This is our third article on the subject of Pediatric Massage (see two previous issues of JMS). The first two articles were dedicated to Infant Massage of prematurely born but overall healthy children. The goal of massage therapy in these cases was to stimulate the child’s development and help pre-term infants to close the gap with full term infants as soon as possible.
However, there is another aspect of Infant Massage: How to work with those children who were born with various pathological conditions ranging from CNS abnormalities to torticollis (i.e., lateral tilt of the head due to flexion contracture of the cervical musculature). Reading various articles on Infant Massage recently published in professional literature leaves the impression that practitioners are taught by various sources to use basic sets of stress reduction massage strokes on each baby without any differention between a healthy child or a baby with various pathological conditions.
In clinical reality, the application of correct and scientifically sound MEDICAL MASSAGE PROTOCOLs to help children born with various pathological conditions is a separate and extremely valuable branch of Pediatric Massage. Of course, we are unable to address all infant abnormalities in just one article. This is why we decided to discuss here the protocol of medical massage for infants with abnormalities in the CNS function which have developed as a result of Perinatal Asphyxia (PA) or lack of oxygen at birth.
There are various causes of PA: abnormalities of placenta and umblical cord, pre-mature delivery, birth trauma during labour, infections, etc. PA happens in 2 to 10 per 1000 newborns that are born at term, and this number rises more significantly for pre-term infants (Barkovich & Truwit, 1990).
Even a short decrease in the blood perfusion to the brain or failure of respiration greatly affects the function of infants’ CNS. In cases of severe PA the damage to the brain is irreversable,and for these patients medical massage helps to maintain quality of life only. However, the mild to moderate cases of PA are much more common, and early medical massage rehabilitation plays a critical role in the infants’ recovery. When conducted correctly and on time medical massage helps to increase brain perfusion and save neurons which may have a chance to recover. As stated by Prof. A.M. Aksenova MD, (2003):
“Application of proper rehabilitation during phase of reversible changes after PA allows to save larger number of neurons affected by oxygen insufficiency. This why therapeutic modalities to enhance the blood supply to the brain and spinal cord must be used since infant’s first days of life.”
We would like to share with our readers the results of anextensive clinical study conducted by Prof. A.M. Aksenova, MD in Russia. She is one of the most respected world authorities in the field of medical massage and pediatric massage in particular. This publication is based on the treatment of 700 newborns who experienced PA of various degree. We don’t want to overwelm the readers with the statistical analysis and data the authors obtained before and after the applied treatment, but we think it will be beneficial to our readers if we discuss the actual protocol Prof. Aksenova developed as a result of this study.
The method of Deep Reflex Massage (DRM) was developed by Prof. Aksenova for infants experiencing even short intervals of PA and is accepted as a standard treatment procedure in many pediatric hospitals. The goal of DRM is to increase blood circulation through the brain and spinal cord by using intense reflex stimulation of the soft tissues.
The basic physiological fact that any stimulation of the peripheral sensory receptors requires formation of the reflex motor response to the stimulated tissue is the theoretic foundation of DRM. Formation of motor response requires activation of the CNS function, and it can be done only by increasing the blood supply to CNS and activation of local metabolism (e.g. glucose metabolism in the brain). As Prof. Aksenova’s measurements showed the application of regular full body massage for infants with PA significantly increased blood circulation through the brain and spinal cord. Based on these initial results Prof. A.M. Aksenova experimented with different massage protocols while examining blood circulation through the brain. DRM developed by the author showed the largest stimulation of blood circulation through CNS.
DEEP REFLEX MASSAGE FOR INFANTS AFTER PA
The initial course of DRM consists of 3-5 sessions two times per week in the hospital starting on the first day of life and 10-15 sessions 2-3 times per week conducted after the child is discharged from the hospital. The duration of each session is 10-20 minutes, depending on the size of the infant’s body. The entire course of 10-15 sessions can be repeated in 2 months, if needed.
PLAN OF SESSION
The protocol of DRM is a very important factor in the overall success of the therapy. The sequence of the treatment consists of consequent application of massage in the following areas: anterior neck, lateral neck (alternating right and left sides), posterior neck, upper shoulders, both temporal areas, head, back and gluteal areas. The practitioner must start with neck massage and spend more time on the neck and head.
Another critically important aspect is the set of massage techniques. 80% of used techniques during each session are various types of kneading. These techniques require lifting, stretching, compressing and rolling soft tissue between fingers and against bone structures. Scrolling, double scrolling, transverse kneading, simple kneading and etc. are used. Considering that massage areas are small the practitioner should use pinching (or three fingers) prehension while working with the tissues. The readers may find a detailed description and video presentation of all kneading techniques in the Therapeutic Part of our Video Library.
DRP doesn’t mean the application of pinpoint deep pressure. The author uses the term ‘deep’ to emphasize the necessity to address deeper layers of the soft tissue. Only in this case the DRM has stimulating impact on the circulation in the CNS.
STEP BY STEP PROTOCOL OF DRM
Place the infant on the back. Start with bimanual light effleurage strokes on the anterior neck starting from the origin of the sternocleidomastoid muscle (i.e. mastoid processes behind both ears) down along the muscle and lymph drainage. Use both thumbs, keep them flat and direct pressure forward to the clavicles. When you reach the supraclavicular area move thumbs laterally along both clavicles while applying pressure on both trapezius muscles using thenar area of each hand until you reach both acromioclavicular joints.
Apply kneading along the sternocleidomastoid muscles as well as moderate friction at its origin at the mastoid process. The contact areas are the palmar surfaces of distal phalanges of index or index and third fingers. Be sure to stretch muscle fibers between hands and alternate it with careful compression of the muscle tissue against underlying cervical vertebras. While working on the sternocleidomastoid muscle turn the child’ head to the same side.
Finish this step with the application of careful spiral friction along the pathway of major nerves and carotid arteries on the anterior neck. With the fingertips of the index or index and third fingers apply careful friction along the anterior edges of both sternocleidomastoid muscles.
Using thumbs placed flat along the clavicle, work in the both supraclavicular areas using friction and gentle manual vibration in interruptive mode. Slowly increase pressure trying to submerge into supraclavicular areas and even reach first rib, which is on the bottom of the supraclavicular fossa.
Alternate work on the each lateral surface of the neck. Turn the child’s head to the opposite side and use the same combination of techniques.
Work on the posterior neck while the child is placed on their side. Use a small pillow to support the head. Use the same combination of techniques and give attention to the suboccipital area and occipital ridge. While working in the suboccipital area apply circular friction and several repetitive compressions using fingertip of the 5th finger in the area of the vertebral artery.
Both vertebral arteries are hidden in the cervical vertebrae, and they are directly accessible only in vertebral artery point, which is located between occipital ridge and transverse process of the first cervical vertebra which is the most sticking out bone on the lateral surface of the neck just below the skull.
The vertebral artery point is very easy to find, because it is located inferiorly to the occipital ridge just in front of the free edge of the upper portion of trapezius muscle (see Fig. 1).
Red dot – location of the point
Work in this very small area has great impact on the increase of the blood perfusion in the pool of basilar artery (the basilar artery is located on the pons and it is formed by conjunction of two vertebral arteries).
Work on the cervical paravertebral muscles use kneading between fingers as well as kneading against bony structures.
Work on the scalp of both temporal areas first and later on the other parts of the scalp. Start with raking effleurage using fingertips which are moving between hairs in a spiral motion. Later, switch to the careful friction placing the fingers flat. Don’t apply significant pressure especially vertical pressure. Remember the location of cranial fontanelles. Try to move fingers with the scalp applying pressure horizontally along the skull. Vasodilation in the scalp triggers the increase in the brain circulation using the reflex pathways. This reflex reaction is a well established physiological fact.
Briefly work on the entire back and gluteal areas at the end of the session.
If you are working in a pediatric hospital, or you have friends and family members who recently had a child with PA use this protocol to help infants to recover from the consequences of this dangerous condition. Also educate other health practitioners (pediatricians, nurses) in the clinical benefits of Pediatric Massage.
Aksenova AM, Reznikov KM, Trofimova OV. Effects of deep reflex-muscular massage and exercise on regulatory processes in the body. Klin Med (Mosk), 75(7):50-2 1997.
Barkovich A.J., Truwit C.L. Brain Damage From Perinatal Asphyxia: Correlation of MR Findings With Gestational Age. American Journal of Neuroradiology, Vol 11, Issue 6 1087-1096, 1990.
Category: Pediatric Massage