Cerebral Palsy Patients and Massage

Cerebral palsy is an umbrella term covering several brain injuries that damaged different areas of the brain at various stages of development. It is divided into four groups or types based on symptoms, and can also be classified by at what age the child received the brain injury.

The four types are: Spastic cerebral palsy, Athetoid cerebral palsy, Ataxic cerebral palsy, and Mixed cerebral palsy. The spastic type is far more common than the others; it features muscles whose tonicity is so high that the antagonist muscles have “completely let go” to use Ruth Werner’s expression (Werner, 2002). Athetoid accounts for up to a third of cerebral palsy cases, and features very weak muscles and involuntary writhing movements. The Ataxic type exhibits chronic shaking and tremors with very poor balance. Some include a fifth type, Dystonic, which also involves involuntary twisting movements of trunk and extremities. Symptoms depend on whether the cerebral cortex, basal ganglia, or cerebellum is the most severely affected (Turkington, 2002).

Brain injuries can occur either prenatally, in birth trauma, or can be an acquired defect in early infancy. Prenatal diseases that can cause cerebral palsy include rubella, toxoplasmosis, hyperthyroidism, diabetes, Rh sensitization, toxic exposure, or abdominal trauma. Birth traumas include anoxia or asphyxia (where the oxygen supply is cut off), or head trauma as in a forceps delivery. Injuries in infancy include things like shaken baby syndrome, car accidents, infections like meningitis or encephalitis, and neoplasms (Werner, 2009). Cerebral palsy is also linked to fetal alcohol syndrome (UPI, 2007 and Gwinnell and Adamec, 2005). The majority of infants who survive severe shaking will have some form of neurological or mental disability, such as cerebral palsy. Yet another environmental cause is exposure to high levels of methyl mercury (thimerosal) (Turkington and Tzeel, 2004).

Diagnosis of cerebral palsy can be very tricky. Doctors often wait till after the child’s first birthday for the permanent appearance of specific motor problems. Most children are diagnosed by the age of 18 months. Strangely, X-rays or blood tests only exclude other brain diseases. Cerebral palsy is not a hereditary condition, and these tests will neither establish nor rule out a diagnosis of CP. Magnetic resonance imaging (MRI) and CAT scans are often ordered if a doctor suspects that the child has cerebral palsy, but these tests are better at catching cases of hydrocephalus and, as I said, are usually used to exclude other causes of delayed motor development. It is odd that “children with normal scans may have severe cerebral palsy, and children with clearly abnormal scans occasionally appear totally normal or have only mild physical evidence of cerebral palsy” (Turkington, 2002).

However one of the distinguishing characteristics is called the “scissors” gait. A gait that also occurs in cervical spondylosis, the scissors gait allows the knees and thighs to thump against each other or to cross in a cutting movement akin to that of a pair of shears. A trauma to the spinal cord can also cause this type of gait (Sayler, 2005).

Cerebral palsy is not a progressive disorder, but conventional medicine holds that it is not a curable condition, either. Milder cases can resolve themselves by the age of 7 (Werner, 2009). Treatment may include braces for weak limbs, extended occupational and physical therapy, or even surgical intervention to correct scoliosis or correct hip dislocations.

Fortunately, patients with cerebral palsy have been shown to respond very positively to massage therapy. Pioneer Sister Elizabeth Kenny was first developing her techniques when she treated a seven-year-old girl named Daphne Cregan. Miss Kenny applied her usual program of hot baths or packs, with muscle re-education and massage. The Australian child progressed from not even being able to sit up, to walking with a stick. Daphne later earned prizes in school, at St. Ursula’s, for art, composition, and spelling (Cohn, 1975).

A research study conducted by Maria Hernandez-Reif recruited volunteer licensed massage therapists to administer to cerebral palsy patients two days a week. Following 12 weeks of twice weekly massage therapy sessions (added to standard care), very young children with CP showed reduced spasticity and less overall and arm hypertonic (rigid) muscle tone. Range of motion scores for hip extension also improved. Few developmental measures improved for a control group given standard care plus being read to over the 12 weeks; this program only produced improved language and feeding scores. The additional reading sessions might have contributed to the improved language scores and might be encouraging news for parents who have children with CP who may want to add reading to their daily or nightly routine. In contrast, the children in the standard care/massage therapy group showed improved scores in cognition, fine and gross motor functioning, dressing and social skills (Hernandez-Reif, 2005).

Their treatment protocol follows:
The therapist started each session by cradling the child’s head and making small circular strokes on the scalp while making eye contact to orient the child to being touched. Subsequently, the therapist applied non-scented oil to his/her hands and massaged the child in the following sequence:
Head/face/scalp: (a) using flats of fingers, stroking forehead and temple area; (b) stroking cheekbones outwards toward temple; (c) massaging, using circular movements, under the chin, cheeks, jawline around the ears, back of neck and base of skull.
Shoulders/arms/hands: applying oil to the hands, (a) kneading shoulders, including scapula area, deltoids and pectoral muscles; (b) making hands like the letter ‘C’ and milking the arms from the shoulder to the wrist; (c) with hands turning opposite each other, twisting and wringing from the shoulder to the wrist and off the hand; (d) using thumb over thumb motion to massage the palm of the hand; (e) massaging and gently pulling each finger; (f) massaging the top of hand, including the wrist and areas in between fingers; (g) flexing and extending wrist and fingers; (h) rolling the arm from shoulder to wrist; and finishing by (h) using long milking strokes and smooth strokes from wrist to the shoulder.
Chest: (a) making small finger circles down and then up both sides of sternum; (b) making small lateral movements with fingertips under clavicles from sternum to shoulder, working both sides of chest simultaneously; (c) with one hand on each shoulder, squeezing whole deltoid area with entire hand, then lightly moving both shoulders back and forth to open up chest area (relaxing and repeating three times).
Hips: (a) without forcing joints since knees may not bend, holding the lower legs and moving both knees toward chest (relaxing and repeating three times); (b) repeating same step but alternating lower leg towards opposite shoulder (relaxing and repeating three times).
Legs and feet: applying oil to the hands, following procedure for arms and hands to one, then the other, leg and foot.
Back: (a) holding chest with fingers and thumbs on child’s back, applying small thumb circles down sides of spine from the neck to the tailbone and back up to the neck; (b) making soothing circular strokes around the tops of the shoulders; (c) using heel of hand, making circles around entire back, including shoulder blade and lower back areas; (d) making large full palm circles across entire back.

Conventional massage therapy works well but must be part of a course of long-term treatment. “The damage for a person who has CP does not begin in the muscle and connective tissues. Although this is where we feel the tightening of the connective tissue wrappings around muscles, the contractures themselves are simply a symptom-a complication of a problem deep in the brain. Therefore, if all we try to do is lengthen the muscles and stretch the fascia, we will run smack into a brick wall: either no progress will happed at all, or symptoms may even be temporarily exacerbated. Most people with CP get best results if bodywork focuses on indirectly affecting muscle tone through craniosacral work, gentle rocking, slow range of motion exercises, and manipulation of the arms and legs that engages the client in ways he or she doesn't automatically resist-this often means going with the direction of muscle shortening in order to disengage the reflex. Ultimately, the therapist will have to experiment with lots of different approaches, often accompanied by extremely supportive bolstering, in order to find what techniques allow their clients to relax and enjoy their massage (Werner, 2002). Patients are able to sleep through the night, and breathe more easily.

A specific type of massage therapy, craniosacral therapy, may also be helpful to patients with cerebral palsy. A system of therapy based on the idea that there is a rhythmic pressure and flow of cerebrospinal fluid between the cranium (skull) and sacrum (the base of the spine) that governs the way the craniosacral structures, including the brain, pituitary and pineal glands, spinal cord, and meninges, or membranes, function and maintain the body's well-being. Gentle hands-on "manipulation" of the skull, the spinal column, rib cage, and limbs is believed to restore the flow and maintain the body's well-being (Navarra, 2004).

Fortunately now cerebral palsy patients and their parents have several organizations and even a website to turn to for information and advice. They include: American Academy for Cerebral Palsy and Developmental Medicine, Gillette Children's Hospital, Ontario Foundation for Cerebral Palsy, United Cerebral Palsy Association, and Your Smile Web site.

Understanding of this condition has come a long way from an era when victims were thought to be mentally deficient. However, we are still a long way from erasing its effects or preventing most cases. Progress has been slow and new approaches come into general use only against resistance. Let’s hope that the new millennium has brought a greater openness to effective massage and other therapies.

SOURCES:
Cohn, Victor, Sister Kenny: The Woman Who Challenged the Doctors, University of Minnesota Press, 1975.
Gwinnell, Esther and Christine Adamec, Fetal alcohol syndrome (FAS), The Encyclopedia of Addictions and Addictive Behaviors, 2005.
Hernandez-Reif, Maria et al, Cerebral palsy symptoms in children decreased following massage therapy, Early Child Development and Care, 2005.
Navarra, Tova, Craniosacral therapy, The Encyclopedia of Complementary and Alternative Medicine, 2004.
Sayler, Mary Harwell, Gait, The Encyclopedia of the Muscle and Skeletal Systems and Disorders, 2005.
Turkington, Carol, Cerebral palsy (CP), The Encyclopedia of the Brain and Brain Disorders, Second Edition, 2002.
Turkington, Carol, and Albert Tzeel, Thimerosal, The Encyclopedia of Children's Health and Wellness, 2004.
United Press International, Diseases caused by fetal toxicity studied, 2007.
Werner, Ruth, A Massage Therapist’s Guide to Pathology, Lippincott Williams & Wilkins, 2009.
Werner, Ruth, Working with Clients Who Have Cerebral Palsy, Massage Today, Aug. 2002.