Can Massage Therapy Improve Focus, Behavior, and Motor Function in Children with Developmental

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Can massage therapy improve focus, behavior, and motor function in children with developmental disabilities

Can massage therapy improve focus, behavior, and motor function in children with developmental disabilities: A case study

Chelsea L. Frenkel

Acknowledgements

I would like to express my gratitude to Matthew Fleet, RMT for his amazing guidance as my advisor throughout this study.

I would also like to thank the supervisors and staff at WCCMT Victoria who took the time to offer detailed suggestions, encouragement, and interest.

Finally, many thanks to the subject and parent guardian of this study, without dedication and willingness to follow through with treatment this study would not have had such clear results and this excellent learning opportunity would not have been available to me.

Table of Contents

Abstract……………………………………………………………………………4

Introduction………………………………………………………………………..6

Methods……………………………………………………………………………9

Client profile………………………………………………………………9

Assessment protocol.……………………………………………….……12

Treatment Protocol………………………………………………………16

Results……………………………………………………………………………22

Discussion………………………………………………………………………..28

References………………………………………………………………………..32

Appendix…………………………………………………………………………33

Abstract

Objective: To determine if the effectiveness of massage therapy could improve focus, behavior and motor function in children with developmental disabilities.

Case participant: The patient is a nine year old male with a diagnosis of Pervasive Development Delay (PDD), moderate intellectual disability, asthma, seizure disorder, and an educational designation of physical disability or chronic health impairment (PDCVH). The patient also experiences challenges with focus, aggression, and functional movements as a part of his diagnosis.

Methods: This case study was performed over the course of three months and was broken into fifteen treatments, seventy minutes in duration, which were divided into three phases (phase 1- introduction to touch and massage, phase 2- behavior and focus, and phase 3- motor function). Treatments consisted of manual modalities to the lower extremities and back such as: deep pressure general Swedish techniques, myofascial release techniques, joint mobilizations and vibration techniques. Measurement tools included; postural assessment, gait analysis, orthopedic tests, and Range of motion (ROM) for the motor function aspect of the study as well as focus tests and qualitative feedback from the patients’ guardian for the focus and behavior aspect.

Results: the results from the case study concluded that the patients focus and behavior had improved, the patient had become more social with other children, less aggressive with others at times of frustration, less anxiety, and the client’s balance, motor function, gait, and posture had improved.

Conclusion: During this case study, massage therapy had proven to significantly improve the patient’s focus, behavior, and motor function therefore improving quality of life.

Key words: Pervasive Development delay, children, behavior, motor function, massage therapy

Introduction

Developmental disabilities are common in children and occur in all racial and socioeconomic groups. Such developmental disabilities may include Attention Deficit Disorder (ADD), Autism Spectrum Disorder, Cerebral Palsy, Downs Syndrome, intellectual disorders, hearing loss, vision impairment, learning disabilities, and other development delay. One in six or fifteen percent of children in the United States of America from ages three to seventeen have these developmental disabilities according to the Center for Disease Control and Prevention. In that fifteen percent, Autism spectrum disorder and or Pervasive Development Delay (PDD) are very common and come with varying ranges of qualitative impairments. Children with Autism or PDD may experience impairments in some or all of the following: in social interaction, communication, speech and language, general physical development, behavior, learning, and cognitive skills.

Massage therapy has been proven useful in helping these children with their associated qualitative impairments and has been shown beneficial in improving sleep, behavior and focus impairment. According to the Journal of Early Child Development and Care, authors Hernandez‐Reif, M., Field, T., Largie, S., Mora, D., Bornstein, J., & Waldman, R. (2006), children with Downs Syndrome who received massage therapy revealed gains in fine and gross motor functioning and less severe limb hypotonicity. The treatments were spanned over eight weeks , were thirty minutes in duration, and consisted of whole body general Swedish massage and non Swedish massage techniques. A study by Escalona, A., Field, T., Singer-Strunck, R., Cullen, C., & Hartshorn, K. (2001), found massage therapy for children aged three to six with Autism Spectrum Disorder, resulted in less stereotypic behaviour and the children demonstrating more on-task and social relatedness behaviour at school. They also experienced fewer sleep problems. Treatments were performed fifteen minutes before bed, on a daily basis for one month.

Both studies used slow, general Swedish massage techniques in their studies and according to Rattray and Ludwig (2000) Swedish massage techniques applied in a slow, rhythmical and repetitive manor will result in a response of relaxation and decrease sympathetic nervous system firing. These results can be complimented with the use to hot hydrotherapy and other non Swedish massage techniques to achieve physiological and psychological effects to treat the clients’ condition.

The purpose of this study is to evaluate the effects of therapeutic massage, which included the modalities of General Swedish Massage (GSM) and non Swedish massage (muscle approximation, golgi tendon organ release (GTO release), myofascial release (MFR), vibrations, rocking, neutral warmth hydrotherapy, and joint mobilizations) to improve motor function, focus and behaviour in a patient with diagnosed pervasive development delay (PDD) and seizure disorder. Swedish massage was used in this study as it has proven to be beneficial in previous studies and also as explained in Rattray and Ludwig, could have great effects for the client. The non Swedish massage techniques that were chosen to decrease muscle tone in spastic muscles included muscle approximation, GTO release, and high frequency vibrations due to the neurological affects to decrease hyper tonicity. According to Rattray and Ludwig (2000), the technique of muscle approximation uses the reflex effect of muscle spindles to reduce tone or spasm in a muscle. This technique is done by approximating, or bringing the ends of muscle closer together, which results in decreasing the stretch on the muscle spindles. This decreases gamma firing and reduces muscle tone and firing”. Also according to Rattray and Ludwig (2000), the GTO release technique can also be used to decrease spasm and tone within a muscle. Its primary effect is on the Golgi Tendon Organ, which is part of a protective reflex to prevent the muscle injury by relaxing the muscle. This reflex is stimulated when excessive load is placed on the tendon. This technique involves placing direct compression to the musculotendinous junction to decrease tone within the muscle. Vibrations were used as they can play a part in both decreasing muscle tone and, in the case of the client taking part in the study, as a sensory stimulation and central nervous system distraction technique. MFR was used to help decrease restrictions that caused hyper tonicity. Joint mobilization techniques were applied on the ankle to increase dorsi flexion (posterior glide) during phase three of the case study. According to Rattray and Ludwig (2000) this technique assesses joint dysfunction, increase range of motion, stretch tight capsules, reduce adhesions, pain and spasm, and encourage the proper action of the joint.

The primary objectives of treatment interventions were to determine if massage therapy could decrease adverse behaviour such as hitting or scratching when frustrated, and full body rocking behaviour when anxious, improve focus and learning ability, and improve motor function by decreasing hyper toned muscles, and increasing strength and firing of hypo toned muscles and encouraging proper movement within the joints, which could result in improved ambulation and balance.

Methods

Client Profile:

The client participating in this case study is a nine-year-old male who is diagnosed with Pervasive Development Disorder (PDD), Physical Disability or Chronic Health Impairment (PDCVH), asthma, and seizure disorder. He has full time support from his parent guardian and two education assistants in his living skills program at school. The client also receives Occupational Therapy, Physiotherapy, Speech therapy, and visits a sensory room twice weekly. The patient has a significant medical history of which includes atypical and long in duration seizures as an infant, globally and developmentally delayed yet verbal until a significant seizure in 2010 which caused a loss of verbal ability, and a grand mal seizure in November, 2013. Currently the patient is undergoing assessment by the Complex Developmental Behavioural Condition Clinic (CDBC) to explore a possible diagnosis of Autism Spectrum Disorder. As for Physical assistance, the patient also has been fitted for and wears custom orthotics to support pes planus. The patient takes the following medications: 600 mg of Trileptal two times daily plus 75 mg of Topomax twice daily which help treat his seizure disorder. These medications were increased in April 2014. After the medication increase, the patient had not experienced any seizure activity until September 2014, when he experienced a grand mal seizure. The client also takes Ativan as needed for anxiety and Provent and Ventalin as needed for asthma. With the patients’ diagnosis in PDD, he does experience some impairment in his emotional and behavioural status and is non-verbal. At times of frustration, the client often exhibits aggressive behaviours such as grabbing, hitting, scratching, and biting. Due to this behaviour, he had been denied massage therapy by registered massage therapists. When the participant experiences anxiety, he will elicit a rocking behaviour where he sits with his legs firmly crossed, ankles firmly in dorsi flexion, and toes firmly flexed as he rocks back and forth. These behaviours often happen at times where the clients doesn’t receive enough sensory input or at times of frustration. The client also appears to not be very social with other children his age and prefers the company of adults. As for the clients’ focus and learning abilities, the client appears to attend mostly to sensory experiences and is easily distracted. He has a limited attention for unfamiliar, directed, or non- preferred activities. He also has emerging understanding of cause and effect. The patient is also impaired in many activities of daily living such as using the toilet, dressing himself, ambulation, balance, and properly going up and down stairs. When it comes to using the facilities, the clients learning and attention impairments distract him from learning this life skill. As for ambulation and balance, the client has both hypertoned and spastic muscles which include biceps femoris (long and short head), gastrocnemius, soleus, flexor halluces longus, flexor digitorum longus, and tibialis posterior (all of which present bilateral) and hypotoned muscles of which include gluteus maximus, gluteus medius, gluteus minimus, and tibialis anterior (all of which present bilateral) which cause the client to present with a sluggish gait. As for going up and down stairs, the client tends to lead with his left foot and goes one-step at a time.

As part of the clients’ occupational therapy (OT) assessment, it was suggested that the client had a very strong threshold for sensory input and would benefit from extensive sensory stimulation such as auditory stimulation, visual stimulation, and tactile stimulation. The client reacts well with deep pressure and vibration, which were taken into account towards his treatment plan. It was also mentioned that with receiving enough sensory input, the client would react positively. The clients’ physiotherapist (PT) also recommended that massage be indicated for the client’s presentation of impairments. As per the client’s parent guardian, some main goals of treatment included that he become more body aware, less anxious, more comfortable with touch, and more focused. The client had never received massage before, therefore phase one-introduction to touch was established as a key point of the case study to allow the goals of the clients support team, and the therapist, to be successful. Once phase one was completed, treatment strategies would become more specific as the client could tolerate the modalities. Phase two was concentrated on improving the focus and learning ability of the client while decreasing sympathetic nervous system firing and phase three would focus mostly on motor function and postural impairments while still maintaining relaxation goals.

Assessment Protocol:

Due to the clients’ physical and mental status the following assessment tools that were chosen best fit the clients’ ability to focus and participate. The majority of assessment in this case study mostly focused on a qualitative interview each treatment to determine the clients’ physical and mental status.

Qualitative questions were asked every treatment visit. Such questions evolved around the clients’ sleep patterns, behaviour, focus, weekly routines, mental or physical changes post treatment, learning activities, physical activity, routine changes, and other therapy. Along with the interview questions every treatment, therapist observations were also made. Observations included things such as emotional state, physical presentation, ability to focus and respond to direction, and gait when walking from reception to treatment room. Observations were also noted during treatment. During phase one especially, time length of remaining still was noted along with ability to relax, be calm, times of body awareness, and specific treatment modalities that had a positive affect. Observational changes will be noted in the results section.

As for physical examination and assessment, upon the initial treatment, a postural scan was completed. Due to the lack of focus and mental awareness, a plum line was not used, as the client could not stand still and in line with the plum line however, the postural scan revealed a significant pes planus, genu valgum and internally rotated hips. It also revealed head forward posture. A postural scan was also preformed on the last treatment and revealed slight positive change. Results from this assessment will be revealed in results section.

To further assess the postural impairments within the hips, knees and ankles, palpation was preformed to decipher the muscle tone and restrictions. This was preformed each treatment, however during the initial treatment, hypertonicity was found bilaterally in the: rectus femoris, biceps femoris long and short head, semimembranosus, semitendinosus, adductor group, triceps surae, peronials, tibialis posterior, flexor halluces longus and brevis, and flexor digitorum longus and brevis. Hypotonicity was discovered bilaterally in the following: the gluteus maximus, medius, and minimus along with tibialis anterior, extensor digitorum lonus, extensor digitorum brevis, extensor digitorum longus and brevis. Results from palpation will be found in the results section.

To further assess the lower extremity, range of motion (ROM) was bilaterally preformed passively (PROM) to the hips, knees and ankles. For the hips; flexion, extension, abduction, adduction, external rotation, and internal rotation was preformed. As for the knee, flexion and extension was preformed. For the ankle; plantar flexion, dorsi flexion, inversion, and eversion where preformed. These ranges of motion took part over the first four treatments; hip and knee PROM during the first three treatments, and ankle during the forth treatment. Hip range of motion showed full range of motion however internal and external rotation showed to be hypermobile. Knee range of motion showed full range of motion, and ankle as well however dorsi flexion was very limited. Range of motion of the ankle was then assessed again during phase three- motor function in treatment 11- where range of motion would be addressed further in treatment. PROM results are addressed further in table A of the results section.