Rajiv Gandhi University of Health Sciences, Karnataka s15

Rajiv Gandhi University of Health Sciences, Karnataka Bangalore

Annexure II

CHARUL GUPTA 1. Name of the Candidate and DR.M.V.SHETTY COLLEGE OF Address (in block letters) PHYSIOTHERAPY VIDYANAGAR, KULOOR, MANGALORE-575013

2. Name of the Institution DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY

3. Course of Study and Subject MASTERS OF PHYSIOTHERAPY (MPT) PAEDIATRICS

4. Date of Admission to Course 4th JUNE 2009

EFFECTS OF MODERATE VERSUS LIGHT 5. Title of the Topic PRESSURE MASSAGE ON MOTOR FUNCTIONS IN DOWN SYNDROME CHILDREN :A COMPARATIVE STUDY 6. BRIEF RESUME OF THE INTENDED WORK

6.1) Introduction and Need of the Study: 36,000 babies are born with Down syndrome every year in India1.16% of those born globally1. This syndrome is characterised by cognitive deficits, speech problems, motor and perceptual developmental problems. Children with Down syndrome also frequently present with decreased muscle tone. Fine motor skills are delayed and often lag behind gross motor skills and can interfere with cognitive development2,3,4,.

Massage therapy shows promise of being an effective mean of treatment currently but lacks a solid evidence to showcase its benefits and risks better. It is a widely used therapeutic procedure that has been used for thousands of years for healing various diseases. It also has a preventive aspect which is to protect and preserve the health.

Massage is the practice of soft tissue manipulation with physical, functional and in some cases psychological purposes and goals. Massage involves acting on and manipulating the body with pressure –structured, unstructured, stationary or moving-tension, motion or vibration done manually or with mechanical aids5.

1 Massage therapy has been shown to improve muscle tone for other children ,it might enhance physical development for children with Down syndrome. If increasing muscle tone facilitates motor functioning , then children with Down syndrome receiving massage therapy might also show improved motor functioning and muscle strength2.

Moderate Pressure affects by causing a flow of positive physiological changes. Light Pressure Massage is used to induce mental relaxation and stress relief . Physical goals include increasing circulation and reducing tension through nervous system relaxation. During Light Pressure Massage, sensation is produced when the hands move at a speed of between 1 to 10 centimeters per second, with an optimum stroke speed of about 5 cm per second(2 inches per second)6,8,9.

Need of the study: Massage therapy, one of the oldest treatment modalities, has been re-emerging as one of the most popular forms of alternative therapy. Despite its long history , controlled studies have only recently been conducted to assess the biochemical, physiological, cognitive and emotional effects of massage therapy but very less clear cut data is available about different pressure used in massage therapy 7.

Only a handful of studies have investigated differential effects of Light Pressure Massage v/s Moderate Pressure Massage . Studies have proved positive effects of massage therapy in pain syndrome, autoimmune diseases, muscular problems, attention deficit etc but due to lack of investigation in the field of Down syndrome a need arises for further research. Massage therapy is also economic and easy to administer. If proved beneficial it can be used as an adjunct to early intervention programme in Down syndrome children.

Research Question:

Will there be any difference on motor function in Down syndrome using Moderate Pressure Massage and Light Pressure Massage?

Hypothesis:

Null hypothesis:

There will not be a significant difference between the effects of Moderate Pressure Massage and Light Pressure Massage in improving the motor functions in Down syndrome children.

Alternate hypothesis:

There will be a significant difference between the effects of Moderate Pressure Massage versus Light Pressure Massage in improving the motor functions in Down syndrome children.

2 6.2) REVIEW OF LITERATURE:

Linkous & Stutts S., did a pilot study on “Passive tactile stimulation effects on the muscle tone of hypotonic, developmentally delayed young children” with 13 children with Down syndrome between 1 and 4 years revealed increased muscle activation and less severe hypertonicity suggesting positive massage effects10.

Field, T., Schanberg, S., Scafidi, F., Bauer, C., Vega-Lahr, N., Garcia, R., Nystrom, J. & Kuhn, C ., Tucci, K., Roberts, J., Morrow, C. , studied performance for preterms on the Brazelton motor items, following 3 daily 15 minutes massage for 10 days, suggesting that massage therapy facilitates motor development11.

Uvnas-Moberg & Field reported that massage increased vagal activity and secretions of insulin and gastrin improving the absorption of food and reduction in salivary cortisol11,13.

Bodensteiner , J., Smith, S. Schaefer; Martin, K. performed studies on hypotonia and concluded that children with Down syndrome present with decreased muscle tone or hypotonia3.

Angelica Escalano , Tiffany Field, Ruth Singer-Strunck , Christy Cullen and Kristen Hartshorn conducted a study on twenty children with autism, ages 3 to 6 years and were given massage therapy for 15 minutes prior to bedtime everynight for 1 month. Results suggested that the children exhibited less stereotypical and off-task behaviour and showed more on-task and social relatedness behaviour during play observations at school14.

Maria Hernandez-Reif, Tiffany Field, Shay Largie, Miguel Diego, Natasha Manigat, Jacqueline Seoanes and Joan Bornstein performed a study on 20 children with Cerebral Palsy recruited from early intervention programs who received 30 minutes of massage or reading twice weekly for 12 weeks. The children receiving massage therapy showed fewer physical symptoms including reduced spasticity and improved fine and gross motor functioning 15 .

Diego, Field, Sanders & Hernandez-Reif evaluated that Moderate Pressure Massage is more effective than Light Pressure Massage therapy for both adults and infants. The infants include: premature infants, cocaine-exposed infants, HIV-exposed infants, infants parented by depressed mothers, and full-term infants without medical problems. The childhood conditions include: abuse (sexual and physical), asthma, autism, burns, cancer, developmental delays, dermatitis (psoriasis), diabetes, eating disorders (bulimia), juvenile rheumatoid arthritis, post-traumatic stress disorder, and psychiatric problems 16.

3 6.3) OBJECTIVES OF STUDY:

1. To examine if massage therapy improves muscle tone in Down syndrome children. 2. To assess if the children receiving massage therapy show improved motor function and muscle strength. 3. To compare the efficacy between Moderate Pressure Massage and Light Pressure Massage 4. To examine if enhancing muscle tone and motor functioning would be associated With enhanced development of other areas since motor proficiency is believed tp provide the basis for development of other areas(like muscle strength, grip strength etc).

MATERIALS AND METHODOLOGY: 7. 7.1) STUDY DESIGN:

Quasi Experimental Study.

7.2) SOURCE OF DATA:

Data will be collected from various special schools and rehabilitation centres in and around Mangalore.

7.2(I) Definition of Study Subjects:

In this study , subjects with mild to moderate Down syndrome from various special schools and rehabilitation centres will be assessed and included as study subjects keeping the inclusion criteria in mind.

7.2(II) Inclusion and Exclusion Criteria:

INCLUSION CRITERIA: 1. Subjects in the age group of 2 years to 6years 11 months. 2. Males and Females. 3. Subjects receiving early intervention programs like physical therapy occupational therapy or speech therapy. 4. Moderate cases of Down syndrome. 5. Parental informed consent.

EXCLUSION CRITERIA: 1. Patients with even low grade fever. 2. Infectious diseases of any type, including a cold or flu. 3. Any skin lesions or bruises or conditions like eczema. 4. Cardiovascular condition of any type. 5. Joint dysfunction. 6. Sensory impairment. 4 7. Severe Down syndrome cases. 8. Children less than 2 years and more than or equal to 7 years of age. 9. Recent fractures. 10. Malignant tumors

7.2(III) Study, Sampling Design, Method and Size:

SAMPLE DESIGN:

Purposive sampling technique.

METHOD OF COLLECTION DATA

After due consideration of inclusion and exclusion criteria an informed consent will be obtained from the subjects. Subjects will be screened by a standard screen form and assessed before the treatment. Then the assessment of the subject will be done every 2 weeks for better results using Peabody Developmental Gross Motor Scale, Manual Muscle Testing and Modified Ashworth Scale.

SAMPLE – SIZE:

60 subjects with Down syndrome will be selected after conducting the screening test for all the children. The subjects will be divided into 2 groups of 30 each, namely Group A receiving Moderate Pressure Massage and Group B receiving Light Pressure Massage.

7.2(IV) Follow Up:

The subjects will be assessed every 2 weeks for their motor function, muscle tone and muscle strength.

7.2(V) Parameters used for comparison and statistical analysis used:

. Collected data will be analysed by ANOVA for repeated measures.

7.2(VI) Duration of study:

The study will be conducted over a duration of 10-12 months

7.2(VII) Methodology: The subjects will be assessed clinically and keeping the inclusion criteria into consideration, the subjects who fulfill the criteria will be included in the study after attaining the consent. The baseline measures using Peabody Developmental Gross Motor Scale, Manual Muscle Testing , Modified Ashworth Scale will be taken. Each subject will receive two sessions per week of massage therapy for eight weeks. The Moderate Pressure Massage therapy session of 30 minutes will be started with the

5 child lying on a small mat on the floor. The therapist will conduct the following sequence three times with the child in a supine position: Legs and feet—(a) while forming hands like a letter ‘C’ and wrapping the fingers around the child’s leg, long, milking and twisting strokes from the thigh to the ankles; (b) massaging foot by gliding thumbs across bottom of foot followed by squeezing and tugging each toe; (c) massaging across top of foot by gliding thumbs from ankle to toes; (d) flexing and extending the foot; (e) massaging from ankle to foot and back to ankle; (f) stroking from the ankle up towards the thigh; and (g) back and forth rolling movements (as if making a rope from dough) from the ankle to the thigh. Stomach—(a) slow, circular, rubbing movements to stomach area with one hand; (b) using the palms, hand over hand down the stomach in a paddlewheel fashion; (c) starting with thumbs together at the umbilicus, stroking horizontally to sides of body and then twice above and twice below the umbilicus; (d) using fingertips and starting below the umbilicus on the child’s right side, small circular upward movements until even with the umbilicus, then continuing across to the left side, and then down on the left side to below the umbilicus; (e) with one hand following the other, short upward stroking from right side below the umbilicus, then across the umbilicus to the left side of the body, and then down on the left side to below the umbilicus; and (f) cupping or holding sides of knees, bending both knees simultaneously towards the stomach and holding for three to five seconds. Chest—(a)with palms of hands on child’s sternum, stroking outward across chest; (b) starting at sternum, stroking upwards and over tops of shoulders and down the sides of the ribs; and (c) starting at the right thigh, stroking diagonally through the chest to the opposite shoulder and back down to the same thigh; repeat starting at the left thigh; Arms and hands—same as legs and feet (i.e. replace ‘legs’ with ‘arms’ and ‘feet’ with ‘hands’). Face—(a) making small circles to entire scalp (as if shampooing hair); (b) with flats of thumbs together on midline of forehead, stroking outward towards the temples; (c) stroking gently over the eyes and brows; (d) starting at the bridge of the nose, stroking across the cheekbones to the ears; and (e) making circular movements under the chin, around the jaw line, around the ears, to the back of the neck and the rest of the scalp. The following sequences will be done after placing the children on their stomach (in a prone position). Back—applying oil to the hands: (a) starting at the top of the spine, alternating hand strokes across the back working down towards the tail bone (never pressing the spine) and reaching over to include the sides; (b) hand over hand movements from upper back to hips with flats of hands and then continuing to feet; (c) using circular motion with fingertips, from neck to hips stroking over the long muscles next to the spine and retracing on the other side of the spine; (d) making circular strokes with the palm of the hand to rub the tops of the shoulders; and (e) ending with long gliding strokes from the neck to the feet. Light Pressure Massage will be given with the same protocol but with only light strokes with very little pressure. 7.3) Does the study require any investigations to be conducted on patients or other human or animal? If so, please describe briefly.

6 Yes, Moderate Pressure Massage and Light Pressure Massage will be given as treatment. Clinical method to measure: Peabody Developmental Gross Motor Scale, Manual Muscle Testing, Modified Ashworth Scale.

7.4) Has ethical clearance been obtained from your institution in case of 7.3? Yes.

LIST OF REFERENCES:

8. 1. Down syndrome Education International News, 27 nov, (2008)

2. Early child development and care, Vol. 176 , NO.3 & 4, MAY 2006 , pp. 395-410 Children with Down syndrome improved in motor functioning and muscle tone following massage therapy , Maria hernandez-reifa* , Tiffany Fielda , Shay Largiea, Dona Moraa , Joan Bornsteinb and Ronnie Waldmanb a University of Miami school of Medicine, USA; b Easter Seal Society of Miami , USA

3. Bondsteiner, J., Smith, S. & Schaefer, G. (2003) Hypotonia , congenital hearing Loss and hypoactive labyrinths, Journal of Child Neurology , 18, 171-173.

4. Nichols, S., Jones, W., Roman, M., Wulfeck, B., Delis, D., Reilly, J. & Bellugi, U. (2003) Mechanisms of verbal memory impairment in four neurodevelopmental disorder, Brains and language , 88 , 180-189

5. Massage Therapy as CAM. The National center for Complementary and Alternative Medicine (NACCAM). 2006 – 09 – 01.

6. Shirley vanderbilt , Modreate vs. Light Pressure in Massage , Massage and Bodywork Magazine , April/May (2005)

7. Miguel A . Diego , Tiffany Field , Chris Sanders , Maria Hernandez-Reif , University of Miami School of Medicine, Touch Research institute , Miami, Florida, USA, 2004

8. Loken , Line S., Wessberg, Johan, Morrison , India., McGlone, Francis., Olausson,H. “ Nature Neuroscience” , April 2009

9. Bryan A. born , The Essential Massage Companion, Evertything You Need To Know To Navigate Safely Through Today’s Drugs And Diseases, By Concepts Born, llc, Berkley , USA. (Book , 2005) , 16-18

10. Linkous, L. & Stutts, R. (1990) Passive tactile stimulation effects on the muscle tone of hypotonic, developmentally delayed young children, Perceptual Motor Skills , 71 , 951-954

7 11. Tiffany Field , Miguel A. Diego , Maria Hernandez-Reif , osvelia Deeds, and Barbara Figuereido, Moderate Versus Light Pressure Massage Therapy Leads to Greater Weight Gain in Preterm Infants , December (2006); 29(4) : 574-578

12. Field, T. (1998) Massage therapy effects , American Psychologist , 53 , 1270-1287

13. Field, T., Scafidi, F. & Schanberg, S. (1987) massage of Preterm Newborns to improve growth and Development , Pediatric Nursing , 13 , 385-387

14. Angelica Escalona , Tiffany Field, Ruth Singer-Strunck , Christy Cullen and Kristen Hartshorn, Improvement in the Behaviour of children with Autism Folowing Massage Therapy, Journal of Autism and developmental Disorder, Vol 31, No.5/ October , 2001

15. Maria Hernandez-Reif , Tiffany Field, Shay Largie , Miguel Diego , Natasha manigat, Jacqueline Seoanes and Joan Bornstein, Cerebarl palsy symptoms in children decreased following massage therapy, Early Child Development and Care, Vol. 175, No.5, July 2005, pp. 445-456

16. Field, Tiffany PH.D. Massage Therapy For Infants , Journal Of Development Abd Behaviour Pediatrics, April 1995 , Volume -16, Issue 2

17. Boyce , William F., Validity of the Peabody Developmental Gross Motor Scale as an evaluative measure of infants receiving physical therapy, Physical Therapy, Nov 1, 1995.

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