Written by: Sam Mishra, Executive Contributor
Executive Contributors at Brainz Magazine are handpicked and invited to contribute because of their knowledge and valuable insight within their area of expertise.
The sudden diagnosis of spastic diplegia cerebral palsy in my 15-month-old daughter was the catalyst for my decision to leave the midwifery profession. Despite her developmental delay and my sense that something wasn't right even during the pregnancy, I had never once given the possibility that she might have cerebral palsy any thought.
I honestly hadn't anticipated going down the route that her diagnosis, the years of at-home physical therapy that followed, and the many activities I introduced to help keep her active took me. I spent nine years learning about the condition, available therapies, and working at sports camps and wheelchair skills days for children with disabilities. I introduced massage as part of her therapy, and it was invaluable in preventing bowel obstructions and reducing her muscle spasticity.
What is cerebral palsy?
Although everyone knows the basic definition of cerebral palsy, many people are unaware of the various forms, causes, and spectrum of symptoms that can develop, as well as related conditions. Brain injuries that occur during foetal development, birth, and the early years of infancy are grouped into distinct types under the general name cerebral palsy (CP). It is not a progressive condition, but it will impact how motor abilities, sensory perception, and cognitive processes develop.
In the UK, 2-2.5 out of every 1000 children receive a diagnosis, or about 1800 babies and infants each year. Accordingly, there are about 30,000 kids in the UK who have cerebral palsy.
The three distinct times that cerebral palsy can be caused by brain damage will define the brain's development at the time of injury and, consequently, the type and symptoms of cerebral palsy. Prenatal infections (Group B Strep, herpes, or toxoplasmosis), hyperthyroidism, diabetes, Rh sensitization (the mother essentially has an allergic reaction to the blood type of her unborn child), malnourishment, and abdominal trauma are common maternal health issues during pregnancy. This is when the majority of cases of cerebral palsy (CP) can be traced back.
Cerebral palsy can also result from head trauma (typically from a difficult presentation or the use of forceps during delivery), respiratory distress, and trauma sustained at birth from anoxia or asphyxia (loss of air from a mechanical blockage).
The final causes of acquired cerebral palsy in the early stages of infancy are head trauma (from car accidents or child abuse: "shaken baby syndrome"), infection (meningitis or encephalitis), vascular issues (brain haemorrhages), and brain tumours. Later on in this piece, I will relate the experience of my youngest client, who was diagnosed with cerebral palsy (with permission).
Regardless of the reason for the brain damage, there will be some functional impairment; the degree and location of the damage will determine how severe it is, from a little, mostly undetectable impairment to one that is physically and cognitively incapacitating.
Cerebral palsy types
The way that different forms of cerebral palsy impact posture, muscular coordination, and movement of the body varies because they cause damage to different areas of the brain. The range of symptoms is broad, both in terms of their manifestation and severity.
Hemiplegics (affecting either the left or right side of the body), diplegics (affecting either two arms or two legs), and quadriplegics (affecting all extremities to some degree) are other classifications for cerebral palsy.
Although CP is not a progressive condition, the type of cerebral palsy may alter as the child gets older. It is therefore important to take into account other CNS dysfunctions if symptoms get noticeably worse with time.
With symptoms resembling an upper motor neuron lesion in the brain, spastic cerebral palsy is the most prevalent type of cerebral palsy, accounting for 50–80% of cases. These symptoms include trouble shifting from one posture to another, difficulty gripping onto and letting go of items, stiffness, jerkyness, and limited mobility. The "clasp knife" effect describes how the antagonists of a tight muscle may entirely release in regions of hypertonia. The quadriceps and hamstrings are examples of agonist and antagonist muscles that frequently occur in pairs, with one muscle contracting as the other relaxes.
Less frequently occurring than spastic cerebral palsy, athetoid cerebral palsy affects 20–30 percent of cases of cerebral palsy. It is characterised by symptoms related to injury to the brain's cerebellum or basal ganglia as well as the neurological systems that control posture, involuntary movements, and coordination. Extremities, face, and mouth writhing involuntarily, uncontrollably moving muscles, weak, flaccid muscles, and frequent dribbling are some of these signs. It will have an impact on daily tasks like eating, reaching, grabbing, speaking, and other abilities requiring coordinated movements. Athetoid cerebral palsy is characterised by a mixed presentation of hypotonia and hypertonia.
Ataxic cerebral palsy is the rarest; it affects 5–10 percent of cases and is characterised by cerebellar damage symptoms. These symptoms include tremors and poor balance, low muscle tone and poor motor coordination, unsteadiness when walking, and impaired depth perception and balance.
Between 10 and 20 percent of instances of cerebral palsy present with a combination of the two forms, exhibiting both the involuntary motions of athetoid cerebral palsy and the tight muscle tone of spastic cerebral palsy. Damage to the brain's extrapyramidal and pyramidal regions can cause mixed cerebral palsy.
Symptoms and related conditions
As was previously mentioned, the location of brain damage will dictate the symptoms, which often become apparent when the child is six months old and begins to develop voluntary motor abilities.
Because of muscle exhaustion, those with CP typically age more quickly. The goal of treatment, which may include speech, occupational, or physical therapy, is to manage symptoms in order to increase functionality.
The most common symptoms of cerebral palsy (CP) include hypertonicity, abnormally weak muscles, random movements, seizure disorders, early visual and/or hearing impairments, progressive muscle contractures, some degree of mental retardation in about 50 percent of cases, and verbal communication difficulties.
The majority of children with cerebral palsy have at least one health problem that is related to or caused by their condition. Seizures affect about 35 percent of children with cerebral palsy, and the symptoms vary depending on the kind of seizure (absence, atonic, clonic, myoclonic, or tonic-clonic). Brain injury, head injuries, dehydration, infection, and other conditions can cause electrical activity in the brain to malfunction, resulting in seizures. Additional issues that are related to this condition include dysphagia, vision problems, cognitive and behavioural issues, oral health issues, digestive issues, skin conditions, respiratory issues, behavioural and emotional issues, physical and mobility issues (which can vary depending on the type of cerebral palsy, from mild spastic movements to being wheelchair dependent), autism, sleeping issues, and ADHD (attention deficit hyperactivity disorder).
Cerebral palsy treatment
The goal of CP treatment is to manage symptoms to maximise functioning and quality of life. Occupational therapy, speech therapy, physiotherapy, hydrotherapy, equine therapy, rebound therapy, medication, casting, botox therapy, and surgery (to realign vertebrae, lengthen contracted muscles, reduce spasticity, and reduce the severity of tremors and severe bowel obstructions) are some of the options available.
Since different muscles will be impacted, the typical gait patterns associated with spastic cerebral palsy—also known as spastic hemiplegia or spastic diplegia—and their type will also affect the available treatment options. In order to diagnose conditions like true equinus (which is observed during the stance phase of gait due to spasticity and/or contracture of the gastrocnemius-soleus muscles), genu recurvatum (a deformity in which the knee hyperextends), drop foot, jump gait, hip subluxation, apparent equinus, crouch gait, and lever arm disease (which is characterised by torsional deformities of the long bones, foot deformities, and musculo-tendinous contractures), all need to be thoroughly assessed.
Cerebral palsy: massage therapy
Undoubtedly, massage therapy can significantly enhance a client with cerebral palsy's quality of life; yet, modifications to the way the treatment is administered might be necessary. Along with physiotherapy and other services, massage therapy will support them.
Although massage therapists have a variety of tools at their disposal, slow deep tissue techniques are typically the most advantageous for persistent CP-related muscular problems. Children with cerebral palsy can benefit from effective spasticity reduction when pressure or friction is applied against the muscle's grain. The issue is not with the muscle or connective tissues, though. Stretching the muscles and fascia by themselves will not relieve the contractures at all or only temporarily because they are a sign of a brain injury. In order to disengage the reflex and give the client better movement without resistance, gentle craniosacral work and passive manipulation of the arms and legs in the direction of muscle shortening are recommended. To determine the approaches that each client finds most calming, the first part of the session will be a bit exploratory.
For CP patients, who will present with a wide range of symptoms, many approaches will need to be used in order to have beneficial results. Joint manipulation and the whole spectrum of methods can be used in massage therapy. Muscle contractures can be avoided and/or maintained with the aid of passive range-of-motion exercises.
Mechanical aids should be used with caution as they have a tendency to enable a much higher level of pressure without much effort, which could overstimulate the muscle. Manual massage tools, massage chairs, heated or cooled stones, rollers, and heat packs are examples of aids that can occasionally be used to reinforce results.
Precautions and contraindications
Before beginning any massage therapy, it is imperative to communicate with the child's paediatrician and the therapy team. This is because certain conditions, such as inflammation of the muscles or joints, numbness in certain areas, fever, acute infections, skin disorders, open sores, swollen lymph nodes, recent vaccinations within the last 72 hours, blood clots, etc., would make massage therapy contraindicated. Additionally, overstretching the muscle tissue or using tapotement on a client with a history of seizures should be avoided, as these actions may potentially cause seizures.
As with any child treatment, the standard protocols will be followed, including acknowledging that children could be afraid of strangers giving them a massage and that they might feel self-conscious about their bodies. Consideration must be given to initiating contact in an appropriate way to win the trust of a child with cerebral palsy, as this may be more problematic if they have experienced negative touch experiences in the hospital or feel pain. Understanding non-verbal cues like breathing patterns and facial expressions will help the therapist better understand their clients' needs and comfort levels. This is especially important in situations where verbal communication may be problematic.
Positioning may need to be modified for each unique instance, as with any massage; this may involve utilising a side-lying posture or using bolsters more frequently.
By going over the treatment plan with the child's paediatrician and therapy team, therapists can ensure that they are covered for insurance purposes. Working together with the child's familiar therapy team will also maximise the beneficial results.
Massage benefits for children with cerebral palsy
Many invasive and painful medical procedures that involve handling rather than touching children with cerebral palsy are frequently performed on them, potentially making the child afraid of a stranger touching them. For children with cerebral palsy, massage treatment can significantly enhance their quality of life by mitigating physical symptoms and promoting cognitive and social functioning. As therapists, we have the unique ability to provide non-invasive, painless treatments that help patients sleep better, breathe better, or maintain better posture.
For CP patients, massage has many advantages. The most obvious advantage is that massage can help with spasticity (an involuntary tightening of the muscles) and contractures (abnormal positioning of a joint). These conditions can lead to enhanced muscle flexibility and improved posture, which promote healthy movement patterns. Massage can also raise or lower muscular tone, depending on the techniques employed and how they are applied.
The benefits of massage include improved circulation and lymphatic functions, which improve tissue nutrition and oxygenation, reduce swelling, and increase the body's ability to heal—particularly after surgery. In addition to circulation issues, immobility associated with cerebral palsy can also result in a high metabolic rate in spastic CP, which can make a kid extremely sensitive to the cold. Because massage protects the integumentary system, it helps children with cerebral palsy regulate their body temperature and also changes the colour and warmth of their paralysed limbs as a result of improved circulation. Additional advantages of the integumentary system include enhancing skin tone and texture, hydrating the skin, eliminating dead skin cells, and encouraging tissue healing in kids who might be more vulnerable to skin infections because of their incapacity to take care of themselves. Moreover, massage activates the skin's sensory receptors.
Improved fine and gross motor function, decreased limb activity, and better learning, playing, and doing daily tasks are some of the additional physical benefits of massage. Other physical benefits include better respiratory health, better sleeping patterns, lower blood pressure, and a lower heart rate because stress hormone secretion is reduced.
In addition to employing massage to support musculoskeletal health, I also use it to support gastrointestinal health in my clients with cerebral palsy. Normal bowel function can be supported by massage, as problems with the digestive system can arise from anatomical anomalies in the central and peripheral nerve systems. Among the benefits are less gas and bloating (especially in patients with gastrostomies or enteral tubes), increased peristalsis, decreased constipation and bowel blockages, aiding in the release of digestive enzymes, and increased kidney and liver function.
Because massage activates the brain's pressure receptors through cranial work, it also has a host of psycho-social benefits for people with cerebral palsy (CP), such as enhanced attention and concentration, increased brain activity, and improved cognition. Since cerebral stimulation is the outcome of a brain injury in CP patients, it may help to soothe and lessen anxiety. Additional advantages include enhanced social engagement and good facial expressions, higher developmental scores, and enhanced academic performance.
Paediatric instrument assisted soft tissue mobilisation
Kanu Kaushik, a paediatric physiotherapist and the CEO of Kinesio Prehab Institute (a provider of continuing education programmes) and Physio Mantra (a specialised physiotherapy centre) in Bengaluru, India, created the therapeutic technique known as Paediatric Instrument Assisted Soft Tissue Mobilisation (PIASTM). For kids with contractures and tight muscles, it is a ground-breaking therapy.
Using a specialised IASTM Tool, it helps children with autism control their tactile defensiveness and improves flexibility, range of motion, and reduction of contractures by encouraging the mobilisation of restricted tissue.
This tool is ergonomically intended to assist therapists in locating constraints and applying the right amount of pressure to treat the problem area. It breaks away fascial restrictions and adhesions with effectiveness.
Through the use of controlled microtrauma, the therapist uses the PIASTM approach to stimulate a local inflammatory response in the soft tissue structure being treated. Through the facilitation of healing processes that lead to the remodelling of injured soft tissue structures, this procedure aids in the reduction of inappropriate fibrosis or excessive scar tissue. Adhesions in children can arise from a variety of causes, including surgery, immobilisation, repetitive strain, or persistent stretching that breaks down to allow for a full recovery of function.
By modifying the physiologic reactions to damage or promoting normal function in the musculoskeletal system, this therapy aims to create the optimal conditions for the body's self-maintenance systems. The strategy entails a careful assessment of the changed tissue characteristics and the use of treatments that are intended to promote the normalisation of soft tissue dysfunctions.
PIASTM, in theory, is predicated on a deep massage method that, in order to reach the soft tissue structures of muscle, tendon, and ligament, must be administered transversely to the direction of the particular tissue affected. It is hypothesised that by inducing local hyperaemia, this approach could help preserve mobility and provide therapeutic movement inside the damaged tissue, thereby preventing scar adhesions.
According to certain theories, using instruments gives the doctor a mechanical edge that enables quicker localization, deeper penetration, and more efficient therapy.
PIASTM affects every system in the body in different ways. It facilitates collagen production, reabsorption of inappropriate fibrosis, and tissue maturation by breaking down scar tissue and adhesions, increasing fibroblast proliferation, and releasing fascial constraints. Additionally, Golgi receptor stimulation and mechanoreceptor activation are hypothesised effects.
There are several advantages, similar to IASTM generally, such as enhanced flexibility and range of motion, enhanced circulation, and enhanced tissue healing. Improved proprioception, function, and balance, enhanced nerve conduction, and, naturally, improved muscular tone are among the more particular advantages for children with cerebral palsy.
Low muscle tone (Hypotonia)
A muscle's potential to balance an external force or stretch is measured by its muscular tone. via balancing reactions, corrective reactions, or defensive reactions, and to unwind as soon as the alleged alteration disappears. The muscles of a child with hypotonia from cerebral palsy (CP), especially athetoid CP, contract slowly in response to external forces and cannot contract for an extended period of time. The cause of this is a disturbance in the central nervous system's nerve pathways, which provide signals to the body from the brain to activate or deactivate muscle action. This results in improper posture and muscle tone.
The hallmarks of hypotonia include poor posture, limited head control, trouble with hand-eye coordination, and difficulties sitting up straight without the need for assistance or leaning. When sitting upright, excessive forward tilting is caused by underactive trunk muscles that are meant to preserve posture. The 'W-sit' position is preferred by these children in order to lock into a sitting position without using their postural and core muscles, but when the ball and socket joint is underdeveloped, this can also raise the risk of hip dislocation. A child may appear awkward and have inefficient movement patterns due to ligament and joint laxity, poor reflexes, and trouble transitioning into and out of positions. It is possible to experience breathing and speech issues, as well as delayed motor milestone achievement. When it comes to physically demanding chores, children with hypotonia frequently seem languid, have a low threshold for frustration, and would much rather watch than engage.
Massage can assist in reawakening muscles since muscle tone is an automatic response. It does this by providing the muscle with an abundance of sensory information, which helps the brain recognise variations in muscle length and send a signal to the muscle to contract. Regular treatment may lead to improved hypotonic muscle function, more consistent responses, better motor control, and increased body strength.
Perseverance is crucial because this will be a gradual process. However, by maintaining the same exercise and making appropriate modifications, it is possible to enhance digestive function and, to some extent, activate muscles and move fluids.
Massage helps improve distal strength and function, postural control, postural responses, and protective reactions, motor development, fluidity and efficiency of movement, and functional strength. It does this by strengthening the affected muscles, the core muscles to address postural issues, and the muscles of the arms and legs to provide more stability. It also works on passive range of motion to practice impaired movements. Facilitating bilateral play, which involves moving both sides of the body and crossing the midline, can help improve coordination. Physiotherapists frequently use this strategy.
Therapists need to be aware of the methods they employ and how they apply them. When joints are well-aligned from proximal to distal, joint compressions may enhance the co-activation of surrounding muscles, which aids in keeping the joint in its proper alignment against gravity. Coordination can be enhanced by encouraging crossing the midline through joint manipulation and passive range of motion exercises. Children with hypotonia benefit from heavier treatments like frictions and kneading, whereas light pressure massage can enhance bone growth and mineralization and encourage muscular activation. While gentler tapotement and vibrations can be helpful in raising the tone, they should be avoided in cases where there has been a history of seizures. Stretching and effleurage should be avoided in athetoid CP, as they will negate the effect of raising muscle tone.
High muscle tone (Hypertonia)
A muscle's potential to balance an external force or stretch is measured by its muscular tone. via balancing reactions, corrective reactions, or defensive reactions, and to unwind as soon as the alleged alteration disappears. Spasticity, fast muscle contractions, tight muscles, and fixated joints are characteristics of hypertonia that cause function loss, a reduction in range of motion, and frequently deformity. In addition to involuntary leg crossing, the afflicted muscles may be sensitive and experience pain and spasms.
When a child has spastic cerebral palsy (CP-related hypertonia), the brain injury either overstimulates the nerves or interferes with the signals that the muscles need to contract, making the arms and legs rigid. Youngsters with spastic cerebral palsy may prefer the "w-sit" because of tense muscles; however, this should be avoided as it raises the possibility of hip dislocation and exacerbates muscle tension. Massage therapy has the potential to mitigate muscular stress and enhance its elongation properties, hence aiding in the prevention of contractures that result in diminished range of motion and functional loss.
Applying pressure or friction against the muscle's grain can successfully relieve spasticity, release tension, lower tone, and improve flexibility. Slow, deep tissue treatments are often the most beneficial for chronic muscle hypertonia due to cerebral palsy. To disengage the reflex, passive manipulation of the arms and legs in the direction of muscle shortening will also provide resistance-free movement, preserve or improve flexibility, and avoid muscular contractures. Proper alignment of the body through stretching can facilitate unrestricted mobility and enhance one's posture. With high muscular tone, effleurage and stretching treatments are highly useful, unlike in cases of hypotonia. Although tapotement is not recommended for muscles that are spastic, frictions and kneading may still be useful, as they will just cause the muscle to become even more overstimulated. For the hypertonic client, these softer methods might also enhance the digestive system. Given that the contractures are a sign of brain injury, slow craniosacral therapy is also believed to be advantageous.
All that therapists really need to do is exercise the same cautions they would with any other client: avoid overstretching muscles or working on numb areas; consider positioning the client so that, for some, side positions with a pillow between the legs and under the head may be more comfortable. A different strategy is required if your actions exacerbate the symptoms. In order to ensure that a client with spastic CP is warm enough, therapists must also become more adept at recognising nonverbal cues and elevated metabolic rates in these clients. In addition to guaranteeing the client's comfort, chilly temperatures will aggravate the stiffness in their limbs. Finally, it's critical to be aware of any medical devices, such as feeding tubes, since massage should not be applied directly to such areas.
At www.medicalmassagelady.com, I provide training courses for massage for children with cerebral palsy; nevertheless, it is crucial to remember that learning doesn't stop after the course when working with clients who have this condition. Working with disabilities is an excellent way to uncover prejudices we weren't even aware we had, as society is inherently afraid of things it doesn't understand or of those who look different. Speaking with someone who has a speech impediment and excessive drooling can be intimidating. Training can help us increase our knowledge, but all of that information really doesn't start to make sense until we really start treating patients; therefore, we should seize these difficult learning chances. The way that each client sees themselves and their condition will inform much of what you learn about CP.
My recommendation is that if you want to start treating people with cerebral palsy, volunteer with organisations like Wheelpower sports camps for children with disabilities or Whizzkidz wheelchair skills days before taking on any clients.
Fundraising & case study
Kit, one of my frequent clients, turned four years old recently. He met all the usual milestones and was a happy, healthy boy for the first eighteen months of his life. According to his parents, he would say, "There you go," to everything he took out of the dishwasher.
In 2021, he suddenly experienced a two-hour seizure (for which there was no known explanation). He had previously suffered from routine ailments like tonsillitis. Due to the enlargement of his brain caused by this seizure, he was put into a coma for three weeks in order to protect his brain. His parents were advised to get in touch with the family when he was in the PICU at King's College Hospital, as it was thought he would not survive. They started the organ donation process and got ready to say goodbye to Kit after the most agonising phone calls a parent could ever have to make.
Once off the ventilator and able to breathe on his own, Kit was determined not to give up. After Kit transferred to HDU and subsequently the ward, his parents began to observe little changes, despite the fact that they had been informed he would be in a vegetative state. They spent three months in the hospital before starting a new life at home. It needed renovations, and they had barely moved into their new home six weeks before the seizure.
Even though Kit now has a life-altering brain injury, partial blindness, motor dysfunction, and epilepsy, his parents are just happy that he is still alive and well. All of the abilities he possessed prior to the seizure are gone, with the exception of smiling; he is unable to walk or talk. He can now grasp things and bring them to his mouth.
I've been giving hour-long massages that include the legs, arms, stomach, and back to Kit once a week for the past eight months. From the start, Kit has shown remarkable tolerance and response to this kind of treatment. Because of this consistent therapy, Kit's parents and I have observed remarkable progress over the past eight months. After a two-week summer break, Kit returned to the programme considerably tighter.
Kit has begun interacting more through non-verbal means, but he has recently made more of an effort to speak with others. His stiffness has mostly decreased; he is lifting his head and turning over, and he only occasionally experiences mini-clonus episodes while working on specific muscles. He clearly has a stronger hold and can push against my hand with greater force with his feet. He also experiences bloating from gas as a result of the tube used to administer his medication, but the abdominal part of the massage effectively eliminates this.
Without a doubt, Kit is benefiting from these frequent sessions as he continues to advance and realise his full potential. I know this since I had a child with spastic diplegia and have professional expertise with children's disabilities.
Kit's hips were found to be dislocated during a routine x-ray two months ago. His recuperation period will be six weeks after he undergoes two procedures, one for each hip. The pain will prevent him from being lifted. If there was a path that could easily transfer him from the wheelchair-accessible car into the home, and if his bedroom and bathroom were downstairs, his parents could handle this.
In order to make their home accessible and safe for Kit and to enable them to provide for his basic care needs in the same way that a normal parent could, Kit's parents are raising money through Just Giving and the Tree of Hope charity. To enable him to spend time with the rest of the family, they are seeking money to create an extension that will provide him with a separate room downstairs with a wet room, wheelchair access, and entry. The single-story extension required to future-proof his room will cost between £80,000 and £100,000, which his parents would be eligible for in government subsidies of around £30,000. Since he is becoming too heavy to be carried upstairs safely and some therapists are no longer willing to lift him, they are currently waiting for the installation of hoists and a stair climber as a temporary solution.
Currently working two days a week following maternity leave with his younger brother, Kit's mother is a teacher, while his father works as a nurse at Demelza, a children's hospice and respite care facility. Due to their professional employment and mortgage, they are unable to receive much assistance, even though providing Kit with a "normal" and happy life would incur significant costs, especially for therapy, cars, and neurological support that can only be obtained privately. Though it has only been two years since the traumatic event, Kit has shown tremendous promise for development. We have observed him make gains in vocalisations, strength and flexibility, and eyesight. He has already proved the physicians wrong, but he still needs the room in the family home to continue getting better.
Please feel free to watch the brief film that Kit's parents made about what happened to him. @roomofkitsown is his Instagram handle. If you would like to donate, please click the Just Giving links:
Sam Mishra, Executive Contributor Brainz Magazine
Sam Mishra (The Medical Massage Lady), is a multi-award winning massage therapist, aromatherapist, accredited course tutor, oncology practitioner, trauma practitioner and breathwork facilitator. Her medical background as a nurse and a midwife, combined with her own experiences of childhood disability and abuse, have resulted in a diverse and specialised service. She is motivated by the adversity she has faced, using it as a driving force in her charity work and in offering the vulnerable a means of support. Her aim is to educate about medical conditions using easily understood language, to avoid inappropriate treatments being carried out and for health promotion purposes in the general public.
References:
De Mostafa (2022) Effect of Instrument Assisted Soft Tissue Mobilization on Hamstring Flexibility in Children with Diplegic Cerebral Palsy. Egyptian Journal of Hospital Medicine Article 111, Volume 89, Issue 1, October, Page 4842-4847
Gielalis, J. (2019) What massage therapists should know when working with cerebral palsy patients. https://www.integrativehealthcare.org June
Güçhan Topcu Z, Tomaç H. (2020) The Effectiveness of Massage for Children With Cerebral Palsy: A Systematic Review. Advanced Mind and Body Medicine. Spring;34(2):4-13.
Ward R, Reynolds JE, Bear N, Elliott C, Valentine J. (2017) What is the evidence for managing tone in young children with, or at risk of developing, cerebral palsy: a systematic review. Disability and Rehabilitation. Apr;39(7):619-630.
Kinesio Prehab Institute. (2020) Paediatric Instrument Assisted Soft Tissue Mobilization (PIASTM).
