ORIGINAL ARTICLE
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Gaps Between the Indication and the Home
Execution of Massage Therapy in Children in the
Postsurgical Stage of Primary Cheiloplasty or
Rhinocheiloplasty
María José Montero-Orellana, MS, MEd,*† María Rosa Fuentes-Orellana, PT,‡
and Matías Ossa-Cox, PT, MEd†
Purpose: This study describes the compliance rate with home
massage therapy in children in the postsurgical stage of primary
cheiloplasty or rhinocheiloplasty and the factors that facilitate
or hinder its execution.
Methods: The parents of 15 children treated at the Gantz
Foundation - Children’s hospital for cleft lip and palate in
Santiago, Chile were recruited. Parents received instructions to
perform massages at home 5 times daily and were followed up
for 3 months by recording in a log. Qualitative information on
facilitators and barriers was collected in a focus group session.
Results: Compliance rate was close to 75%, and the factors that
facilitated the execution were performing the massage with
some distracting activity and noticing the positive changes in the
appearance of the scars. The most important factors that hindered the execution were the infant’s crying and changes in the
routine.
Conclusion: The authors conclude that the compliance rate is
high and suggest that parents and guardians identify and implement a routine with a distracting activity that allows the
massage to be carried out effectively.
Key Words: Cleft lip, massage therapy, physiotherapy, scar
(J Craniofac Surg 2023;00: 000–000)
C
left lip, cleft palate, and cleft lip and palate (CL/P) are types
of orofacial malformations with a prevalence of 9 to 11 per
10,000 live births.1 In Chile, there is an incidence of 12.1 per
10,000 live births with cleft lip, with or without palate involvement, and 6.0 per 10,000 live births with cleft palate.2,3
In Chile, since 2005, the CL/Ps have been part of the explicit
health guarantees program, offering a set of medical, surgical,
From the *Physiotherapy Unit, Gantz Foundation - Children’s hospital
for cleft lip and palate; †School of Physiotherapy, Faculty of Medicine, Universidad Finis Terrae, Santiago; and ‡Department of
physiotherapy, Metropolitan University of Education Sciences,
Chile.
Received March 31, 2023.
Accepted for publication May 17, 2023.
The authors report no conflicts of interest.
Address correspondence and reprint requests to Maria José MonteroOrellana, MS, MEd, Universidad Finis Terrae. Av. Pedro de Valdivia
1509, Providencia 7501015, Santiago, Chile; E-mail: mjmontero@uft.cl
Copyright © 2023 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000009474
The Journal of Craniofacial Surgery
and rehabilitation care benefits that must be delivered to patients affected by this condition free of charge. The benefits
include evaluation and diagnosis, reconstructive surgeries,
speech therapy, orthodontics, and psychotherapy from birth to
15 years of age (MINSAL).
The treatment of CL/P begins with cheiloplasty, which aims
to close the lip’s separation to improve functionality in speech,
chewing, dental protection, breathing, and eating. In addition, it
seeks to protect facial esthetics by promoting the formation of
scars that are as invisible as possible as the scar resulting from
cleft lip repair can significantly affect people’s quality of life
functionally, esthetically, and psychologically. The scar has a
functional consequence, interfering with activities of daily living, such as feeding, speaking, and sucking, and can also generate concerns about appearance among patients. In addition,
the scar can generate feelings of insecurity and low self-esteem.4
Several modalities are described as effective in treating
cheiloplasty lip scars, such as laser, silicone, botulinum toxin,
IPL, and massage.5–8
Scar massage is the therapeutic manipulation of soft tissue
formed during tissue repair and delivered primarily by hands.9
It has been suggested that massage can reduce postoperative
fibrosis, increase the flexibility of scars, and decrease adhesions
to the deep plane.6,10,11 According to Scott et al,9 massage
therapy and other scar management techniques may improve
the appearance of scars in patients with CL/P. However, they
highlighted the need for more research to determine the best or
combination techniques for managing scars in these patients.
More research reported that massage significantly improved
mobility and decreased restrictions, increasing symmetry, and
positively impacting self-perception of their appearance.12
For massage therapy in children to be cost-effective, physiotherapists must rely on the cooperation of parents or guardians, as they play a crucial role in the success of the treatment by
providing the massage therapy themselves. The main reason for
treatment failure in children with long-term health conditions is
limited compliance with prescribed treatments. To optimize the
results in children with CL/P, it is necessary to understand why
parents and caregivers do not fully follow the treatment
instructions.13 The purpose of this study was to describe the
completion rate of home therapy and the factors that facilitate
or hinder the execution of massage therapy indications, which
are part of the physiotherapy of children in the postsurgical
stage of cheiloplasty or primary rhinocheiloplasty.
METHODS
Parents or guardians of children in the postsurgical stage
of primary cheiloplasty or rhinocheiloplasty (n = 15) were
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1
Copyright © 2023 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Montero-Orellana et al
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recruited. All children who underwent surgery were between
4 and 6 months of age at the beginning of the study and were
cared for at the Hospital del Niño con Fisura - Fundación
Gantz in Santiago de Chile between March and August 2022.
These parents were instructed to perform massages at home,
which had to be done 5 times a day, and were followed up for
3 months using a logbook, in which they were to record the
hours when the massages were done. Researchers then collected
these logs to extract information regarding the scheduling and
quantity of the massage therapy intervention, from which the
average and range were calculated.
Afterward, through a focus group with the parents, information was collected on the factors that made it easier for
them to carry out the indicated dosage and the barriers that
prevented them from complying with said indications given by
the physiotherapist. The information obtained was subjected to
the qualitative data analysis process through content analysis.
RESULTS
Reported adherence, defined as the number of massages recorded in a log compared with the number indicated for the
period, was 76.75% (range: 56.5%–83.6%), performed by the
mothers and mainly in the afternoon. The main barriers mentioned by the caregivers are the crying of the boy or girl,
changes in the routine, not being at home, or having more than
one child in charge. Although not complying with the instructions generates a feeling of guilt in some caregivers, it does
not convey demotivation or abandonment of treatment.
As facilitators, some distracting activity or element is mentioned (watching videos, changing the diaper, or playing games
during the massage), and seeing positive changes in esthetic or
functional aspects of the scars is a motivating factor to continue
with directions.
The indications on the execution of massage therapy are
fulfilled in a high percentage, carried out when the tutor oversees the child. The barriers detected are generally related to
environmental changes or an overload of the tutor’s duties. As a
facilitator, it is suggested that parents or guardians identify and
implement an activity that captures the child’s attention and
gives him pleasure to create a favorable environment that allows
massages to be carried out effectively.
DISCUSSION
The scope of this study is limited to describing caregivers’ adherence to the indicated treatment and understanding the performance of home therapy as a complex multifactorial
phenomenon, which implies an adaptation to each socio-family
context of the child, which must be approached with flexibility.
The degree of compliance with home massage may be improved
by incorporating educational instances.14 in moments before surgery, even during pregnancy, in those cases of prenatal diagnosis.
Among the barriers described by parents, changes in the
routine impede performing massages. This aspect coincides with
what has been reported in the literature; however, no studies were
found that specifically describe the frequency of massage applications in this population; it is described that in the management
of chronic conditions in children, it is positive to establish a
routine, which was considered beneficial to adjust the treatment
regimens to family life and could help to avoid the development
of child resistance as the children wait for their treatment as part
of a routine.13 One way to include this treatment in the family’s
daily routine would be to use smartphone alarms that allow them
to remember the massage schedules or paper reminders located in
Volume 00, Number 00, ’’ 2023
strategic places inside the house that help them remember, such as
changing tables or inside the child’s bathroom.
Considering that mothers are in charge of performing the
massage, it is essential to investigate their emotional state and
mental health since, as reported by Namdar et al15 they have a
greater tendency to show depressive signs than mothers of
children without CL/P,16 which can be enhanced by the feeling
of guilt reported by some mothers for not being able to carry
out the indicated therapy. It would be appropriate to assess the
mental health of the mothers of children with CL/P as a
screening method for those who need support in this area, which
would improve adherence to physical therapy.
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Copyright © 2023 by Mutaz B. Habal, MD
Copyright © 2023 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.