Hello Readers,

In my last article, I discussed the special challenges of working with clients who have survived spinal cord injuries. I had been surprised at how little input I got before I prepared that piece, and I have likewise been surprised (happily) at how much feedback I got afterward - from both massage therapists and SCI survivors (and in one case, a person who is both). Here are some examples:

Hello Ruth,

My name is Richard C.C. Bloomquist. I've been an incomplete paraplegic for almost 11 years, due to a motorcycle accident. I went to massage school just three years ago to become certified as a massage therapist. It's a wonderful feeling, just knowing I can still get out there and work. I actually massage from my chair. My clients love me too. I tend to give very deep work in Swedish and connective tissue modalities, strongly due to having the upper body strength to apply such work. I've personally known for years that massage should be a modality offered in all hospitals that rehab SCI people. I remember it reeducating my mind after my injury, in addition to all the circulatory benefits.

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Hi Ruth,

As first a yoga instructor for over 27 years working with everyone from world-class athletes to chronically ill and injured people; and then as a Florida licensed and certified neuromuscular therapist for over 10 years, my experience with SCI patients is that yoga, when appropriately practiced at whatever level attainable by the patient (even in the cases of quadriplegia), and when supplemented with occasional superficial NMT or fascia work, provides far better results that either yoga or therapy alone.

However, I must stress that regardless of my expertise as a soft-tissue therapist, my experience with patients/students continually reaffirms that, therapy notwithstanding, superior long-term results are consistently generated when the person takes active (and intelligent) responsibility for their own health maintenance through yoga.

Sam Dworkis, MA, LMT

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Ruth:

Good article in Massage Today. I read it after the massage therapist that works here at the same office that I work in gave it to me. I am a T-8 paraplegic, and you hit on some good points in your article. This should give many massage therapists a good start when giving a massage to someone with a spinal cord injury. I remember the first time that I received a massage, and I told the therapist to just massage the rest of my body that I am not able to feel as if I could feel it.

Mark Singer

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I want to extend my thanks to all the people who responded to my article. It certainly seems clear that many massage therapists feel they need more education on working with clients with a wide variety of CNS dysfunction.

This month, I have chosen to focus on another type of CNS disorder: cerebral palsy. As usual, I will review some of the technical information about what manifests this set of signs and symptoms; then I will discuss some of the special issues this disorder raises in the context of bodywork.

Cerebral Palsy: What Is It?

Cerebral palsy (CP) is a term that refers to many possible injuries to the brain during gestational development, birth, and early infancy. Several different types of CP have been identified, each involving damage to different parts of the brain.

The incidence of CP in the United States is two to four out of every 1,000 live births. Around half a million CP patients live in the U.S. today. In spite of improved prenatal care, the rate of CP in the U.S. has remained unchanged for many years.

Etiology: What Happens?

Cerebral palsy is the result of brain damage, usually to motor areas of the brain, specifically the basal ganglia and/or cerebellum. The damage can be brought about in a number of ways.

• Prenatal causes. Most cases of CP can be traced to problems during pregnancy, often due to maternal illness. Contributing factors include infections with herpes or toxoplasmosis, hyperthyroidism, diabetes, Rh sensitization (the mother essentially has an allergic reaction to the blood type of her unborn child), malnutrition, or abdominal trauma.
• Birth trauma. CP can result if the child experiences anoxia or asphyxia (lack of air from a mechanical blockage) during birth. Respiratory distress and head trauma (often from a difficult presentation or the use of forceps in delivery) may also increase the risk of brain damage.
• Acquired CP. This type of CP is acquired in early infancy. Causes include head trauma (often from car accidents or child abuse: "shaken baby syndrome"), infection with meningitis or encephalitis, vascular problems (brain hemorrhages) or neoplasms in the brain that may lead to brain damage.

Regardless of the cause of brain damage, the child with cerebral palsy will have some impairment of function. The problem could be so minor that only people who know what to look for may see it, or it may be completely debilitating both physically and mentally; it all depends on what part and how much of the brain has been affected.

Types of Cerebral Palsy

CP is classified into four types: spastic, athetoid, ataxic, and mixed.

• Spastic cerebral palsy. This is the most common form of the disorder, accounting for 50 to 80% of all CP patients. Spastic CP means that in some areas of the body muscle tone is so high that the tight muscle's antagonists have completely let go. This is called the "clasp knife" effect.
• Athetoid cerebral palsy. This variety is less common than spastic CP, accounting for up to 30% of all patients. It involves very weak muscles, and frequent involuntary writhing movements.
• Ataxic cerebral palsy. This rare variety of the disorder involves chronic shaking and tremors, and very poor balance. Fewer than 10% of all CP patients live with ataxic CP.
• Mixed cerebral palsy. Many CP patients live with combinations of the CP forms.

CP may also be classified by what part of the body is affected. These terms are consistent with those used for other CNS disorders: hemiplegic CP means the left or right side is affected; diplegic CP means either two arms or two legs are affected; and quadriplegic CP means all the extremities are affected to some extent.

Types of CP may come and go, or change entirely from one kind to another, as the child grows. CP is not a progressive disorder, however, and if symptoms seem to be getting significantly worse over time, a different kind of CNS dysfunction must be considered.

Signs and Symptoms

Signs and symptoms of CP vary according to the location and extent of brain injury. Damage to the cerebellum produces different symptoms from damage to the frontal lobe, for instance. But some of the most common features of CP include hypertonicity; hypotonicity; poor coordination and voluntary muscle control; unusually weak muscles; random movements; seizure disorders; early hearing and/or vision problems; and progressive muscle contractures. About half of all CP patients have some level of mental retardation, and many are unable to communicate verbally.

Because infants don't develop voluntary motor skills until they are around six months old, CP may be difficult to diagnose earlier than this point.

Treatment

CP is incurable and irreversible; as such, it is managed, rather than treated, by providing skills and equipment to live as fully and functionally as possible. For some CP patients this could mean using a brace for one foot that is slightly weaker than the other; for others it could mean intensive occupational, physical, and speech therapy for many years.

Medication for CP is occasionally prescribed to help manage seizures, and to reduce muscle spasm. Some surgical interventions have been developed to lengthen contracted muscles, to realign vertebrae that have become distorted by scoliosis, and to alter nerve pathways in the brain to reduce the severity of tremors.

Physical therapy is recommended for people with CP because the process of developing muscle contractures is slow and can be made even slower when muscles and joints are specifically stretched and manipulated to maintain flexibility. Patients may also be encouraged to use and strengthen their weaker limbs. It is important to note the many uses and benefits physical therapy has to offer CP patients, because massage therapy may also be a valuable adjunct in these cases.

What about Massage?

There is no question that massage therapy can have a valuable role in improving the quality of life of a person with CP. Unlike many CNS disorders, a lot of information about bodywork for CP patients is easily available; I'll list some wonderful sources at the end of this article. Nonetheless, these clients require some special adjustments in the way bodywork is administered, and I've had several letters from massage therapists who would like to feel their work is more effective with this population.

The damage for a person who has CP does not begin in the muscle and connective tissues. Although this is where we feel the tightening of the connective tissue wrappings around muscles, the contractures themselves are simply a symptom-a complication of a problem deep in the brain. Therefore, if all we try to do is lengthen the muscles and stretch the fascia, we will run smack into a brick wall: either no progress will happed at all, or symptoms may even be temporarily exacerbated. Most people with CP get best results if bodywork focuses on indirectly affecting muscle tone through craniosacral work, gentle rocking, slow range of motion exercises, and manipulation of the arms and legs that engages the client in ways he or she doesn't automatically resist-this often means going with the direction of muscle shortening in order to disengage the reflex. Ultimately, the therapist will have to experiment with lots of different approaches, often accompanied by extremely supportive bolstering, in order to find what techniques allow their clients to relax and enjoy their massage.

The benefits of massage to CP patients are undeniable. Parents write of their satisfaction when their child is able to sleep through the night, when postural distortions unbind, when breathing eases, when faces light up with joy because the massage therapist has arrived for a session. Imagine a child who is the object of vast numbers of painful, intrusive, unpleasant, dehumanizing medical procedures (regardless of the supportive intentions behind them). This child is handled rather than touched. Then his massage therapist arrives and arranges him carefully among pillows and bolsters on the table. She cradles his occiput and straightens his neck so he can breathe more easily. She rocks his arms and legs until their tension eases. She plays with his fingers until he realizes he can move them in lots of directions. Nothing she does hurts. What a gift, what a privilege to be invited into such a relationship!

If physical therapy is used to stretch and strengthen skeletal muscles, massage will also be a safe choice. The only caution is that people with very severe CP may not be able to communicate their wants or concerns clearly. If a massage therapist works with a client who cannot speak, other modes of communication, including nonverbal signals, become especially important. It is the responsibility of the massage therapist to make sure that his or her work is welcome and freely accepted at all times.

Our culture harbors a fear of people who look, or sound, or act differently from ourselves. Seeing or being with someone with CP can raise all kinds of fears or judgments that we never realized were there. Maybe this person can't speak, or drools, or walks funny, or doesn't walk at all. Speaking for myself, I will share that it's especially hard for me to deal with disabilities when they occur in children. And yet, here is a population that so needs the work we do! As long as basic common-sense precautions are respected (don't overwork numb areas, be sensitive to nonverbal communications, if anything you do makes symptoms worse then stop and try something else) massage can be a central coping mechanism for a child or adult with CP.

I am hopeful that any readers who have the opportunity to work with clients who have CP will feel more confident to do so. I am especially delighted to share some valuable resources that help me put together the parts of this article about bodywork:

• Denise Edwards and Gary Bruce: For cerebral palsy patients, massage makes life better. Massage Magazine, July/Aug 2001, pp. 93-110
• Vickie M. Johnson: My healing journey. Massage Magazine, July/Aug 2001, pp. 97-101.
• Russell A. Bourne: To Onar, with love. Massage Therapy Journal, spring 1996, pp. 68-76.
• Interview with Mary Beth Sinclair, author of Massage for Healthier Children, (thank you so much!)

For my next column, I'm going to offer readers a choice. I've had requests for articles on these topics:

• Hyperthyroidism vs. hypothyroidism;
• Adhesive capsulitis; and
• Reflex sympathetic dystrophy syndrome (also known as RSDS or causalgia)

So, what do you want to have discussed next in What's On Your Table?

Until then,

Blessings,

Ruth Werner, LMT, NCTMB