Can massage therapy improve focus, behavior, and motor function in
children with developmental disabilities: A case study
Chelsea L. Frenkel
Can massage therapy improve focus, behavior, and motor function in children
with developmental disabilities
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.
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Can massage therapy improve focus, behavior, and motor function in children
with developmental disabilities
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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
Can massage therapy improve focus, behavior, and motor function in children
with developmental disabilities
4
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 2behavior 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.
Can massage therapy improve focus, behavior, and motor function in children
with developmental disabilities
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
5
Can massage therapy improve focus, behavior, and motor function in children
with developmental disabilities
6
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
Can massage therapy improve focus, behavior, and motor function in children
with developmental disabilities
7
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
Can massage therapy improve focus, behavior, and motor function in children
with developmental disabilities
8
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
Can massage therapy improve focus, behavior, and motor function in children
with developmental disabilities
9
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,
Can massage therapy improve focus, behavior, and motor function in children 10
with developmental disabilities
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
Can massage therapy improve focus, behavior, and motor function in children 11
with developmental disabilities
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
Can massage therapy improve focus, behavior, and motor function in children 12
with developmental disabilities
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,
Can massage therapy improve focus, behavior, and motor function in children 13
with developmental disabilities
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,
Can massage therapy improve focus, behavior, and motor function in children 14
with developmental disabilities
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.
Upon discovery of hypotonicity with the hip abductors and excessive
internal ROM, the Trendelenburg test was preformed from the second treatment
onward. As explained in ‘Orthopedic Physical Assessment’, D.Magee(2008)
Can massage therapy improve focus, behavior, and motor function in children 15
with developmental disabilities
explains “this test assesses the stability of the hip and the ability of the hip
abductors to stabilize the pelvis on the femur. The patient is asked to stand on one
lower limb. Normally, the pelvis on the opposite side should rise; this finding
indicates a negative test. If the pelvis on the opposite side (non stance side) drops
when the patient stands on the affected leg, a positive test is indicated”. This test
was chosen to determine if the client had weak hip stabilization due to the
hypotonicity within the gluteals. Modifications were made to this test however,
due to the lack of language understanding from the clients’ perspective. The
modified test preformed was conducted in the following matter; the client was
told to lift his leg and balance on the other while the guardian attempted to put his
shoes on. While this took place, the client was observed to see if there was any
hip drop on the opposite side of the stance leg and he was timed to determine how
long he could stand on one leg for. Results from this test will be found in table B
of the results section.
To further investigate the hyper tonicity within the hip flexors, the Elys
test was preformed. As outlined in “orthopedic Physical Assessment”, Magee
(2008),”The patient lies prone, and the examiner passively flexes the knee. On
flexion of the knee, the patient’s hip on the same side spontaneously flexes,
indicating that the rectus femoris muscle is tight on that side and that the test is
positive”. This test was preformed from the second treatment onward until the test
Can massage therapy improve focus, behavior, and motor function in children 16
with developmental disabilities
showed a negative result and the impairment was corrected. Results of this test
will be presented in the results section.
To test whether each treatment helped to decrease the patients
sympathetic nervous system and to see whether the treatments has a relaxing
effect on the client, heart rate was measured by taking the clients pulse via the
radial artery. It was taken before and after each treatment. Results will be further
presented in table C of the results section.
As for testing the focus of the client, each treatment a finger flexion test
was preformed. This was done pre and post treatment. The test was preformed to
test how many fingers the client could focus on before becoming distracted with
something else. It was created to be similar to a game. The therapist would make
eye contact with the client then touch each finger one by one and ask the clients to
apply pressure in the motion of flexion into their index finger. The test measured
each hand separately. Results of this focus test will be shown in table D in the
results section.
Treatment Protocol:
Each treatment was preformed clothed in shorts and undraped as the
client moved a lot and seemed to prefer being on top of the sheets. The client was
pillowed under the head and knees while in supine and prone. When work to the
back was completed, the client was typically in three quarters prone as for his
comfort. From treatment 4 onwards, a thermaphore was warmed up and placed on
Can massage therapy improve focus, behavior, and motor function in children 17
with developmental disabilities
the clients back while in prone, and abdomen while in supine. It was not kept on
as it would get to hot; however the temperature was carefully monitored to remain
warm but not hot throughout the treatments. The treatment room was also kept
warm, as the client was not draped and was only clothed in shorts. The parent
guardian also remained in the room during each treatment and would assist with
emotional support when needed by the client, however, during treatment 14, the
client’s education assistant took place of the parent guardian. As for focus and
learning, following each treatment, the client was allowed to turn the light of the
treatment room on and off as a reward to listening and participating. This was
preformed after he got dressed and was completely done his treatment. As for a
learning aspect, it helped teach a lesson of being rewarded after doing something
asked of him and it also helped teach a skill of properly turning the light off and
on. Results of this will further be discussed in the results section. As for actual
treatment modalities, they were divided into three sections; phase oneintroduction to touch and massage, phase two- focus and behaviour, and phase
three- motor function. Although there were results of improvements in focus,
behaviour and motor function in all three phases, each phase best resulted in what
the purpose of that phase was for.
Each treatment through out the case study kept the same routine
however modalities and assessment tools did change slightly throughout each
phase. The routine began with client pickup in the reception area. The client
Can massage therapy improve focus, behavior, and motor function in children 18
with developmental disabilities
would be seated on the floor and be looking through books. The client would then
be taken into the treatment room where he would sit on the floor and continue to
look through his book while the interview took place between the therapist and
parent guardian. Once the interview was completed, additional notes were taken
by the therapist on the client’s behaviour, mood, etc. While notes were taken, the
parent guardian assisted the client with getting changed. Assessment then took
place and following that treatment began. Hands on treatment took about fifty
minutes. Once that was completed, tests (pulse and finger focus test) were
reassessed. The guardian then dressed the client and then the client was able to
turn the light on and off. The clients was then instructed on how to open the door
and then walked out to the lobby where he was instructed to put his book back on
the shelf. Once the book was put away, the treatment session was complete.
Phase One: treatments 1-3
The treatment modalities and goals for phase one- Introduction to touch,
included the following goals of introducing the clients to massage modalities,
increase body awareness of the client, assist the therapist in finding which
modalities best suited the client, and introduce the client to touch. Phase one of
treatment occurred during the first three treatments of the case study. During this
time, sensory devices were a part of treatment. These devices consisted of a book
to look through, shoe laces to play with, and a light up turtle that played music.
The treatments modalities are as followed:
Can massage therapy improve focus, behavior, and motor function in children 19
with developmental disabilities
Assessment tests included PROM of hips, knees and ankles, postural
scan, pulse (pre and post treatment), Elys test, Trendelenburg test, and palpation.
The client was first started in supine and the therapist preformed full
body compressions followed by gentle rocking. PROM to the hip, knee, and ankle
followed by vibrations and shaking to the lower extremity was preformed to lower
extremity. General Swedish massage (GSM) (Rattray, 2000) techniques:
longitudinal palmar stroking, forearm stroking, fingertip kneading, c-scooping,
and wringing to the quadriceps group. In between each technique, vibration and
shaking was applied briefly to help decrease the movement of the client’s leg.
Finished with a full anterior leg longitudinal flushing strokes. This routine was
applied over vastus medialis muscle, vastus intermedius muscle, vastus lateralis
muscle, and rectus femoris muscle, also known as the quadriceps femoris group
(quads) and adductors group, sartorius and gracilis muscles, tibialis anterior,
extensor digitorum longus, extensor halluces longus, and peronials. This routine
was completed bilaterally. The client was then turned over to prone where the
same techniques were applied as the anterior leg, however muscle approximation
and isolytic release was to gastrocnemius, soleus, and the hamstrings group; and
GTO release was applied to the Achilles tendon. GSM flushing techniques were
then applied over the whole posterior leg followed by compressions over the
gluteals, posterior leg, and foot. Treatment then continued onto the back where
GSM techniques were applied to the back including longitudinal palmar stroking,
Can massage therapy improve focus, behavior, and motor function in children 20
with developmental disabilities
forearm stroking, fingertip kneading, c-scooping, and wringing. MFR to the
thoracolumbar fascia was also applied. The treatment finished with a bilateral legpull.
Phase two: Treatments 6-10
Treatment goals for phase two- improvement of focus and behaviour
were to increase focus and behaviour of the client during and after treatment,
decrease the amount of sensory stimuli needed during treatment, and to decrease
sympathetic nervous system firing which would decrease the amount of muscle
spasticity and movement of the lower extremity. During this phase, the client was
still allotted a book before treatment started during the assessment but then was
taken away during the treatment. A thermaphore became part of the treatment as a
sensory tool as weight and heat can create a relaxing effect to sensory seeking
children according to Chasnoff (2011). It was applied throughout the treatment
and placed on the abdomen with a warm temperature during anterior leg work,
placed on the back during posterior leg work, and placed of the posterior legs
during back treatment. The use of the thermaphore had an instant calming effect
on the client when it was applied. The treatment room was made dark during
treatment and the light up turtle was still used. Treatment modalities continued
with the same sequence as phase one, however some new techniques were added
as the client was able to remain still for longer.
Can massage therapy improve focus, behavior, and motor function in children 21
with developmental disabilities
Assessment included pulse (pre and post treatment), finger focus test,
trendelenburg test, elys test and palpation. Modalities were as followed:
The treatments remained with the same sequence as in phase one
however, tapotement to tibialis anterior was added to increase muscle firing,
isolytic release to the adductor group was added to decrease muscle hypertonicity,
and light joint play to the hips and ankles was also added.
Phase three:
Treatment goals for phase three- improvement of motor function were to
decrease impairments in gait by increasing dorsi flexion and to continue with
improving previous goals. As for the treatments, sensory stimuli was decreased to
just the thermaphore and the room remained darkened during treatments.
Assessment included pulse (pre and post treatment), finger focus test,
trendelenburg test, ankle PROM, and palpation.
Modalities for treatment were still continued the same as previously,
however joint mobilizations of the ankle to increase dorsi flexion were included
and light joint play to the lumbar spine.
Homecare:
Homecare throughout the duration of the treatment plan included going
on a trampoline for 20-30 minutes, four days a week or as much as possible, going
for a walk one time a day as long as tolerated, and balancing on tip toes each night
Can massage therapy improve focus, behavior, and motor function in children 22
with developmental disabilities
for 5 minutes. Light massage by the parent before bed was also given as
homecare.
Results
The greatest outcomes of this case study included the client’s
improvements in both behaviour and focus. The qualitative section of this case
study showed very positive results. During phase one, results concluded in: more
affection, less grabbing, less scratching, less pinching, and an increase in time of
being still during treatment. The first break though in stillness occurred during
treatment three with a twelve minute time period of remaining still. This
eventually evolved into full treatment focus in phase two and even the ability to
fall asleep during the tenth treatment in phase three. Phase one showed an
increase in trust and comfort with touch, and beginning changes in behaviour.
In the beginning of phase two, the qualitative changes included an
increased focus in school, more easily redirected, and more relaxed at home. At
this point, changes in routine did affect the client and an example being, when the
client went on a weekend trip, poor behaviour increased but only lasted until the
next treatment. By treatment five, a significant decrease in rocking behaviour was
noticed and had stopped completely by treatment seven. By treatment eight, the
Can massage therapy improve focus, behavior, and motor function in children 23
with developmental disabilities
rocking behaviour had started again, however, the client had missed a treatment
and did not receive massage for twelve days. After the ninth treatment, rocking
behaviour had decreased and then stopped completely by treatment ten.
Support from the parent guardian was also stopped by treatment six and
the patient was able to lie on the table alone for the duration of the treatment.
Muscle spasticity had also deceased significantly during phase two. The client
began sitting much less rigidly and would sit in a relaxed, cross-legged position
while he looked through his books. During phase two, it was also noticed by the
speech pathologist that there was an increase in productive vocalizations and an
increase in learning ability was recognized by his support group. At this point the
client was able to learn how to turn the light switch on and off in a slow,
controlled manner and as well, open a door. Education assistants observed an
increased interaction with other children at this point.
During phase three, qualitative results included the learned ability of
using the toilet for the first time without encouragement from a guardian. He was
also able to last the duration of treatment at this point without sensory
distractions. A weekend trip showed no negative changes in behaviour.
Transitions during treatment from one area of the body to another did not affect
relaxation. During this phase of treatment, the client also began a new behaviour
of tapping lightly with his palms to gain attention rather than hitting or scratching.
Can massage therapy improve focus, behavior, and motor function in children 24
with developmental disabilities
Other qualitative changes noted during the three months of treatment
included learning new skills at home such as: opening cupboards, walking up and
down stairs without using the left foot; he would go up and down stairs one foot
after the other. There were also no reports of any seizure activity during the whole
time period of treatment.
As for motor function changes, results were seen throughout all three
phases. The postural scan showed slight improvements in head forward posture as
the client was less sluggish when standing. Knees were slightly less in genu
valgum and hips less coxa valgus due to an increase in hip stability. Pes planus
remained the same.
The hypertonicity found bilaterally in 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 had decreased significantly due to the decrease in the
rocking behaviour and spasticity. The hypotonicity bilaterally in the gluteus
maximus, medius, and minimus along with tibialis anterior, extensor digitorum
lonus, extensor digitorum brevis, extensor digitorum longus and brevis, had
improved causing an increase in balance and motor function.
Range of motion also showed improvements in ankle ROM. Hip and
knee ROM were not reassessed as they had full mobility. Refer to table A below
for results.
Can massage therapy improve focus, behavior, and motor function in children 25
with developmental disabilities
Table A-1: Ankle passive ROM
ACTION
Treatment 4
Treatment 15:
pre and post
8
12
60 degrees
Treatment 11:
pre and post
5
8
degrees
5
8
degrees
60
Dorsi flexion (L)
2 degrees
Dorsi flexion (R)
2 degrees
Plantar flexion
(L)
Plantar flexion
(R)
Inversion (L)
Inversion (R)
Eversion (L)
Eversion (R)
50 degrees
60
60
60 degrees
60 degrees
30 degrees
30 degrees
60
60
30
30
60
60
30
30
8
12
60
The trendelenburg test also showed improvements throughout the course
of the study. Refer to table B below for results summary.
Can massage therapy improve focus, behavior, and motor function in children 26
with developmental disabilities
Table B: Trendelenburg results summary
Result
Time of Balance
Treatment 1
(+) Left (+) Right
0
Treatment 2
(+) Left (+) Right
0
Treatment 3
(+) Left (+) Right
0
Treatment 4
(+) Left (+) Right
0
Treatment 5
(-) Left (-) Right
0
Treatment 6
(-) Left (-) Right
20 sec. (L+R)
Treatment 7
(-) Left (-) Right
20 sec.(L) 25 sec (R)
Treatment 8
(-) Left (-) Right
12 sec (L) 15 sec (R)
Treatment 9
(-)
10 sec (L) 15 sec (R)
Treatment 10
(-)
15 sec (L) 12 sec (R)
Treatment 11
(-)
15 sec (L) 12 sec (R)
Treatment 12
(-)
15 sec (L) 14 sec (R)
Treatment 13
(-)
15 sec (L) 12 sec (R)
Treatment 14
(-)
No results
Treatment 15
(-)
23 sec (L) 25 sec (R)
(L)=left (R)=right
Can massage therapy improve focus, behavior, and motor function in children 27
with developmental disabilities
The Elys test provided positive results from treatment. The test was
initially found positive however after eight treatments, the test was found negative
showing a decrease in hypertonicity of the hip flexors.
The results for heart rate before and after treatment also shows a
decrease in sympathetic nervous system firing and shows the relaxation that the
client was able to achieve. Refer to table C below for summary.
Table C- heart rate results
Treatment 1
Treatment 2
Treatment 3
Treatment 4
Treatment 5
Treatment 6
Treatment 7
Treatment 8
Treatment 9
Treatment 10
Treatment 11
Treatment 12
Treatment 13
Treatment 14
Treatment 15
Before treatment: beats
per minute
90
84
90
78
84
72
78
84
78
78
84
72
72
78
78
After treatment: beats
per minute
78
72
72
72
72
66
72
72
72
72
72
66
66
60
78
The finger focus test also showed positive results for the client’s ability
to focus. Throughout the treatment schedule the client was able to increasingly
focus on the task. The results are summarized below in table D.
Can massage therapy improve focus, behavior, and motor function in children 28
with developmental disabilities
Table D: Finger Focus test results
Treatment 4
Treatment 5
Treatment 6
Treatment 7
Treatment 8
Treatment 9
Treatment 10
Treatment 11
Treatment 12
Treatment 13
Treatment 14
Treatment 15
(L)=left (R)= right
Before treatment
2(L) 1(R)
1(L) 2(R)
3(L) 4(R)
4(L) 0(R)
2(L) 1(R)
2(L) 1(R)
2(L) 3(R)
2(L) 3(R)
3(L) 2(R)
2(L) 5(R)
5(L) 5(R)
5(L) 5(R)
After treatment
3(L) 4(R)
3(L) 4(R)
5(L) 5(R)
5(L) 5(R)
5(L) 5(R)
5(L) 5(R)
4(L) 5(R)
4(L) 4(R)
5(L) 5(R)
5(L) 5(R)
5(L) 5(R)
5(L) 5(R)
Discussion and Conclusion
The goals of creating a case study to explore the benefits of massage
therapy for children with developmental disabilities to benefit them both
physically and mentally were achieved. This case study successfully demonstrates
Can massage therapy improve focus, behavior, and motor function in children 29
with developmental disabilities
that the benefits of massage therapy were able to increase focus, good behaviour
and motor function of a child with Pervasive Development Delay. Throughout the
course of the study, the client was able to learn new life skills such as using the
toilet, turning a light on and off, opening doors, and even began making more
progressive vocalizations. He also became more interactive with other children his
age, more affectionate, calmer, demonstrated less aggressive behaviour, and
completely stopped his rocking behaviour (which was thought to be a behaviour
of anxiety). The client also became less affected by changes to routine. By the end
of the study, the client was able to go on a weekend trip without having negative
affects to behaviour or focus. He was even able to have his education assistant
assist him during a treatment instead of his parent guardian. Relaxation also
showed to improve in the treatment room. In the initial treatment, the client could
barely remain still throughout the entire session and by treatment thirteen, the
client remained completely still and even fell asleep during last thirty minutes. As
for the major health concerns of seizure activity, there were none to report since
massage therapy began, however, the clients medications were increased five
months previous to treatment so that could be a major component to the lack of
seizure activity.
The client demonstrated positive motor function changes in gait, posture,
ability to go up and down stairs, balance, and general muscle tone. Although it
was challenging to perform a lot of tests properly due to the mental status of the
Can massage therapy improve focus, behavior, and motor function in children 30
with developmental disabilities
client, the tests that were performed did show improvements. Gait appeared much
less sluggish as well as posture, balance increased, muscle spasticity decreased,
and weak muscles became stronger (hip abductors in trendelenburg test). By the
end of the study, the client was able to walk up and down stairs without using the
left foot as the lead; he was able to go up and down properly. The client’s parent
guardian expressed the changes noticed since the study began,
“Any changes I have noticed in behavior, focus, energy level, postural
differences, and differences in spacticity:
-
Overall, my son is much more calm and focused (observation by me, EAs, and
after-school support worker). He is not fidgeting as much, and is more likely
to engage in activity when his fidget (i.e., shoelaces) are not readily
accessible. He is going more frequently without his shoelaces, and has not had
any escalations associated with this change.
-
He pays much more attention to what the other kids are doing in the
playground, and initiates contact (e.g., approaches them, wants to touch them).
-
He is taking stairs – going from left foot to right to left, etc rather than using
same foot to go up stairs).
-
More communicative, vocalizing.
-
Seldom rocking or crossing legs in rigid pose any more. Was doing that
several times per day prior to massage. Before, when we would uncross his
Can massage therapy improve focus, behavior, and motor function in children 31
with developmental disabilities
legs, he would move them back to that rigid pose; now when he does this and
we move his legs, he does not cross them again.
-
He appears a lot less aggressive.
-
Requests music; copies movements to songs (both hand gestures – tapping or
clapping – and awkward dance moves).
-
Loves to twirl around now. His balance appears to have improved. He can lift
both legs much higher than he used to, and hold them above the ground for a
longer time.”
The client’s education assisstent would note another insight to the changes
experienced. She mentioned, “I believe that he is more calm and focused after
massage. In the sensory room, we have been doing lots of sighing and I must say
that he is sustaining joint attention during action songs for a longer time (this is a
perceptual observation as I never time his attention time)”.
Due to the small body of research on manual therapies such as massage for
children with PDD and autism spectrum disorders, as well and the complexity and
wide spectrum of how they can present, it is challenging to draw a solid
conclusion that the results of this case study can be transferred to other developing
children with these disorders. Due to the profound results in this particular case
study, it would be of great benefit to continue research on how massage therapy
can benefit these children.
Can massage therapy improve focus, behavior, and motor function in children 32
with developmental disabilities
References
Baird, G., Charman, T., Cox, A., Baron-Cohen, S., Swettenham, J., Wheelwright,
S., & Drew, A. (2001). Screening and surveillance for autism and pervasive
developmental disorders. Archives of Disease in Childhood, 84(6), 468-475.
Centers for disease control and prevention. N.p., 26 Dec. 2013. Web. 17 Dec.
2014. http://www.cdc.gov/ncbddd/developmentaldisabilities/facts.html
Chasnoff, Ira J. "To sleep.a parent's dream." Psychology Today (2011). Web. 28
Dec. 2014. http://www.psychologytoday.com/blog/aristotles-child/201107/sleepaparents-dream
Escalona, A., Field, T., Singer-Strunck, R., Cullen, C., & Hartshorn, K. (2001).
Brief report: improvements in the behavior of children with autism following
massage therapy. Journal of autism and developmental disorders, 31(5), 513-516
Hernandez‐Reif, M., Field, T., Largie, S., Mora, D., Bornstein, J., & Waldman, R.
(2006). Children with Down syndrome improved in motor functioning and muscle
tone following massage therapy. Early child development and care,176(3-4), 395410.
Ludwig, L. & Rattray, F. (2000). Clinical massage therapy: Understanding
assessing and treating over 70 conditions. Elora, Ont.: Talus Incorporated.
Magee, D.J. (2008). Orthopedic physical assessment (5th ed.). St. Louis, MO:
Saunders
.
Can massage therapy improve focus, behavior, and motor function in children 33
with developmental disabilities
Appendix
Appendix A- health history form
Can massage therapy improve focus, behavior, and motor function in children 34
with developmental disabilities
Appendix B: treatment forms