therapies are attractive to both clinicians and patients, how pervasive the utilization of such treatments is within the American population, and what implications these practices might have for the health care system (Eisenberg et al., 1998; Studdert et al., 1998; Pelletier, Marie, Krasner, & Haskell, 1997). CAM treatments include meditation and relaxation exercises, herbal remedies, visualization, biofeedback, nutrition and dietary supplements, acupuncture, chiropractic, massage, self-help, homeopathy, prayer, touch healing techniques, energy healing, and forms of spiritual healing (Eisenberg et al., 1998; Flynn, 1980). This classification, therefore, includes diverse practices, most of which have little or no scientific research to evaluate the claims of their effectiveness. Research in some fields of CAM, such as acupuncture, herbal remedies, and touch healing are increasingly being funded by research organizations, but controversy surrounds the research and the conclusions that are drawn from the research. What seems to be true despite the disputes within the scientific community is that the public is receptive to CAM, and that some treatments offered by CAM have potential to help the healing process.

Touch Healing’s Place in CAM

Among the CAM interventions available, none seems to receive more attention from both supporters and detractors than touch healing. There are many modalities of touch healing, the most prominent of which (Reiki TouchTM, Therapeutic TouchTM, Healing TouchTM) ascribe their power to heal to the ability to manipulate the human energy field (Kreiger, 1979; Kreiger, Peper, & Ancoli, 1979; Wardell & Engebretson, 2001). These understandings of the human energy field often come from Eastern metaphysical constructions, such as the Japanese concept of ki, or the Indian concept of prana, both of which can be understood as energy (Wardell & Engebretson, 2001; Krieger, 1975). The practitioner of these touch therapies is understood to sense and manipulate energy with his or her will and body (Wardell & Engebretson, 2001; Malinski, 1993). The primary benefit derived from these energy/touch-healing techniques is relaxation and stress reduction (Wardell & Engebretson, 2001; Krieger et al., 1979), which is directly related to the function of the immune system and many disease states (Shelby & McCance, 1998).

The human response to a stressful stimulus is one that affects the nervous system, and through it, the endocrine system and the immune system (see Fig 9-3A of Shelby & McCance, 1998). The stress response, also known as the “fight or flight” response, is marked by the activation of the sympathetic nervous system and suppression of the parasympathetic nervous system, which then causes the secretion of chemicals that lead to the production and secretion of stress hormones. The stress hormones, particularly cortisol, inhibit the synthesis of immunoglobulin, reduce blood populations of eosinophils, lymphocytes, and macrophages, and promote atrophy of lymphoid tissue in the thymus, spleen, and lymph nodes. Cortisol has many effects on human physiology, which may be adaptive to channel the body’s energy into an immediate survival situation. The effects of cortisol include the reduction of the body’s ability to mount an immune response, through many mechanisms from inhibition of protein synthesis and immune cell production to relocation of immune cells from the bloodstream to reduced fibroblast function at the site of an inflammatory response. The overall result is the inhibition of the immune system. (The information from this paragraph was taken from Shelby & McCance, 1998. See Appendix II.)

Research has been performed to assess the validity of touch healing techniques, but the results are inconsistent – scientific journals express biased opinions of CAM therapies, according to CAM supporters, publishing only those studies that seem to debunk complementary treatments (Eskinazi & Muehsam, 1999). CAM journals and nursing journals assert that CAM treatments in conventional journals are misrepresented, and point out that the studies that debunk CAM treatments, even when they exhibit poor scientific merit and obvious bias, are published in prestigious medical journals while well designed studies that support CAM treatments are not published (Eskinazi & Muehsam, 1999). This is especially applicable to touch healing, because of the highly visible Rosa et al. (1998) paper that claimed to prove the illegitimacy of Therapeutic Touch. That paper was published in the Journal of the American Medical Association, despite its questionable citations and assertions that were far extrapolated from the scope of the study (Eskinazi & Muehsam, 1999). Eskinazi and Muehsam (1999) point out that there have been well written studies that report data that contradict Rosa’s findings, but that have been largely unaddressed by the medical community (Schwartz, Russek, & Beltran, 1995). The exclusivity of the biomedical paradigm that guides medical research means that the medical field does not seriously consider healing practices that offer an energetic framework.

Introduction to Bio-TouchTM

Bio-TouchTM, also known as Bio-Magnetic Touch HealingTM, is a touch healing technique that is intended to “encourage the body toward healing itself and restoring its harmony.” (IFBM, 1997, p. 2) The technique consists of the associate lightly touching specific points directly on the skin of the recipient with the index and middle fingers of each hand (IFBM, 1997; Learn Online, 1996). It is simple, easy to learn, and there is anecdotal evidence that it can be used in conjunction with conventional and alternative health practices to help encourage and maintain a state of health (IFBM, 1997). It is open to anyone to learn, and the literature states that beginners are just as effective as experienced practitioners (IFBM, 1997; Justtouch.com, 1996). It has a number of practitioners and recipients in the US and internationally of all ages, with centers and chapters in Arizona, Hawaii, California, Brazil, the Philippines, and recently in Egypt. It is currently being researched in the Human Energy Systems Laboratory of the University of Arizona, and the research findings show significant psychological and physiological effects of Bio-TouchTM (Bucky & Schwartz, 2000).

Bio-TouchTM is taught and administered by the International Foundation of Bio-Magnetics (IFBM) and its representatives. The IFBM is a non-profit, tax-exempt educational foundation that is based in Tuscon, Arizona, and Honolulu, Hawaii that is supported entirely by donations (FAQ#12 IFBM, 1996). The foundation offers sessions and instruction in Bio-TouchTM to anyone who is interested, and it publishes a manual and video that detail the method (IFBM, 2000). The IFBM practitioners, administrators, and researchers are all volunteers, and sessions of Bio-TouchTM are given to any who make an appointment entirely on a donation basis (Bucky & Schwartz, 2000; Phelps, 2000). There are no hierarchies of effectiveness of Bio-Touch – everyone is just as effective as everyone else who follows the technique as presented (IFBM, 1997; Justtouch.com, 1996) – but there are Certified Practitioners and Certified Instructors to maintain standards for training of IFBM representatives (Classes, 1996). The IFBM does not propose a framework to describe the effects of Bio-TouchTM and it is open scientific investigation its mechanisms (IFBM, 1997; Bucky & Schwartz, 2000; FAQ#6, 1996). The IFBM has no religious affiliations, promulgates no spiritual guidelines or frameworks, and does not require centeredness, awareness of energy field, or certain state of mind (IFBM, 1997; Justtouch.com, 1996).

Here is a brief summary of the Bio-TouchTM procedure, selected from the handbook, A Presentation of Bio-Magnetic Touch Healing (IFBM, 1997). When using Bio-TouchTM, there is a “recipient,” who receives and benefits from the touch therapy, and an “associate” who administers the touch. The technique is performed using a very light touch directly on the skin (there should be no pressure at all, excepting the “Lower Abdomen” set), most often with the index and middle fingers of both hands, for six to eight seconds at each point. A “point” is a place on the recipient’s body. There is also a kind of touch called a “sweep”, in which the fingers are moved in constant contact slowly across the recipient’s skin. A “set” is a collection of points and sweeps that is used to address a certain condition or body part. “Enhancements” are performed using points and sweeps that are not necessarily associated with sets, but are used to address pains or conditions that do not have a specific sets, or as an extension of a set. Bio-TouchTM always begins with the “Greeting” set, which is the only set that uses only the dominant hand. Sets and enhancements as appropriate are selected by the recipient and the associate to follow the “Greeting” set (See Appendix IV).

This technique has all of the components to be a great asset to public health. It is cheap and simple to learn, there are no hierarchies or limitations to effective practice based on physical, mental, social, economic, educational or political boundaries. It does not violate or challenge belief systems, does not purport to take the place of medical practice, requires minimal training, and it is taught and offered for free by volunteers. Once it is learned, it can be performed under nearly any circumstances. In addition, it is not invasive and has not been reported to be harmful, and if the associate touches according to the procedure, it cannot be irresponsibly performed. Due to its simplicity and the charity of its purveyors, this technique has the potential be a supplement to strained health care systems throughout the world at individual, familial, and institutional levels.

The effectiveness of Bio-TouchTM must be assessed so that its limitations and possibilities as a supplemental intervention can be more fully understood. The most informative ways to measure its ability to encourage healing processes are through psychometric and physiological data. There are already data from the Human Energy Systems Laboratory that indicate significant decrease in stress and pain levels from pre- to post-session, as well as decrease in systolic blood pressure from pre- to mid-session (Bucky & Schwartz, 2000). These studies also show that Bio-TouchTM is more effective than touch through clothing and no touch at all. These are promising preliminary data, but there were limitations to these studies. The greatest limitation is the lack of control group in the stress, pain, and blood pressure measures (Bucky & Schwartz, 2000). Regardless, the data were consistent across gender and location for the data taken, and consistent with the hypothesis suggested by the anecdotal evidence.

Purpose

The purpose of this study is to evaluate the effectiveness of Bio-TouchTM in helping encourage the healing process by inducing relaxation through the mind, the autonomic nervous system, and the endocrine system. The secondary purpose of this study is to assess if Bio-TouchTM has a different effect than a continual light touch on the skin. The design of the experiment should show whether the Bio-TouchTM Greeting, Head, and Neck sets plus Enhancements have a different effect on the body than a light touch without the Greeting or the sets.

According to psychoneuroimmunology and psychoneuroendocrinology, all of the factors measured are important in the functioning of the immune system. The instruments were chosen with the time scale of the experiment in mind – a response could be measured in any of the measures.

The body’s response to Bio-TouchTM may follow a progression that takes place over a longer period than is feasible to study at this time. Some physiological markers may not significantly change during the experiment period, and that also is important information that is useful in the understanding of the effectiveness of Bio-TouchTM.

Theoretical Framework

The relaxation and stress reduction framework provides an appropriate framework for this study, since recipients of Bio-TouchTM report both stress reduction and improved healing. It incorporates through the assertions of psychoneuroendocrinology and psychoneuroimmunology the complex interplay of the psyche, the nervous system, the endocrine system, and the immune system. The body’s response to stress includes change in autonomic nervous system tone toward the dominance of the sympathetic nervous system, activation of the adrenocorticoid hormones such as cortisol, and the perception of anxiety. The body’s response to relaxation is the reversal of these processes. Response to stimulus, whether stressful or relaxing, is both psychological and physiological, and each process influences the other, since the central nervous system innervates the organs of the immune and endocrine systems (Wardell & Engebretson, 2001).

Theoretical Definitions

Bio-TouchTM – The touch intervention (also known as Bio-Magnetic Touch HealingTM or BMTHTM) that is taught and administered by the International Foundation of Bio-Magnetics, especially in the handbook: A Presentation of Bio-Magnetic Touch Healing (1997).

Relaxation – as a state it is the absence of stress; as a process it is the reversal of stress processes in the body (Wardell & Engebretson, 2001).

State Anxiety – an emotional state that is characterized by subjective feelings of tension, apprehension, nervousness, and worry (Spielberger, 1983, p. 4)

Stress – the internal perception of an event that elicits a state of anxiety, which is mediated by an individual’s cognitive and emotional processes (Hubbard and Workman 1997 p 300). Also, the biological response to stressful situations, namely, autonomic nervous system activation (particularly the sympathetic nervous system) and activation of the hypothalamic-pituitary-adrenocortial (HPA) axis (Workman, 1997, p. 302).

Autonomic nervous system tone – the relative dominance of the sympathetic or parasympathetic branch of the autonomic nervous system (Tiller, McCraty, & Atkinson, 1996).

Cortisol level – the concentration of free cortisol in the bloodstream. This level can be assessed by measuring cortisol in the saliva. Cortisol is the hormone that is indicative of the activation of the HPA axis. It is released in times of stress, has many metabolic effects, and acts as an immunosuppressant (Shelby & McCance, 1998).

Hypotheses

Bio-TouchTM is an intervention that relies on mental and physical relaxation processes. Bio-TouchTM has a different effect than light touch on the skin.

Supporting statements:

  • If Bio-TouchTM is a healing intervention that relies on relaxation through action on the autonomic nervous system, there will be a decrease in heart rate, a reduction of the LF/HF ratio of heart rate variance during the session in the Bio-TouchTM group that is statistically significant and exceeds the response from the time control group. Other data from the heart rate variance power spectrum will yield important information about the effects of Bio-TouchTM. An example of this is to use the MF/(LF+HF) ratio as a tentative glance into the reported effect of

“feeling cared for.” (Bucky and Schwartz 2000)

  • If Bio-TouchTM acts through action on the endocrine system, there will be a significant drop in salivary cortisol pre- and post- session in the Bio-TouchTM group that exceeds the response from the control groups.
  • If Bio-TouchTM acts through psychological mechanisms, there will be a decrease in reported anxiety between pre- and post-intervention state anxiety scores that exceeds the response from the control groups.
  • If the touch group differs significantly from the time control group, it indicates any activity that a light touch intervention may have on the body.
  • Any significant differences found between the touch group and the Bio-TouchTM group as a result of the intervention will indicate activity inherent to Bio-TouchTM that is not inherent in light touch alone.

Method

 

Methods

Research Design

Quasi-experimental – There was a convenience sampling process and a random assignment of participants to groups, a control group, and manipulation of the variable, touch.

Sample

The sample consisted of 48 participants: 16 participants in each of the three groups. Participants were adults (mostly students) recruited from the USC – Columbia and MUSC campus using mostly the psychology participant pool though also through notices posted on campus giving relevant information on the study. Each participant was randomly assigned by a predetermined random number table to one of the three groups.

Operational definitions

Cortisol. The concentration of saliva cortisol measured by a radioimmunoassay of the saliva samples.

Autonomic nervous system tone. Indicated by the LF/HF ratio in the power spectral density of heart rate variability (Tiller et al., 1996, McCraty, Atkinson, Tiller, Rein, & Watkins, 1995). Activity of the parasympathetic nervous system is indicated by increased power in the HF band, and activity of the sympathetic nervous system is indicated by increased power in the LF band.

Stress – the presence of psychological and physiological stress indicators, elevated heart rate, dominance of the LF band in the power spectral density of heart rate variability, and a high score on the Spielberger State Anxiety Inventory.

Relaxation – reduced heart rate, dominance of the HF band in the power spectral density of heart rate variability, and decreased score on the Spielberger State Anxiety Inventory.

Experimental Period – the five five-minute periods when the heart rate data were collected were considered the experimental periods.

Intervention Period – the second and third five-minute periods, when the subject either received a touch or no touch as per the protocol.

Recovery Period – the fourth five-minute period that follows the Intervention Period.

Instrumentation

Spielberger State-Trait Anxiety Inventory Form Y (STAI). The State Anxiety Inventory (SAI) has been shown to be reliable for the measurement of anxiety at a point in time, including a point in time in the recent past. The Trait Anxiety Inventory (TAI) is useful for measuring relatively stable individual differences in the perception of stressful situations as dangerous or threatening. In addition, both have been shown to be a reliable measure for student and working populations, those with whom the researchers will likely be working. A high score on this inventory indicates a high level of anxiety. The alpha coefficients for the SAI among college students is .91 for males and .93 for females, and .93 for working adults, both male and female. The Trait Anxiety form alpha coefficients among college students are .90 and .91 for males and females, respectively, and .91 for working adults, both sexes. (All information from Spielberger, 1983.)

Heart Rate and Heart Rate Variability. Heart rate is a reliable measure of stress response and relaxation (Workman, 1998, p. 302-303). Heart rate variance (HRV) is a measure that has recently been studied as a way to gauge the activity of the autonomic nervous system through the variation in the heart’s rhythm. The autonomic nervous system acts on the sinus node of the heart, thereby modulating heart rate (Tiller et al., 1996, Figure 1). Power spectral analysis of heart rate variance began in 1981 with Akselrod et al., who first drew the correlation between the appearance of sympathetic and parasympathetic nervous functioning in the power spectrum of heart rate variance. Since then, HRV has been used as a predictor of mortality among healthy adults, post-myocardial-infarction patients, and other patients with heart conditions (Stein & Kleiger 1999). HRV was very useful in this study, because it was capable of measuring directly and non-invasively the activity of the autonomic nervous system. It was used to ascertain the relative dominance of the sympathetic nervous system, which is responsible for the stress response, and was also used to reveal the effects of elusive changes in psychological state, such as emotion (Tiller et al., 1996; McCraty et al., 1995). (See Appendix II).

Heart rate and heart rate variability were measured using a Polar T-31 thoracic belt monitor. This apparatus did not require external electrodes or wires (the electrodes are embedded in the plastic of the device). Data reported at 5kHz +/- 10% through low-frequency electromagnetic pulses directly to an adjacent computer data collection system provided by Vernier. Data are collected at a frequency of 100 Hz. This system recorded heart rate through R to R intervals measured at EKG accuracy (Vernier, 2001). Polar instruments have been shown to have Holter instrument accuracy repeatedly since 1990 (Polar, 2002). The data was automatically entered into the Vernier Logger-ProTM Data Management program, to be processed and analyzed.

Perceived Stress Scale – This scale was used as part of the demographic data form to ascertain the levels of stress of the subjects during the last month of their lives. It was the most widely used psychological instrument for measuring the perception of stress. High scores on the PSS are associated with high levels of stress. This instrument was chosen to give a baseline of stress within and between the experimental groups. The internal consistency coefficients of this measure fall between .84 and .86, and test-retest correlations among college students were .85 (Workman, 1998, pp 301).

 

Procedure

The procedure began with a description of the protocol as presented in this section. The researcher then reviewed the informed consent form with the subject. The demographic data form was then presented and completed by the subject, following which the heart monitor was placed on the thorax of the individual. The subject was asked not to talk conversationally or sleep during the experimental period. There was then a five-minute rest period following which the first saliva sample and State Anxiety Inventory were obtained. There followed a ten-minute rest period, during the last five minutes of which heart-rate data were collected continuously (Experimental Period “1”). The participant was then informed as to which intervention they would receive. There was then a ten-minute test period, during which the Bio-TouchTM intervention, the casual touch intervention, or the time-control lack of intervention took place (see below). Heart-rate data was taken continuously in two five-minute epochs during this time (Experimental Periods “2” and “3” which are also referred to as the Intervention Periods). After this test period was a ten-minute rest period, the first five minutes of which heart-rate data was recorded continuously (Experimental Period ‘5’ which is also referred to as the Recovery Period). After this final rest period, the heart monitor was removed and the final saliva and State Anxiety Inventory samples were taken. The subject was then debriefed.

Procedure for test period interventions (See Appendix IV and page 10):

  1. Bio-TouchTM: Greeting, Head, Neck, Enhancements on neck and head
  2. Casual touch: Enhancements on neck and head
  3. Time Control: No interaction with subject

Data Analysis

Pre- and Post-Intervention State Anxiety Inventories, heart rate, and heart rate variance measures were analyzed using paired t-tests. The difference between baseline (Experimental Period 1) and data from the other Experimental Periods was computed and subjected to t-tests with an alpha coefficient of 0.5.   The data from unclear instrument signals were discarded. Statistical outliers (values more than 2 standard deviations from the mean) were removed from the data sets to help smooth the data – this process is especially important considering the relatively small sample size, but it can also compromise the validity of the data. It was decided that smoothing the data to look for trends was the most important part of a preliminary study such as this one.

The power spectral analysis of heart rate variability waveform was performed on the R to R interval tachogram by taking the successive discrete series of R to R duration values from the heart-rate monitor signal and subsequently transforming the data by the Fast Fourier technique. The Fast Fourier data were then separated into spectral components and analyzed. A program written explicitly for the given data format performed the process of peak detection. Fast Fourier Transform, power spectral density, and time domain measurements were performed with data processing software from Nevrokard obtained from the Internet on a time-sensitive license (Nevrokard, 2002).

Time domain data and Fast Fourier Transforms were analyzed by dividing the power spectra into three frequency regions, low frequency, or LF (.01-.05), mid frequency, or MF (.05-.15), and high frequency, or HF (.15-.5) [all frequencies in Hz]. The integral of the total power in each region as well as the LF/HF ratio and MF/(LF+HF) ratio were computed.

The LF, MF, and HF integrals are indicative of sympathetic, mixed sympathetic and parasympathetic (with a predominance of parasympathetic), and parasympathetic autonomic nervous system activity, respectively. The total power gives an indication of the rhythmicity of the heartbeat. The LF/HF ratio is an indicator of sympathovagal balance, or the activity of the sympathetic nervous system relative to the activity of the parasympathetic nervous system. The MF/(LF+HF) ratio has been found to be sensitive to changing emotional states, so it may be an interesting measure to further investigate the findings reported by Bucky and Schwartz (2000) of recipients of Bio-TouchTM feeling cared for. (McCraty et al., 1995; Tiller et al., 1996)

Cortisol Assay

The salivettes were collected and refrigerated as per the protocol, but the laboratory was not able to perform the cortisol assay. Samples remain in refrigerated storage.

Chapter 3:

Results

Demographic Data
There were 48 participants in the study, 30 of whom were female, and 18 of whom were male. 39 of the participants were self-identified Caucasians, 6 were self-identified African Americans, and 3 were self-identified Asian Americans. 33 of the participants had no experience with complementary therapies and forty had no experience with touch therapies. Most of those familiar with touch therapies indicated that they were also familiar with Bio-TouchTM.

The average age of the participants was 24.7 years. The average age of the Bio-TouchTM group was 26.7, while the average age of the time control group and the touch group are 23.1 and 24.3 respectively. 10 of the males were in the control group, an imbalance that resulted from random assignment of participants to the experimental groups. There were 5 males in the Bio-TouchTM group and 3 in the touch group. Males and females showed the same cardiovascular trends within groups.

 

Table 1. Perceived Stress Scale Scores and Trait Anxiety Inventory Scores by Group

 

PSS SD TAI SD
biotouch 12.94 4.99 biotouch 33.69 6.54
control 16.94 4.12 control 38.63 7.61
touch 14.50 5.27 touch 34.94 7.78
 

PSS, Perceived Stress Scale; TAI, Trait Anxiety Inventory; SD, standard deviation.

 

Out of the 48 participants, 7 did not regularly consume caffeine, 14 consumed less than two cups of caffeinated beverages a day, 25 consumed less than 5 caffeinated beverages a day, and 3 consumed more than 5. There were 38 non-smokers in the sample, with 4 who smoke but less than 5 cigarettes a day, and 6 who smoke more than 5 cigarettes a day. The smokers and caffeine consumers were evenly distributed between the groups.

The sample had 10-item Perceived Stress Scale (PSS) and Trait Anxiety Inventory (TAI) scores of 14.79 and 35.75, respectively. The group averages for these instruments are given in Table 1. The PSS score correlated highly with the TAI score, with a Pearson’s R of 0.766 and a p value of <0.01. This correlation held for all three experimental groups.

Anxiety Scale Data
Instrument responses from State Anxiety Inventory pre- and post-intervention and difference values are reported in Table 2. State Anxiety Inventory scores from the pre-intervention period that did not, by the nature of the scale, permit a difference to be reported were discarded so that they should not skew the average. The data show that both the Bio-TouchTM and touch groups show a significant change in SAI score after the intervention period while the time control group does not.

 

Table 2 State Anxiety Inventory Means by Group

 

Group           SAI Pre-Intervention       SD       SAI Post-Intervention     SD

Biotouch 26.18 5.19 23.64 4.82
Control 31.36 5.76 30.07 4.42
Touch 27.55 5.47 24.45 4.90
SD indicates standard deviation; ns, not significant.
SAI change as compared to baseline
Post-SAI – Pre-SAI SD p value
Biotouch -2.55 2.42 <0.01
Control -1.29 3.75 ns
Touch -3.09 3.62 0.02

 

Cardiovascular data

Tables 3-8 provide cardiovascular data for the subjects. These results can be seen as well on Figures 2-7, where the change in the spectral density and average heart rate over the intervention periods can be easily visualized. Notice that some of the p values may seem unusual compared to the numbers around them. Variable sample sizes between intervention periods within the same group (a necessity in this case) cause such phenomena.

Note that the control group did not show a significant change in any of the parameters studied. The touch group showed a significant change in the LF/HF ratio and in heart rate during the two intervention periods. The Bio-TouchTM group showed significant change in MF and HF power as well as in the MF/(LF+HF) ratio during the third experimental period, and also showed significant change in both LF/HF and heart rate during both of the intervention periods. There was no significant correlation between the change in SAI score and change in any of the cardiovascular measures. There was also no significant correlation in the PSS or TAI and the change in SAI score.

 

 

Table 3. Heart rate measured during the experimental periods.

 

Baseline SD 2 SD 3 SD 4 SD
Biotouch 76.66 3.93 71.20 3.71 70.02 3.28 75.30 3.25
Control 71.34 5.54 71.33 4.88 70.52 6.58 72.91 4.46
Touch 78.71 6.29 70.13 8.29 71.43 8.67 76.10 6.75
 

Heart rate given in beats per minute; experimental period 1 is marked “baseline,” experimental periods 2 and 3 are the intervention periods, experimental period 4 is the recovery period; SD, standard deviation; ns, not significant.

Heart rate change as compared to baseline
2 – 1 SD p value 3 – 1 SD p value
Biotouch -6.01 5.08 <0.01 Biotouch -6.15 4.15 <0.01
Control -0.01 2.34 ns Control -0.82 2.57 ns
Touch -8.07 3.49 <0.01 Touch -7.06 4.02 <0.01
4 – 1 SD p value
Biotouch -1.34 3.31 ns
Control 1.10 3.48 ns
Touch -2.09 3.73 ns
Table 4. LF power measured during experimental periods.

 

Baseline SD 2 SD 3 SD 4 SD
Biotouch 45.52 27.45 36.23 34.34 36.42 7.59 42.84 19.45
Control 41.78 27.34 46.70 25.99 43.75 30.85 48.13 40.35
Touch 49.11 41.36 29.50 29.42 35.92 25.87 37.12 24.42
 

Power given in ms2/Hz; experimental period 1 is marked “baseline,” experimental periods 2 and 3 are the intervention periods, experimental period 4 is the recovery period; SD, standard deviation; ns, not significant

LF power change as compared to baseline
2 – 1 SD p value 3 – 1 SD p value
Biotouch -12.48 32.69 ns Biotouch -9.10 28.14 ns
Control 4.77 25.80 ns Control 1.59 26.03 ns
Touch -19.83 46.39 Ns Touch -17.25 40.01 ns
4 – 1 SD p value
Biotouch -8.41 26.00 ns
Control 7.60 45.39 Ns
Touch -8.27 34.87 Ns

 

Table 5. MF power measured during the experimental periods.

BaselineSD2SD3SD4SDBiotouch48.119.7347.6519.7441.4813.1252.5714.07Control44.7423.0743.7421.9643.2226.8545.6223.39Touch51.1022.3051.5518.6047.3120.3357.8919.27

Power given in ms2/Hz; experimental period 1 is marked “baseline,” experimental periods 2 and 3 are the intervention periods, experimental period 4 is the recovery period; SD, standard deviation; ns, not significant.

MF power change as compared to baseline  2 – 1SDp value 3 – 1SDp value Biotouch-2.7715.08NsBiotouch-8.499.030.01 Control-0.029.83NsControl-1.5215.77ns Touch-1.4817.59NsTouch-5.5418.11ns  4 – 1SDp value Biotouch0.789.51Ns Control1.619.28Ns Touch4.4111.91Ns

 
Table 6. HF power measured during the experimental periods.

BaselineSD2SD3SD4SDBiotouch41.5012.4446.7619.2752.9113.2740.3412.25Control47.7126.0648.2223.4047.9627.7244.0625.58Touch39.9122.4943.6918.8945.7519.5635.2220.64

 

Power given in ms2/Hz; experimental period 1 is marked “baseline,” experimental periods 2 and 3 are the intervention periods, experimental period 4 is the recovery period; SD, standard deviation; ns, not significant.

HF power change as compared to baseline  2 – 1SDp value 3 – 1SDp value Biotouch7.3916.25NsBiotouch13.2611.76<0.01 Control-0.259.36NsControl0.2511.87ns Touch4.7214.96NsTouch7.9718.58ns  4 – 1SDp value Biotouch2.019.15Ns Control-4.718.74Ns Touch-3.2912.85Ns

 

 

Table 7. LF/HF ratio measured during the experimental periods.

 

Baseline SD 2 SD 3 SD 4 SD
Biotouch 1.23 0.84 1.18 1.43 0.94 0.89 1.47 1.13
Control 1.29 1.18 1.35 0.99 1.50 1.28 1.73 2.22
Touch 2.14 2.56 0.75 0.86 1.15 1.49 1.51 1.51
 

Experimental period 1 is marked “baseline,” experimental periods 2 and 3 are the intervention periods, experimental period 4 is the recovery period; SD, standard deviation; ns, not significant.

LF/HF change as compared to baseline
2 – 1 SD p value 3 – 1 SD p value
Biotouch -0.51 0.78 0.05 Biotouch -0.53 0.84 0.05
Control 0.04 1.16 Ns Control 0.30 1.05 ns
Touch -1.49 2.29 0.04 Touch -1.32 2.24 0.05
4 – 1 SD p value
Biotouch -0.17 0.70 Ns
Control 0.45 2.16 Ns
Touch -0.34 1.28 Ns

 

 

 

Table 8.   MF/(LF+HF) ratio measured during the experimental periods.

 

Baseline SD 2 SD 3 SD 4 SD
Biotouch 0.70 0.47 0.71 0.53 0.46 0.21 0.70 0.30
Control 0.68 0.71 0.55 0.46 0.62 0.64 0.76 0.83
Touch 0.82 0.76 1.15 1.27 0.72 0.58 0.84 0.44
 

Experimental period 1 is marked “baseline,” experimental periods 2 and 3 are the intervention periods, experimental period 4 is the recovery period; SD, standard deviation; ns, not significant.

MF/(LF+HF) change as compared to baseline
2 – 1 SD p value 3 – 1 SD p value
Biotouch 0.03 0.45 Ns Biotouch -0.23 0.36 0.04
Control -0.13 0.68 Ns Control 0.00 0.53 ns
Touch 0.33 1.45 Ns Touch -0.10 0.88 ns
4 – 1 SD p value
Biotouch -0.23 0.33 Ns
Control 0.06 0.58 Ns
Touch -0.03 0.50 Ns

 

Chapter 4:

Discussion

Discussion

The data support both hypotheses: first that Bio-TouchTM induces a state of relaxation through psychological and physiological mechanisms, and second, that Bio-TouchTM is different from casual, continuous, light touch. The data also show that light touch directly to the skin offers many, but not all, of the same benefits that Bio-TouchTM does. It is important to note that the participants did not know which of the touch interventions were Bio-TouchTM which were the touch control group.

There was not a correlation between the changes in anxiety and change in any of the cardiovascular measures. This indicates that the psychological and physiological variables could have been affected independently, which implies that the benefits of being touched do not necessarily arise only from emotional or psychological factors.

The balance of the sympathetic and parasympathetic nervous systems is fundamental in the regulation of the immune system. The proper functioning of the immune system is dependent not only on the activity of the immune cells, but also on the hormones and proteins of the endocrine system which regulate the production and activity at all levels of the immune system. The endocrine system is dependent on the nervous system in part through the balance of the two branches of the autonomic nervous system. The two branches, the sympathetic and the parasympathetic, function in tandem with the other; each controls a set of functions that is complementary to the other’s. They work together dynamically to make sure that the body’s supply of energy is going where it is most needed at a given point in time.

Stress activates the sympathetic branch of the nervous system, which in turn stimulates the secretion of hormones that direct the body’s resources away from passive, regenerative processes, like storing cellular energy, or healing, for example. Relaxation accompanies the activation of the parasympathetic nervous system and favors processes that, like healing, reinforce an organism’s biological well-being on a larger time scale than the immediate contingency responses controlled by the sympathetic nervous system. Increasing the activity of the parasympathetic nervous system relative to the activity of the sympathetic nervous system creates an environment where healing is supported physiologically.

This study has demonstrated the ability of Bio-TouchTM and light skin contact to induce relaxation physically and mentally within minutes, thereby encouraging the healing process. During the first intervention period there was a significant reduction in heart rate, a time-honored measure of relaxation, which was present throughout the intervention period. There was also a decrease in the Bio-TouchTM and touch groups’ LF/HF ratios, further indicating the shift of autonomic nervous system toward parasympathetic activity, which was retained through the intervention period. The immediacy of these changes is interesting, since it is easy to assume that the body would require time to adjust to the treatment, so that a change might occur in the second intervention period at the earliest. However, since these changes were promptly apparent, it shows that Bio-TouchTM acts immediately to balance the autonomic nervous system.

The Bio-TouchTM and touch groups show largely the same trends except the MF and MF/(LF+HF). Bio-TouchTM apparently has an effect beyond that of touch that is apparent in these measures.   It is possible that touch alone activates the MF region, but that the sample size was too small to show the activity due to several anomalous data points, but keep in mind that outliers were eliminated. An interesting aspect of the MF-related data is that an entire intervention period is required to show significant change from the baseline. Another interesting aspect of these data is that touch acts negatively on the MF region. Tiller et al. indicate that among those experiencing feelings of appreciation, the MF band and especially the MF/(LF+HF) ratio increase (1996). It is possible that touch acts on the MF region of the heart rate variance power spectrum, but that it requires a longer time period to fully take effect. Also, notice in Figure 4 that the MF/(LF+HF) ratio begins by increasing, then decreases substantially. Perhaps there is a change in emotional state that occurs not only between the baseline and the intervention period, but also within the intervention period. This area particularly merits investigation, since another part of the Schwartz study remarked that people receiving touch on the skin felt ‘cared for.’ (Bucky and Schwartz 2000, pp. 8) Any such feelings that might be a part of the Bio-TouchTM experience may appear in the MF/(LF+HF) ratio, and it may be a more complex phenomenon, since there were two adjustments in the MF/(LF+HF) ratio across the intervention period.

The cardiovascular responses that were measured returned to baseline values in all cases. This indicates that the effects of Bio-TouchTM on the measured indices stabilized after a relatively short time period. It is possible that a longer period of the Bio-TouchTM intervention would induce longer-lasting physiological states, or give the body longer to balance the autonomic nervous system. There is a clinical application for the observed short-term effects also. The response to the intervention stabilized within 5 minutes, but it was also activated well within 5 minutes of the first touch. Relieving anxiety within minutes has definite clinical applications, especially since the recipient remains lucid during and after the process. Using pharmaceuticals to calm people has some serious drawbacks, including side-effects of the drugs, adverse reactions, and loss of mental capacity. The effects of the drugs may take hours to wear off, and the individual may require observation. This technique offers a practical way to calm someone to prepare them for an operation, an injection, bad news, or just an office visit. Its pain relieving effects have been documented, so it could allow relief in hospitals and in homes. The study of the effects of a longer intervention period may open even more possibilities for applications of touch as a health intervention.

There is much interest in the field of mind-body medicine currently – scientists study many different emotional and mental control techniques to help balance the rising rates of stress (and therefore sympathetic nervous system dominance)-related illness. Some researchers prefer energy manipulation or massage therapies as mind-body interventions. Bio-TouchTM offers distinct advantages over many mind-body and touch interventions. First, it has a very steep learning curve. It is possible to learn the basics of the technique in a matter of minutes, and from that point on, there is no further training necessary. The touch requires no concentration other than to touch, and requires no special state of being. In addition, it is free to learn and free to receive. Scientific evidence is accruing that shows that Bio-TouchTM is an effective treatment for pain and stress relief, on both psychological and physiological levels. In contrast to classes to attend and pay for, the hierarchies of training present in some techniques, and the focus of mind mind-body and touch healing techniques sometimes require, Bio-TouchTM is a very accessible complementary intervention that is effective. That an intervention that is extremely accessible should also be effective is encouraging.

The IFBM does not propose that Bio-TouchTM take the place of highly trained healthcare providers. There is certainly a need for technical expertise and training requirements among health professionals. There are also situations where such a professional is not present or is not really needed (as in the case of uncomplicated cases of the common cold or a scrape or bruise) but where some kind of care is appropriate. There is also a place of rising importance for low-cost health maintenance that can be implemented on a level outside that of the hospital or physician’s office. Touch as a health intervention can support public health, increasing the level of health by decreasing stress, particularly through utilization by families, where touch is often accepted and appreciated.

There is quite a selection of literature that demonstrates the ability of mind-body control and touch-healing techniques to balance people’s lifestyles and their health, but much of it is not subject to the standards of scientific inquiry. Often the sample sizes are a problem, and controls are at times not included in the design of the experiment. This study was not large, though the sample was large enough to reveal statistical significance, and it was controlled in two ways, for time and for a similar type touch.

Studies have shown that Bio-TouchTM reduces stress and pain, as well as blood pressure (Bucky and Schwartz 2000). This study corroborates their findings. One may remark that the magnitude of the stress reduction in the Bucky and Schwartz study is much greater than the amount of anxiety reduction in this study. It must be taken into consideration that the Bucky and Schwartz study was taken at several Bio-TouchTM centers, where people go specifically to seek therapy, whereas the sample in this study was mostly students in the University of South Carolina Psychology Experiment Participant Pool, so this sample was not self-selecting.

One weakness of this study was the relative homogeneity of the population, but the older individuals who participated also experienced change in psychological and physical conditions. In addition, this study could be considered a demographic reference point, particularly since the participants were mostly unfamiliar with Bio-TouchTM and with complementary therapies in general. Another weakness of the study was that it was performed by a single investigator, so the results may be skewed due to personal mannerisms or demeanor. Anxiety levels and therefore physiological measures may have been affected in an unanticipated way by the investigator. But since the Bucky and Schwartz study showed reduction in pain and stress regardless of the Associate performing the touch both within and between locations, it seems safe to assume that any self-reported results are mostly independent of the Associate. It is also possible that the expectation of the power of the touch intervention provided a placebo effect that mimicked the effect of the Bio-TouchTM technique. If this is the case, then it is hard to prove that it is not a placebo-type effect responsible for the response to Bio-TouchTM itself. However, if such an expectation can yield significant reductions in anxiety and physiological strain, then it is important to understand how to create an environment to exploit the healing power of such an expectation, especially if it is as easy as reaching out to touch someone on the skin.

Recommendations for Future Research

The results of this experiment are intriguing. That the touch and Bio-TouchTM groups both demonstrated psychological and physiological relaxation is a fascinating piece of information. Moreover, if there is a difference, as this study showed, in the MF band and the MF/(HF+LF) ratio between the touch and the Bio-TouchTM intervention, much could be learned about the way that emotions play a role in the action of Bio-TouchTM. It could also possibly allow some insight into the way that that feeling ‘cared for’ can affect health. Power spectral analysis of heart rate variance is a very powerful tool to glimpse the workings of the autonomic nervous system, and there is much that could be learned from an expanded study of Bio-TouchTM using this measure.

This study was performed with participants largely unfamiliar with Bio-TouchTM. One essential follow-up is to perform the study with participants who frequently seek Bio-TouchTM as a chosen health intervention and see what differences there are in responses. Another interesting experiment would be to extend the intervention period to see how the human physiology and psychology respond to the typical Bio-TouchTM session, which lasts about 30 minutes. Furthermore, the effects of multiple sessions performed on the same person should be documented to ascertain the kinds of responses that can be expected from multiple treatments.

 

 

Acknowledgments

The Physiology Department of the University of South Carolina Medical School in Columbia, SC generously offered access to their laboratory and instrumentation. The College of Nursing of the University of South Carolina provided research space in which to perform the investigation as well as a computer and other equipment that was essential to this project. The Statistics Laboratory in the College of Nursing assisted with analysis of the data. The Information Resource Center of the College of Nursing provided assistance in many of my endeavors. Nevrokard’s online software made a significant portion of the data processing possible that would not have otherwise been. The South Carolina Honors College funded 60% of the costs of this research. Special thanks also to Adam Turner, for developing a peak recognition program that fit the format of the data exported from the Vernier software. Further thanks are due to James Buggy, Ken Phillips, and Peter Sederberg, for their initial and continued support in developing this project.

 

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Appendix I
Appendix II
Appendix III
Appendix IV

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