Barrett L. Dorko, P.T.

          Early on a cold morning in Northeast Ohio I head for the restaurant again to write for an hour. This is a ritual more powerful than my fatigue, and I rarely go a day without it.

          In a few moments I'll take the thick china cup filled with hot coffee and place my hands just so, and wait for the magic to begin.

          My skin deforms slightly in response to the pressure I choose against the contours of the cup. As it does, the stretch activated ion channels within the cytoskeleton of the epithelium open, and allow the passage of sodium and calcium to exchange some space with the potassium inside. The chemical mix created depolarizes the mechanoreceptors beneath the outermost layers, so that an action potential is produced and conducted along an afferent pathway.

          In response, my sensorium says, "warm," and I adjust via efferent pathways the shape of my hands, careful not to overheat their sensitive structures. I'm searching gently for that alchemy of pressure and position that I know will induce a feeling of warmth that extends far beyond the cup. According to its needs and capabilities, my body will host a reflexive reaction to this that might be felt far into my legs. I know that on a warm day it won't extend beyond the palms of my hands.

          The reflexive effect of touch is dependent upon the neural connections within, and not the force of the mechanical stimulus the coffee cup provides. In fact, the physiologic reaction of blood flow distantly in the body (which I experience as warmth) will diminish if the stimulus increases. This is a physiologic law, and I only need to grip the cup in order to demonstrate to myself that it's still on the books. There is a delicate balance between global warming and local burning, and I can maintain the desired effect only by attending carefully to the force and shape of my grasp.

          You might suggest that it is simply the stimulus of the heat that produces the effect I'm describing, and while I'll admit that it helps, and that simply holding my hands in the vapor above the cup might be pleasant, reflexive reaction truly grows when the skin is bent just so, when we are touched gently. I call it "Baby Bear's bed." You know, "not too hard, not too soft..." .

          Consider how this reaction travels through the incredible maze of the nervous and circulatory systems. Unlike the connective or muscular tissue, these are fractally shaped, meaning that they branch similarly, repeating in their smallest bifurcations the general shape of the whole organ. This means that provocation will not produce a predictable or linear response. The skin that interfaces with the cup is also a fractal, and thus further confounds our ability to know what will happen when we alter it mechanically.

          But when on a cold morning the body craves what this reflexive effect might offer, it welcomes the flow of blood deep within, and we do our best to enhance the cups's effect with handling that is both precise and perfectly human.

          How often is a therapist's touch as potentially therapeutic as what I've described here? I wonder how much of the science of cellular mechanics, reflexive reaction, physiologic law and fractal anatomy is taught before a student is told to "put your hand here and press."

          I've watched manual care rise to prominence during my career, and, in fact, I've taught many of its more popular techniques. But I'm often struck by how a simple cup of coffee can have so profound and enduring an affect, and how different this is than the manipulation I know forms the bulk of our profession's manual expression.

          In 1978, the eminent physiologist Irvin M. Korr stated, "The most critical effect clinically (of manipulation) is the subsidence of sympathetic hyperactivity." He meant that touch should make the patient warmer.

          As I leave the warmth of the restaurant and the china cup, I carry some of my own enhanced blood flow with me, and I hope to touch my patients with the same care I just afforded myself.