Pediatric Massage, Part 2
A case study of a child with cerebral palsy
Written by Nicole Nifo, RMT
In part 1 of this article I argued that in North America, we are a society that lacks physical touch and nurturing. I outlined the benefits of massage to healthy children, preterm babies and special needs children. I explained the purpose of teaching massage to parents and also having an RMT perform massage with a pediatric patient. In Part 2, I’d like to take a deeper look into the massage therapist working directly with special needs children.
I have always had a passion for working with women and children and the continuing education I pursued in pediatric massage therapy has allowed me to work with a lot of very “special” children. For the past seven months, I have had the privilege of working with a child who lives with cerebral palsy. His parents hired me to assess and treat his current spasticity, aid him while he develops further and complement the physiotherapy he would be receiving every week.
At birth this patient presented with meconium aspiration.
He experienced a couple of seizures at one week.
- MRI contributed to the diagnosis of
- cerebral palsy.
- Patient presented to RMT at 10 months with right spastic hemiplegia cerebral palsy.
- The patient was only rolling and pivoting with assisted sitting.
- He had a right spastic hand that was closed and very
- stiff – he was not grabbing with this hand.
- His right arm was held in internal rotation, bicep and wrist flexion.
- He was only able to grasp objects with his left hand and was unable to extend his fingers to open his right hand.
- The patient had previously had a consultation with occupational therapy.
- The massage therapy was proposed for twice a week for a half hour, each session. Physiotherapy would be done once a week for an hour and vision therapy once a week for a half hour. Occupational therapy was set to start at 15 months old.
- All treatments were scheduled at the patient’s daycare facilities.
What is Cerebral Palsy?
Cerebral palsy (CP) is usually caused by brain damage that occurs before or during a child’s birth, or during the first three years of a child’s life. There is no cure for CP, but therapy, special equipment, and, in some cases, surgery can help a child who is living with the condition. Cerebral palsy is not a degenerating disease.
CP is a disorder that affects muscle tone, movement and motor skills (the ability to move in a co-ordinated and purposeful way). Movements such as standing, picking up objects and walking can be difficult. Other vital functions that may be involved are breathing, bladder and bowel control and eating. Cerebral palsy can also affect learning and lead to other health issues, including vision, hearing and speech problems.
Cerebral palsy is classified under three categories: spastic cerebral palsy, which causes stiffness and movement difficulties; athetoid cerebral palsy, which leads to involuntary and uncontrolled movements; and ataxic cerebral palsy, which causes a disturbed sense of balance and depth perception. The categories may overlap, with the patient showing a combination of these signs and symptoms.
How Can Massage Therapy Help?
When working with any child, including one with special needs, massage can promote relaxation, encourage sleep and growth and improve brainwave activity. Massage can also be used to reduce the discomforts of teething, colic and gas; regulate breathing and heart rate; and help develop the digestive and immune systems.
Performing Swedish massage strokes on a child with cerebral palsy can help promote circulation, decrease tone in spastic muscles and increase tone in flaccid muscles. Massage will also help to bring a sense of body awareness to the child, which is very important in brain development and performing tasks. Some special needs children have delayed motor co-ordination and that is why it is very important that the child and family work closely with an RMT, OT or PT to improve muscle function. Although the goal of treatment is similar among the different therapies, it is important to focus mainly on massage.
The parents of this patient asked if I would demonstrate some massage techniques to his daycare teachers. I basically showed them how to gently stretch him and told them that on his spastic side, massage strokes must be performed proximal distal. I also showed them which muscles were important to massage. Tasks like putting on a jacket cannot be forced on a spastic arm and the arm must be massaged to be relaxed enough to easily dress the child.
It is important to know any temperaments that the child has and if they have any sensitivities to touch. The patient I work with is very sensitive on his head and will literally pull your hand off if you are working on that area. Also, he seemed to get sick a lot and was put on a puffer periodically over the last five months. This naturally affects his mood, so sometimes I have to improvise and cannot achieve a full half-hour treatment.
In the first couple of months we focused our massages on decreasing muscle tone in his right leg and arm and improving circulation. Positioning a child into different positions, such as assisted standing while supporting the hips and pelvis, can help develop physical confidence and strength in the core muscles to help with sitting, standing and walking. After I have applied Swedish massage techniques, I can assist my patient in standing by supporting his hips while he looks in the mirror and holds on to the bar using his non-spastic side.
Treatment to his arm:
I worked specifically on his pectoralis major, biceps muscles, brachioradialis, forearm flexors, opponens pollicis and
Treatment to his leg:
I worked mainly on his hamstring and quadriceps group, gastrocnemius, peroneals, tibialis anterior and foot muscles.
We incorporated light stretching of his leg and foot, shoulder, arm, hand and fingers. We also practised a lot of assisted standing. To keep my patient entertained, I had him stand in front of a three-foot-tall mirror that also had a bar to hold on to. Babies love to look at themselves and he kissed that mirror and spoke to himself the whole time!
As my patient developed and passed his first birthday, I naturally found it hard to keep him still for his supine massage treatments. We incorporated puppets and balls that have different surfaces. These objects are a great way to incorporate touch if skin-to-skin massage is not convenient – they also keep patients entertained. At this point, the patient had begun to “commando crawl” and was still only rolling. We also practised weight bearing and walking, which he can almost initiate on his own, with minimal help.
After months of massaging his arm and shoulder, I noticed that the patient stopped holding his arm so tightly to his chest and that his arm was relaxed by his side. He now holds himself up while sitting and he is able to use his arm effectively when grasping objects. Although his thumb is still held in opposition, he can extend his fingers to assist the left hand in holding objects.
At the time this case study is being written, we are now incorporating a technique that we use to hold back his left arm so that he is forced to use his right – this, so far, is working well. He has also started his occupational therapy and that therapist has requested an arm splint.
A few weeks ago, the patient helped himself up from sitting to kneeling using a bookshelf to assist him. Last week, he was able to push himself from lying down to sitting on his own. This week, he is able to pick a tissue out of the box using his right hand.
My patient has gone from being a child who could barely sit up on his own to showing amazing growth and development. His daycare teachers always comment on how much he loves his massage and how much they think it helps him. I am honoured to be a part of his growth and development and to work alongside other great therapists.
I do not know what his limitations will be as he grows, but I do know that he has a team behind him to make sure he becomes the best that he can be.
Nicole Nifo has been practising as a Registered Massage Therapist since 2005. She has extensive massage therapy training in obstetric and pediatric patients. For six years, Nicole has been managing a family-focused practice through her clinic, Fully Alive Wellness Centre in Oakville, Ontario. She has also written many MT-related articles for women and children and continues to strive to find new ways of communicating the importance of nurturing touch for children. Nicole can be reached at www.fullyalivecentre.com or on twitter @FullyAliveWC.