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Х1Ж JOURNAL OF CLINICAL MEDICINE OF KAZAKHSTAN
Шолу Макала / Обзорная Статья / Review Article
DOI: 10.23950/1812-2892-JCMK-00775
The effects of massage therapy on symptoms related cerebral palsy in children with cerebral palsy: A systematic review
Hasan Bingol1, Esedullah Akaras2, Hikmet Kocaman3
Abstract
The purpose of this review was to systematically present the effectiveness of massage therapy on cerebral palsy related symptoms in children with cerebral palsy based on existing evidence. A comprehensive systematic literature search was conducted from inception to February 2020 using the following electronic databases: PubMed, Google Scholar, Science Direct, Cochrane Library Database of Reviews of Effectiveness, Physiotherapy Evidence Database. To evaluate the articles concerning eligibility, a screening process was carried out by two reviewers. Summary of the studies including outcomes, measures, and results, and methodological quality of the studies were described according to the American Academy for Cerebral Palsy and Developmental Medicine guidelines. Five studies with different conducting design met inclusion criteria were included to document the current body of evidence of massage therapy in children with cerebral palsy. Almost all of the included articles reported that massage therapy (with or without conventional physiotherapy) is effective to improve spastic/ hypertonic muscles and gross motor functions. Besides, it was also found that massage therapy could be effective on comorbidities including pain, sleep disorder, and lower perception of life satisfaction. Some of the included studies established the effects of massage therapy on comorbidities related to the cerebral palsy, whereas some of the studies directly demonstrated the effects of massage therapy on secondary problems related to The International Classification of Functioning, Disability and Health body structures/functions, and activity. Consequently, performing massage therapy (with or without physical therapy and/or routine therapy), would be effective to improve most of the symptoms related to cerebral palsy.
Key words: cerebral palsy, spasticity, massage therapy, pain, children
ЕМД1К МАССАЖДЫН, БАЛАЛАРДАГЫ ЦЕРЕБРАЛЬДЫ САЛ АУРУЫМЕН БАЙЛАНЫСТЫ БЕЛГ1ЛЕРГЕ ЭСЕР1: ЖYЙЕЛI ШОЛУ
Х. Бингёль1, Е. Акарас2, Х. Кокаман3
'Терапия жэне оцалту кафедрасы, Кэшби денсаульщ са^тау мектеб^ Муш Алпарслан Университету Муш, Туркия
2Физиотерапия жэне оцалту кафедрасы, Денсаульщ са^тау факультету Еази Университету Анкара, Туркия
3Физиотерапия жэне оцалту кафедрасы, Медициенальщ гылымдар факультету ^араманоглу Мехметбей атындагы Университету ^араман, Туркия
Т¥ЖЫРЫМДАМА
Бул шолудыц максаты колда бар мэлiметreр непзшде церебральды сал ауруы бар балалардагы церебральды сал ауруыныц белгiлерi Yшiн емдiк массаж тшмдтИн ЖYЙелi TYPде усыну болды. 2020 жылдыц басынан акпан айына дешн келесi электронды деректер базасын кол-дана отырып, эдебиеттердi кешендi ЖYЙелi TYPде iздеу ЖYргiзiлдi: PubMed, Google Scholar, Science Direct, Кохран итапханасыныц тшмдтИн шолу дереккоры, Физиотерапиялык дэлелдер дереккоры. ^атысу кукьнына байланысты макалаларды багалау Yшiн рецензияолау процесiн ею рецензент ЖYргiздi.
'Department of Therapy and Rehabilitation, Vocational School of Health Service, Mus Alparslan University, Mu§, Turkey
department of Physiotherapy and Rehabilitation, Faculty of Health Science, Gazi University, Ankara, Turkey Department of Physiotherapy and Rehabilitation, Faculty of Health Science, Karamanoglu Mehmetbey University, Karaman, Turkey
© ®
This work is licensed under a Creative Commons Attribution 4.0 International License
Received: 2020-05-05 Accepted: 2020-06-06 UDC: 616.1
J Clin Med Kaz 2020; 4(58):6-14
Corresponding Author: Hasan Bingöl, Teaching
Assistant, PT, MSc, Department of Therapy and
Rehabilitation, Vocational School of Health Service, Mu§
Alparslan University, Mu§, Turkey.
Tel.: +90 04362494949, +90 05072328100
E-mail: h.bingol@alparslan.edu.tr,
hesenbingol@gmail.com
Зерттеу нэтижелер^ корытындысын коса отырып, керсеташп^ мен нэтижелерi жэне зерттеу эдюнамалык сапасы Американдык Церебральды сал ауруы академиясыныц жэне Даму медицинасыныц нускауларына сэйкес сипатталган. Церебральды сал ауруы бар балалар-дагы емдк массаж туралы колда бар дepeктepдi кужаттау Yшiн эр TYpлi эдicтepi бар жэне eнгiзу кpитepийлepiнe сэйкес келетЫ бес зерттеу eнгiзiлдi. Барлык макалалардагы барлык дepлiк массаж терапиясы (калыпты физикалык терапиямен немесе онсыз) спастикалык/гипертони-ялык булшыкеттер мен мотордыц жалпы функцияларын жаксартуда тиiмдi болып табылады.
Сонымен катар, массаж терапиясы ауырсыну, уйкыныц бузылуы жэне eмipгe канагаттанушылыкты кабылдауды темендету сиякты ауруга карсы жагдайлар Yшiн тиiмдi деп табылды. Бipкатаp зерттеулер массаж терапиясыныц мидыц сал ауруымен байланысты жанама ауруларга эcepiн аныктады, ал кeйбip зерттеулерде Медициналык кызметке, MYгeдeктiккe жэне денсаулыкты коргаудыц халыкаралык жкте-месшщ денеанщ курылымымен / функциясымен байланысты ешшл проблемаларга массаж терапиясыныц эcepi аныкталды.
Сондыктан массаж терапиясын (физиотерапиямен жэне/немесе кэдiмгi терапиямен немесе онсыз) ЖYpгiзу церебральды сал ауруымен байланысты кептеген бeлгiлepдi жаксартуда тиiмдi болады.
Heri3ri сездер: церебральды сал ауруы, сертмдтк, терапиялык массаж, ауырсыну, балалар
ЭФФЕКТ ЛЕЧЕБНОГО МАССАЖА НА СИМПТОМЫ, СВЯЗАННЫЕ С ЦЕРЕБРАЛЬНЫМ ПАРАЛИЧОМ У ДЕТЕЙ: СИСТЕМАТИЧЕСКИЙ ОБЗОР Х. Бингёль1, Е. Акарас2, Х. Кокаман3
'Кафедра терапии и реабилитации, Профессиональная школа здравоохранения, Университет Муш Алпарслан, Муш, Турция 2Кафедра физиотерапии и реабилитации, Факультет здравоохранения, Университет Гази, Анкара, Турция
3Кафедра физиотерапии и реабилитации, Факультет медицинских наук, Университет им. Караманоглу Мехметбей, Караман, Турция
РЕЗЮМЕ
Целью данного обзора было систематически представить эффективность лечебного массажа при симптомах, связанных с церебральным параличом, у детей с церебральным параличом на основании имеющихся данных. Комплексный систематический поиск литературы проводился с начала до февраля 2020 года с использованием следующих электронных баз данных: PubMed, Google Scholar, Science Direct, База данных обзоров эффективности Кокрановской библиотеки, База данных физиотерапевтических доказательств. Для оценки статей, касающихся права на участие, процесс рецензирования был проведен двумя рецензентами. Резюме исследований, включая исход, показатели и результаты, а также методологическое качество исследований были описаны в соответствии с руководящими принципами Американской академии церебрального паралича и медицины развития. Пять исследований с различной методологией и соответствующие критериям включения, были включены для документирования имеющихся данных о лечебном массаже у детей с церебральным параличом. Почти во всех включенных статьях сообщается, что лечебный массаж (со стандартной физиотерапией или без нее) эффективен для улучшения спастических/гипертонических мышц и больших моторных функций. Кроме того, было также обнаружено, что лечебный массаж может быть эффективен при сопутствующих заболеваниях, включая боль, нарушение сна и снижение восприятия удовлетворенности жизнью. Некоторые из включенных исследований установили влияние лечебного массажа на сопутствующие заболевания, связанные с церебральным параличом, в то время как некоторые из исследований прямо продемонстрировали влияние лечебного массажа на вторичные проблемы, связанные со структурами/функциями тела Международной классификации функционирования, ограничений жизнедеятельности и здоровья. Следовательно, выполнение лечебного массажа (с физиотерапией или без нее и/или обычной терапией) будет эффективным для улучшения большинства симптомов, связанных с церебральным параличом.
Ключевые слова: церебральный паралич, спастичность, лечебный массаж, боль, дети
Introduction
Cerebral palsy (CP) is the most common form of motor disorder of childhood [1] and is characterized by a group of disturbance of the development of movement and posture, inducing activity limitation through non-progressive impairments that emerge in the developing fetal or infant brain [2]. Although cerebral palsy stems from a primary disruption in the central nervous system (CNS), clinic symptomatology is largely observed in the peripheral neuromuscular system [3], especially in the skeletal muscles [4]. From the International Classification of Functioning, Disability and Health (ICF)'s perspective, CP compromise a person's 'functioning', (containing body structures [e.g. upper limbs], body functions [e.g. psychological functions], activities [e.g. manual ability], and participation [e.g. park activity]), which may lead to 'disabilities' such as limb involvements, activity and participation restrictions, respectively [5,6]. Children with CP largely experience a wide range of problems (impairments) with motor and sensory functions such as muscle stiffness, spasticity and/or dystonia, reduced muscle length, musculoskeletal deformity [7]; loss of proprioceptive input, light touch perception, two-point discrimination, and weight perception [8]. Spasticity is the most common motor disorder [9], following damage in descending motor pathways [8].
Spasticity can induce muscle stiffness/hypertonia, limitation at the joint movements, muscle contracture, impairments in motor function, and lower functional profile [10]. Moreover, spasticity
frequently leads to pain in children with spastic CP, especially in those classified within the Gross Motor Function Classification System (GMFCS) V [11]. The presence of pain is related to a worse quality of life in children with CP [12]. Of children with moderate to severe CP, 40-73% have various sensory deficits leading to decreased use of the extremity, impaired hand function, and motor ability, diminished spatial perception, or position of the joints [13,14]. Besides, cerebral palsy is generally accompanied by comorbidities, which might be a problem as important as the physical impairments, such as behavior disorder, bladder incontinence, sleep disorder, blindness, nonoral feeding deafness and epilepsy [15]. Therefore, there is a wide range of potential problems a person with cerebral palsy may experience such as motor or sensory deficits, sleep disorder, non-oral feeding, and bladder incontinence.
Although there are various comorbidity-specific treatment approaches in cerebral palsied individuals, management of the most common symptoms mentioned above might be expected to be related to spasticity [10,16], because abnormal physiological features of the skeletal muscle itself might single-handedly lead to most common problems seen in CP.
Management of spasticity includes a major challenge to health professionals. Various types of treatment approaches are available to decrease the severity of spasticity/hypertonia, such as botulinum toxin, several medications, intrathecal baclofen, massage therapy, manual stretching, casting, selective dorsal rhizotomy, and complementary and alternative therapy. Given that these available intervention approaches are effective in
treating spasticity [17], each of these can be applied to spastic muscle depending on the choice of health professionals
However, there is yet no adequate evidence demonstrating comprehensively the advantages of the current intervention approaches regarding reducing of spasticity/hypertonia [18]. Massage therapy, as one of the intervention approaches, was reported to be effective in reducing the severity of spasticity/ hypertonia in children with cerebral palsy [19]. Massage therapy might be effective in improving motor functions, sensory deficits, pain, and other symptoms "of children with CP, by regulating muscle tone or stiffness [20]. It reduces the severity of spasticity/ hypertonia by stretching the muscle-tendon unit and inducing the Golgi Tendon Organ that could suppress alpha motor neurons [17]. Finally, in their study which reported the current evidence about intervention approaches for children with CP, Novak et al [21] showed massage therapy at the "Yellow Light" level, which stands for either lower-level proof establishing its effectiveness or inconclusive evidence. Based on the premise mentioned above, the purpose of this review was to report whether that massage therapy, as a complementary treatment, is effective on cerebral palsy symptoms in children with CP. To answer these questions, we planned to provide a summary of the body of the available evidence regarding massage therapy, and we hypothesized that the massage therapy might be effective on CP-related symptoms in children with CP.
Inclusion and exclusion criteria
All retrieved articles were reviewed for content, methodology, feasibility, target population, generalizability (generic versus specific to region), clinic-based outcome (rather than case-report), and ICF domain (body function, body structure, or activity and participation) [25]. Taken altogether, the trials were included if (1) they had text published in English, (2) subjects of the study were children or adolescents with CP (aged between 31 months and 17 years), (3) they were conducted in a clinical setting (not survey-based), and (4) the effect of massage therapy on improving muscle tone was investigated using at least one outcome measure. Articles featured (1) systemic or non-systematic reviews, (2) only about the baby or adult massage, (3) about a specific country (e.g. Chinese massage), (4) unpublished studies or grey literature publications were excluded. After detailed searches in given databases, a total of 59 articles were initially screened for relevance following inclusion/exclusion criteria. At the first stage, 13 articles were deported due to various reasons. Subsequently, the remaining 46 works were reviewed by authors considering the inclusion criteria. After a detailed examination of each article, the authors agreed on five articles for systematic review. A flow diagram of the retrieved articles, illustrating the inclusion and exclusion process, is shown in Figure 1.
Material and methods Study design
This review was carried out by the guidelines of the American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) methodology for reporting systematic reviews of intervention approaches [22], and Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) [23]. Ethical approval was not provided because the manuscript did not request human participation.
Search Strategy
In June 2019, a comprehensive systematic literature search on all articles regarding massage therapy published from database inception to June 2019 was conducted by searching the following databases: PubMed, Google Scholar, Science Direct, Cochrane Library Database of Reviews of Effectiveness (DARE), and Physiotherapy Evidence Database (PEDro). Besides, literature searches were updated in February 2020. Keywords by The Medical Subject Headings (MeSH)' terminology were specified using: (1) most recognized websites such as Developmental Medicine and Child Neurology (www.aacpdm.org), CanChild (www.canchild.ca), (2) notable articles of the field, and (3) articles selected for this review. The keywords 'cerebral palsy', 'spasticity', 'massage therapy', and 'children' were used as collective search terms. The keyword "cerebral palsy" was searched as a Population Descriptor or Sample Descriptor and then, this keyword was combined with other keywords to reach all relevant studies. 59 articles retrieved from all databases were examined by two authors in terms of their titles and content. Full-text articles qualified with the inclusion criteria or the works that were carried out as clinical studies were selected. The screening process was conducted by two authors, and when the authors could not reach a consensus, they consulted the third author. Each electronic database was searched on an individual basis using the P.I.C.O. Model for Clinical Questions [patient/ problem, intervention, comparison, and outcome] search terms [24].
Figure 1 - Prisma Flow Diagram
(n = 59)
Records excluded with reasons: about baby massage, review, survey-based studies, not clinical trial, about a specific country (i.e. Chinese massage (n =32)
Full-text articles excluded according to exclusion criteria: (n = 9)
u
Studies Included in quantitative synthesis (n = 5 )
Data collection procedure and quality assessment
Two authors, independently from each other, retrieved data from each included paper by utilizing the convenient AACPDM 'study data extraction summary form', and any disagreement was discussed to reach consensus by the third author. These forms were eligible for both study designs including group or single-subject designs. A total of five articles consisting of two single-subject design studies and three group design studies were
included in this study. The tables of summary for each article documented data regarding participants, intervention, outcome measure(s), level of evidence and conduct rating, ICF domain, and the results. For each article studied as subject design or group design, the questions were answered by adhering to the
Table 2
AACPDM guideline [26].
For the studies conducted as a single subject design, changes between the pre- and post-interventions of each participant involved in the study were recorded separately (Tables 2, 3), while changes in participants in group design
Summary of studies: outcomes, measures, and results
Single Level of Participants n Ages Intervention Group Control Outcome of Measure ICF Results
Subject Evidence and group interest Component
Study Conduct Rating
2006 -IV, Non- -Adolescents Total=5 12-15 y -Stretching calf muscle no -Range of Goniom- •B(b710) mo- -consistently increased
Macgregor randomized with CP (mean transversely rather passive and eter bility of joint dorsiflexion of only two
BSc et al.23 controlled (spastic age=14) than longitudinally voluntary -EMG function ankles among ten ankles
diplegia) with a standardized sequence of Swedish movement -Stretch reflex -GMFM-66 •B(b750) Motor reflex - Elongation or shortening in the calf muscles of the
-GMFCS I-IV massage strokes + -Strong Stretch exercise -The data were collected at 1st week before intervention, and 5th week, and 17th week after intervention -Duration of intervention: 14 minutes, twice a week, for 5 weeks. -Motor skills function •B(b789) Neuromus-culoskeletal and movement-related functions, other specified individuals was observed. -increase in GMFM score of four participants -In the first two sessions, a stretch reflex in the soleus muscle of participant 2 began at a more dorsiflexed angle. -decreased phasic stretch reflexes - inhibition of the soleus muscle during stretch in participant 1 in sessions 4 and 5 as a diminution of background EMG activity. -Participant 1 made striking gains in the freedom of movement of both ankles after the third massage session.
Abbreviations: GMFCS, Gross Motor Function Classification System; EMG; electromyography; GMFM; Gross Motor Function Measure
Summary of studies: outcomes, measures, and results
Table 3
Single Subject Study Level of Evidence and Conduct Rating Participants n Ages Intervention Group Control group Outcome of interest Measure ICF Component Results
2010 -I, M (9/14), -Unilateral Total=6 3-17y -Massage therapy Resting -Sleep quality -Parent's B (b280-b289) -no difference in heart
Nilsson42 Randomized spastic CP (1) starting with the for 30 -Well-being report Pain rate between before
Controlled -Bilateral right leg, and min- -Hearth rate -VAS (Visual B (b134) and after massage
Trial spastic CP (3) continued with the utes -Pain Analog Scale) Sleep functions therapy
-Dyskinetic foot, right arm, hand, B (b410) Heart -decreased heart rate
CP (2) left arm, hand, and -CHQ-PF50 functions in the control group
-GMFCS II-V finally the left leg (Child Health
and foot. Questionnaire -low pain in all
Parent Form participants
-Duration: 30 min 50) -no statistically
-Pulseoxyme- significant difference
ter between the study
-CAS (Coloured groups concerning
Analogue pain intensity, well-
Scale) being, or sleep quality.
-Qualitative
report
Abbreviations: M, Moderate; GMFCS, Gross Motor Function Classification System; CHQ, Child Health Questionnaire Parent Form 50; CAS, Colored Analogue Scale
Table 5
Summary of studies: outcomes, measures, and results
Single Level of Participants n Ages Intervention Group Control Outcome of Measure Components of Results
Subject Evidence group interest Health
Study and Conduct Rating
2017 II, M -Spastic and Total=60 3-9 y Routine therapy Routine -Spasticity -Modified B (b735) Muscle reduction in the
Rasool23 (4/7) diplegic (mean= + therapy -Mobility Ashworth Scale tone functions severity of spasticity
Small cerebral palsy 6.03±1.73) -Cross-friction massage (ambulation (MAS) B (b789) Move-
sample -the presence on both the legs at soleus level) -A 9- pointed ment functions, -no significant
size of mild mental retardation and gastrocnemius along Achilles tendon. -Conventional physiotherapy (hot pack and Bobath Therapy) Duration:30 minutes, 5 times a week lasting 6 weeks Scale for defining functional level other specified and unspecified improvement in gross and fine motor function
Abbreviations: M, Moderate; MAS; ModifiedAshworth Scale
Summary of studies: outcomes, measures, and results
Single Level of Participants n Ages Intervention Group Control group Outcome of Measure Components of Results
Subject Evidence interest Health
Study and Conduct Rating
2018 II, W (3/7) Quadriplegic=13 Total=20 5-12 y - 10-minute FM Conventional -Spasticity - MAS B (b735) Muscle - significant
Bingöl40 Small Diplegic=4 (mean= to adductors, physiotherapy -Gross motor -GMFM tone functions improvement in
sample size Hemiplegic=3 8,1511.7) hamstring muscles, calf and hip flexors at each lower extremity function -Mobility level GMFCS D (d410-d429) Changing and maintaining body position D (d450-d469) Walking and moving (d450-d469) muscle spasticity at hamstring group muscles and triceps surae in both group Significant reduction in hip flexor muscles spasticity only for experimental group - significant increase in GMFM Score and GMFCS level for both group
Abbreviations: W, Weak; FM, Functional Massage; MAS, ModifiedAshworth Scale; GMFCS, Gross Motor Function Classification System; GMFM, Gross Motor Function Measure
Summary of studies: outcomes, measures, and results
Single Subject Study Level of Evidence and Conduct Rating Participants n Ages Intervention Group Control group Outcome of interest Measure Components of Health Results
2007 -II, M (5/7) -Cerebral Total=20 Mean -Massage Therapy Read- -Spasticity Modified B (b735) Muscle reduced arm
Hernandez- -Small RCT Palsy (spastic, age=31 to head, face, scalp, ing values of both Ashworth Scale tone functions spasticity
Reif17 athetoid, months shoulders, arms, atten- arm, elbow, B (b710) -improved muscle
ataxic) hands, hips, legs, tion and wrist -Arms, legs, and Mobility of joint tone for the overall
-GMFCS I-IV feet -Spasticity trunk muscle functions body
-in the form of 30 values of right tone scale (ALT B (b789) -improved right hip
minute- sessions and left leg, muscle tone Movement and left hip extension
twice per week for hip, and ankle scale). -D(d910) -improved: (a)
12 weeks Community life cognition (b) fine
-Range of -Goniometer -D (d530) motor (c) gross (d)
motion of hip -Developmental Toileting dressing and (e) social
extension and programming -D(d540) functioning
abduction for infants and Dressing -positive facial
-Perceptual/ young children -D(d550 )Eating expressions
fine motor, (DPIYC)
gross motor,
self-care
(feeding,
toileting,
dressing/
hygiene
skills), social/
emotional,
language and
cognition
Abbreviations: RCT; Randomized Controlled Trial; GMFCS, Gross Motor Function Classification System; M, Moderate
Abbreviations: RCT; Randomized Controlled Trial; GMFCS, Gross Motor Function Classification System; M, Moderate
Conduct of Study Design
Single Subject Study Level /Quality 1 2 3 4 5 6 7 8 9 10 11 12 13 14
2006 Macgregor BSc et al.23 IV, SSRDs - - - - - - - - - - - - - -
2010 Nilsson42 I, M (9/14) yes yes yes no yes no no yes yes yes yes no no yes
Group Study Level/Quality 1 2 3 4 5 6 7 - - - - - - -
2007 Hernandez-Reif17 II, M (5/7) no yes yes yes yes No yes - - - - - - -
2017 Rasool23 II, M (4/7) yes yes no yes yes no no - - - - - - -
2018 Bingöl40 III-W (3/7) yes yes yes no no no no - - - - - - -
Abbreviations: SSRD, Single Subject Study; M, Moderate; W, weak
studies were recorded as the mean value. The quality assessment of each article included was detected in two steps (Tables 5, 6). The first step was to determine the study quality according to the classification of the AACPDM methodology based on the description of Lynne Romeiser (for single-subject design study) and Dr. David Sackett (for group design study) [26]. The second step was to assess the conduct of the studies. For group studies, this step is a quality assessment consisting of seven conduct
questions. Each question was responded "yes" or "no". The quality of the design of an individual trial was evaluated as Strong ('yes' response on 6-7 of the inquiries), Moderate (point 4 or 5) or Weak (point <3) (Table 4). For single-subject design studies, each included study was rated using a 14-item questionnaire, and the quality of design of an individual work was evaluated as Strong ('yes' point on 11-14 inquiries), Moderate (point 7-10), or Weak (point <7) (Table 1).
Results
Types of participants
Studies were involved in this systematic review if they predominantly included children or adolescent participation diagnosed with any subtype of CP. Motor type of CP enrolled in the included studies consisted of various subtypes. In this context, the participants diagnosed with spastic unilateral or bilateral CP, and spastic athetoid or dyskinetic type, and aged between 31 months to 17 years, and with any mobility level (Gross Motor Function Classification System [GMFCS] score I to V) were incorporated in the current review
This systematic review is based on literature search in PubMed, Google Scholar, Science Direct, Cochrane Library Database of Reviews of Effectiveness (DARE), and Physiotherapy Evidence Database (PEDro) utilizing the key phrases "the efficacy of massage therapy on muscle tone/ spasticity in children/individual with CP" with an emphasis on clinical studies. Using the search strategy, a total of 1043 articles were identified; of which 46 were screened for title and abstract. The full text of 14 studies were assessed for eligibility, and only five met inclusion criteria. Among these five articles, two of them involved single-subject design studies (evidence level I, IV), while the other three (evidence level II, III) included group study design studies. Considering the characteristics of the articles, tables were created separately according to the study design (single-subject design or group design) by the AACPDM methodology. Hence, most of the included articles provided low-level evidence by to Romeiser's (for single-subject design study) and Sackett's (for group design study) criteria. Table 1 describes the methodological quality of the included articles. The contents of each article associated with a citation, level of evidence and conduct rating, treatment type, subjects, findings, assessment tools, and coding concerning the ICF-Children & Youth Version [27] were summarized based on the AACPDM principles [26]. Types of massage therapy of which its effectiveness was investigated across reviewed studies were as follows: Swedish massage (in three studies) [28-30], deep cross friction massage (in one study) [31] and functional massage (in one study) [32]. In two studies included, the control groups received usual care, whereas there was no reported intervention approach for control groups of other studies. In two of 5 included articles, participants in the experimental group were delivered only massage therapy, while in two of two included articles, massage therapy was performed as adjunctive therapy. In contrast to these four, massage therapy was integrated with stretch exercise (simultaneously with stretching exercises) in another study.
Efficacy of Different Types of Massage Therapy Across Main Domains of the ICF
The effectiveness of five retrieved studies was elaborately evaluated and abstracted according to the relevant ICF subdomains under the AACPDM guidelines (Table 2-6). In their randomized controlled study, Hernandez Reif et al. carried out a trial with 10 participants in the experimental group. The participants of the study were delivered a 30-minute massage therapy integrated with the children routine therapy including occupational therapy, music therapy, and speech therapy two times per week for 3 months. They revealed a significant reduction in arm spasticity, improved muscle tone for the overall body, increased extension of right and left hip joint, and improved (a) cognition (b) fine motor, (c) gross motor (d) dressing and (e) social functioning in the massage therapy group [28]. According to the study of Rasool et al. conducted with a group design in which 60 participants were distributed
Journal of Clinical Medicine of Kazakhstan: Volume 4, Number 58, Issue 2020
randomly into the experimental and control group, both groups were applied conventional physiotherapy including 10-minute hot pack application and Bobath Therapy followed by a stretch exercise to the Achilles tendon; however, the treatment group was additionally delivered with cross-friction massage on soleus and gastrocnemius of both the side along Achilles tendon. A significant improvement both in the severity of spasticity and in the functional level was revealed in the experimental group [33]. Another study conducted by Nilsson et al. through single-subject design which consisted of a total of six participants who had undergone orthopedic surgery at one or two limbs. Three participants in the experimental group received massage therapy for 30 minutes before the physiotherapy session. In contrary to this, the control group took a rest for 30 minutes before the conventional therapy. After seven intervention sessions, it was found a low score for pain intensity and discomfort in either experimental and control groups. However, participants in both groups demonstrated similar statistical differences in variables regarding pain intensity, well-being, or sleep quality. Besides, there was not found out the statistically meaningful difference in heart rate immediately post-intervention for the experimental group, while there was a significant change in the same variable for control group [30]. In the study conducted as single-subject design by Macgregor [29] which explored the effectiveness of massage therapy on the mechanical properties of muscles in children spastic diplegia, each participant's calf muscles were moved transversely rather than longitudinally with an adjusted sequence of classic massage lasting for 14 minutes, twice a week for 5 weeks. After the massage therapy, it was found that the range of movement increased, but not consistently. Also, the participants within the Gross Motor Function Classification System (GMFCS) Levels I and II exhibited continued improvements in Gross Motor Function Measure-66 scores.
Consequently, the authors of this study reached a consensus that calf muscles could either shorten or lengthen when passively moved. For stretch reflex, in the first two session periods, a stretch reflex in the calf muscle of one subject started at a more dorsiflexed angle after massage therapy, suggesting a decreased responsiveness. On the other hand, in the subsequent massage sessions, reduced phasic stretch reflexes were noted soon after the beginning of stretch. As for voluntary movement, freedom of movement of both ankles after the third massage session was developed significantly for another subject. One subject developed a more modest movement in one limb, also after the third massage session. Besides, one subject made no evident improvements; but, another one subject developed, especially in the last session when forced to contact the calf muscle, rather than inverting and everting the ankle. Subsequently, one subject could not act either ankle voluntarily. Concerning changes that occurred in gross motor function, by the 5th week of the intervention, the ambulant participants developed their GMFM-66 scores by an average of 6.4%, but the score of the non-ambulant subject was unaltered [29]. Finally, another study conducted by Bingol et al [32] suggested that stretch exercise integrated with Swedish massage, described as functional massage, might be more effective on muscle spasticity and gross motor function than forcible exercise alone.
Discussion
Management of CP includes a major challenge for health professionals, and currently there is no standardized treatment option for children with CP [34]. From the ICF perspective, CP commonly compromises a person's body structure/functions and activity/participation [35]. Also, it is often accompanied
by pain, sensory deficit, impaired perception and cognition, communication, and behavioral problems [15].
However, increased muscle tone/spasticity which has serious consequences concerning body position (i.e. joint deformity, joint subluxation, and contracture), functional ability, quality of life, and financial cost is the underlying factor of most notable problems. Thus, it is well known that most of the intervention strategies towards body structures/functions are based upon the management of abnormal muscle tone or spasticity. Many treatment approaches are used to manage increased muscle tone/spasticity in children with CP such as oral medications, physical and occupational therapy, splinting and casting, botulinum toxin, selective dorsal rhizotomy, intrathecal baclofen, orthopedic surgery [36-39]. Massage therapy, as reported in a systematic review by Novak et al [35], was indicated as one of the intervention approach which is used to regulate abnormal muscle tone in the management of CP. When we examine the history of massage therapy, it is seen that published research studies on massage therapy date back to the 1930s, when human and animal studies were popular [28].
Massage therapy is a relatively simple [40], inexpensive and non-invasive treatment, and has been applied to treat stroke subjects for many years [17,41]. In this context, massage therapy is utilized to improve spastic muscle, to augment the elastic quality of muscles and connective tissue, to reduce muscle pain, improve range of motion and muscle contracture, and support relaxation [42,43]. Based on the issues mentioned above, we suggested that massage therapy may be effective on CP-related symptoms and motor function by improving the abnormal muscle tone/spasticity in individuals with CP safely and efficacious. Any intervention to improve spasticity/abnormal muscle tone, either complementary or evidence-based practices, should be assessed in terms of their efficacy on body structures/functions and, activities and participation, as well as comorbidity. Considering our purpose in this systematic review, we selected articles whose resultants were predominantly based on ICF's s body structure/function domains (muscle tone function, mobility of joint function, and pain), ICF's activity domain (gross motor function) and as well as well-being. Hence, the main purpose of this review was to summarize the clinical studies investigating the effectiveness of massage therapy on symptoms related to CP in children with cerebral palsy.
To our knowledge, this pooled study from both group and single-subject designed studies are the first to document the body of evidence of the effectiveness of the massage therapy on symptoms associated with CP within all main subdomains of the ICF. Most of the articles summarized in this review demonstrated level III (moderate) evidence. Almost all of the included articles reported that applying massage therapy to spastic/hypertonic muscles, with or without conventional physiotherapy, is effective for reducing increased muscle tone or
spasticity. Besides, four out of the included articles revealed that massage therapy is effective for improving gross motor function. Besides, one study demonstrated that massage therapy affected fine motor functions Also, two studies found out significant gains in the range of motion at joints in the participants being subjected to massage therapy. Subsequently, one study reported meaningful findings regarding independence in daily activities. Finally, 1 out of the included articles reported notable changes in satisfaction related to well-being, sleep, and pain.
Accordingly, applying massage therapy for sufficient dosage, for instance, 5 to 12 weeks and with a duration of 14 to 30 minutes per session on average, can improve symptoms related to CP including increased muscle tone, gross motor function, and well-being. This could be explained by the presence of the effect of massage therapy on increased stretch reflex stiffness which leads to spasticity. Given that spasticity causes increased muscle tone that induces a diminished range of motion, muscle contracture, restricted movement patterns, and releasing of pain, it might be expected that relaxation of spasticity improves muscle hypertonia, motor functions, and physical or psychological well-being. Consequently, some included studies established the effects of massage therapy on comorbidities related CP, whereas some of the studies directly demonstrated the effects of massage therapy on secondary problems related to ICF's body structures/ functions, and activity.
Study limitation
This study has some limitations. Only studies with low to moderate quality of evidence were included in the review. Besides, we also eliminated nine studies because they featured specific to region or countries. This led to a limited number of studies being included for reporting the effectiveness of massage therapy on symptoms in children with cerebral palsy. Furthermore, the studies included in this review consisted of small sample size which negatively affect the reliability of the studies' findings. Thus, further studies are warranted, before concluding that massage therapy is beneficial.
Conclusion
Performing massage therapy (with or without physical therapy and/or routine therapy), would be effective to improve most of the symptoms related to CP. If so, rather than performing a pure challenging stretch exercise which may lead to disturbance, pain, tendon tear, and an increase in tendon reflex, we recommend that it may be better to perform stretch exercise integrated with massage therapy. Nevertheless, because of the heterogeneity in the study designs of the included studies, this implication should be interpreted also in the light of healthcare professionals' own clinical experiences.
Disclosures: There is no conflict of interest for all authors.
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How to cite this article: Hasan Bingol, Esedullah Akaras, Hikmet Kocaman. The effects of massage therapy on symptoms related cerebral palsy in children with cerebral palsy: A systematic review. J Clin Med Kaz. 2020; 4(58):6-14
