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The Effectiveness of Massage for Children With Cerebral Palsy: A Systematic

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 REVIEW ARTICLE
The Effectiveness of Massage for Children With
Cerebral Palsy: A Systematic Review
Zehra Güçhan Topcu, PT, PhD; Hayriye Tomaç, PT, MS
ABSTRACT
Context • Massage is a widely used alternative therapy
among health professionals and parents for children with
cerebral palsy (CP).
Objective • The review intended to determine the effects
of massage on the rehabilitation of children with CP.
Design • The research team conducted a literature review
that examined the use of massage for children with
various types of CP, such as ataxia, using relevant
keywords. It included articles published up to December
2019. The research team searched the electronic databases
PubMed, MEDLINE, Embase, Scopus, and the Cochrane
Central Register of Controlled Trials.
Setting • The study took place at Eastern Mediterranean
University in Famagusta, Cyprus.
Participants • Participants in the reviewed studies were
children with CP.
Outcome Measures • The strength of the research designs
was rated using Sackett’s Levels of Evidence. The
Physiotherapy Evidence Database (PEDro) scale was used
to assess the studies’ methodological quality. The outcome
measures were classified according to the International
Classification of Functioning, Disability, and Health (ICF).
Zehra Güçhan Topcu, PT, PhD, Instructor, and Hayriye
Tomaç, PT, MS, Research Assistant. Department of
Physiotherapy and Rehabilitation, Faculty of Health Sciences,
Eastern Mediterranean University, Famagusta, Cyprus.
Corresponding author: Zehra Güçhan Topcu, PT, PhD
E-mail address: zehra.guchan@emu.edu.tr
Cerebral palsy (CP) is one of the most commonly seen
childhood disabilities, with a prevalence reported to range
from 1.5 to 4 per 1000 live births.1,2,3 It’s a disorder
characterized by nonprogressive lesions in an immature
brain and has a variety of symptoms that depend on many
factors, such as the lesion’s age and the affected brain region.3
4 ADVANCES, SPRING 2020, VOL. 34, NO. 2
Results • Eleven studies that included 297 CP children
were reviewed. According to the PEDro scores, 5 studies
had high methodological quality; 5 studies had fair
quality; and one study had poor quality. No study
investigated the effects of massage for all classifications of
the ICF. Muscle tone was decreased significantly in the
reviewed studies, either between the groups or within the
massage group (P < .05). No consensus existed about the
other effects of massage due to the limited research.
Conclusions • This study is a first review in this area and
can be an important guide for professionals and caregivers
who want properly use massage for children with CP.
Massage as an adjunct to traditional therapies should be
used to reduce muscle tone in spastic-type CP. More clear
methods and relevant outcome measures should be used
in future studies. Further studies with randomized
controlled trials are required to determine massage type,
massage applier, and oil for this population and to
investigate immediate and long-term effects of massage on
all ICF’s domains. (Adv Mind Body Med. 2020;34(2):##-
##).
Multidisciplinary treatment approaches are required in
the management of the symptoms and lifelong effects of CP,
including tonus abnormalities, postural deformities, deficits
in locomotion and other types of activities of daily living, and
impairments in cognition and social and emotional skills.4
Commonly used interventions for CP include physical
therapy for motor development; occupational therapy for
activities of daily living; speech therapy for language and
communication skills; behavioral therapy and special
education for cognitive and social skills; and braces and
orthotic devices for prevention of postural deformities.4
Moreover, many adjunctive applications such as taping and
reflexology are used to support the therapies.5,6
In a recent review, all interventions that are in current
use for the management of CP-related problems were
Güçhan Topcu—Massage for Children With Cerebral Palsy
collected and assigned categories.7 Massage was included
among them, but no review about it was included. For
pediatric neurodevelopmental disorders, massage is one of
the oldest and most widely used types of alternative and
complementary medicine.3,8 It’s currently practiced in more
than 75 forms today for different purposes.3
Parents often use massage for their children, even for
nonverbal infants who have no disability. According to the
International Association of Infant Massage (IAIM), the
tactile sense is the first to develop, at 6 to 9 weeks within the
uterus, and the skin is the largest sense organ.9
Touching is an easy way to communicate with an infant
in a healthy form and to give him or her the feeling of safety
after birth. Moreover, it can be a lifelong method for good
communication among family members. While hugging,
kangaroo care, and breastfeeding are some ways for healthy
touching, massage is another popular method to nurture
touching in a routine.9 While many parents use massage for
children without any disability, the parents of children with
special needs are almost twice as likely to have used it.10
Massage can be used effectively in the management of
CP, and it can regulate muscle tone, improve range of
motion, enhance motor functioning, improve sleep patterns,
reduce anxiety, reduce pain, and improve bowel and bladder
functions.4,11 The benefits of massage in CP are also explained
in a study by Powell, indicating that it can support blood and
lymph circulation, relieve muscle tension and stiffness,
provide muscle relaxation, and promote flexibility.4,9,11
Moreover, massage has been shown to increase social and
communication skills in children with CP.4
Because massage is inexpensive and practical, it continues
to be applied by various pediatric professionals and by parents.
The current review intended to determine the effects of
massage on the rehabilitation of children with CP.
Methods
Procedures
The study took place at Eastern Mediterranean University
in Famagusta, Cyprus. Participants in the reviewed studies
were 297 children with CP.
The research team conducted a literature review that
examined the use of massage for children with various types
of CP, such as ataxia, using relevant keywords. After assigning
the Population Intervention Comparison Outcome (PICO)
protocol which is a specialized framework to formulate a
research question,5 all relevant studies were identified by
searching the electronic databases PubMed, MEDLINE,
Embase, Scopus, and the Cochrane Central Register of
Controlled Trials. The reference lists of extracted studies
were also searched.
The databases were searched using the text words child*
and cerebral palsy OR hemiplegia OR monoplegia OR
quadriplegia OR diplegia OR tetraplegia and massage. These
were used separately or in Boolean combination. Data were
extracted independently and synthesized by the 2 members
of the research team.
Güçhan Topcu—Massage for Children With Cerebral Palsy
The research team included studies in the review that:
(1) included children under 18 years of age with CP; (2) were
fully published; (3) were of different research designs,
including case reports; (4) were published up to December
2019; (5) investigated the effectiveness of massage in children
with CP; (6) used at least one quantitative outcome measure;
and (7) were published in the English language.
Outcome Measures
Sackett’s Levels of Evidence. These levels were used to
rate the strength of the research design. The reviewed studies
were ranked from strongest to weakest using a 5-point grading
system.12 The levels of evidence are: (1) I: a systematic review
of randomized controlled trials (RCTs) or a large RCT with
narrow confidence intervals (n > 100); (2) II: smaller RCTs
with wider confidence intervals (n < 100), systematic reviews
of cohort studies, or outcomes research such as very large
ecological studies; (3) III: cohort studies, which must have a
concurrent control group, or systematic reviews of case control
studies; (4) IV: case series, a cohort study without a concurrent
control group such as a historical control group, or a case-
control study; and (5) V: an expert opinion, a case study or
report, bench research, an expert opinion based on a theory or
physiological research, or common sense or anecdotes.7
Physiotherapy Evidence Database (PEDro) scale. The
scale was used to assess the reviewed studies’ methodological
quality. The PEDro scale has 11 questions that rate the
studies’: (1) specification of eligibility criteria;
(2) randomization of participants; in a crossover study,
subjects should randomly allocated in the order in which
treatments were received; (3) concealment of allocations;
(4) similarity of groups at baseline regarding the most
important prognostic indicators; (5) blinding of all subjects;
(6) blinding of all therapists who administered massage;
(7) blinding of all assessors who measured at least one key
outcome; (8) acquisition of at least one key outcome from
more than 85% of the subjects initially allocated to the
groups; (9) use of an intention-to-treat analysis;
(10) reporting of between-group statistical comparisons for
at least one key outcome; and (11) inclusion of both point
measures and measures of variability for at least one key
outcome.13
The answers to items 2 to 11 are scored as 0 = unknown
(U) or 0 = no (N) and 1 = yes (Y), resulting in total score
ranging from 0 to 10 according to the PEDro guidelines.
Studies are then classified as being poor in methodological
quality if the total score is ≤3, fair if the score is between 4 and
5, and high if the score is ≥6, as presented in the literature
(https://www.strokengine.ca/en/glossary/pedro-score/).13
The 2 members of the research team independently
scored all of the studies according to the PEDro scale and
discussed disagreements to reach a consensus.
International Classification of Functioning,
Disabilitym and Health (ICF) framework. The ICF domains
include body structure/function, activity, and participation—
capacity and performance. The research team determined if
ADVANCES, SPRING 2020, VOL. 34, NO. 2 5
Figure 1. Progress of Search for Relevant Studies
1057 studies identified through
Identification
database search, and additional
records identified through
other sources
60 studies after duplicates
Eligibility
removed; only titles screened
• Inaccessible full-text records (n = 1)
• Non-English records (n = 45)
14 studies
• Descriptive studies (n = 2)
Included
• Qualitative outcome measures (n = 1)
11 studies included in final
analysis
the reviewed studies used these domains in their evaluations,
identifying the outcome measures that the studies used and
their results to structure the review’s discussion of the
studies’ outcomes.
Modified Ashworth Scale (MAS). Is used to measure
the severity of spasticity with 0-4 points. 0 point is normal,
while higher points show more severe spasticity.1,15 This is
found in the body structure/function domain of ICF.
Gross Motor Function Measures (GMFM). is used for
the depth assessment of the gross motor ability of children.
Higher scores show better gross motor.1 This is found in the
activity domain in ICF.
Peabody Gross Motor Scale (PGMS). is used to evaluate
motor skills of children. Statitionary, locomotion and object
manipulation are its subtitles. Higher scores show better
motor ability.16
In the ICF, the World Health Organization (WHO)
defined body structure as the “anatomical parts of the body
such as organs, limbs, and their components,” whereas body
function is defined as the “physiological functions of body
systems, including psychological functions.” Muscle tone,
abnormal sensory responses, pain, heart rate, reflexes, range
of motion, and muscle activity fit into this domain.
WHO defined the activity component of the ICF as “the
execution of a task or action by an individual,” such as
walking 10 meters.
Results
Figure 1 presents the search strategy and inclusion of
studies in a PRISMA flow chart. Sixty studies were initially
found to be relevant for the review, but 45 studies were in the
Chinese and Korean languages and a full text of one study
6 ADVANCES, SPRING 2020, VOL. 34, NO. 2
couldn’t be accessed.14 Out of the 14 relevant studies, 3 were
then excluded because they used qualitative outcome
measures or descriptive study designs. Eleven studies were
included in the review process.1-4,8,11,15-19 The reviewed
studies’ research designs included randomized controlled
trials, cohort studies, and case series.
Drop-outs occurred in 4 studies1,8,16,18; the reasons were
clearly specified only in Mahmood et al’s1 study, as lack of
motivation, transport difficulties, telecommunication issues,
and surgical correction during study. Alizad et al18 reported
the causes of drop-outs as CP complications and transport
problems. Two other studies8,16 had dropouts, especially 13
children out of 40 children in the study by Alizad et al8, and
they didn’t mention the reasons.
No adverse effect occurred for massage in the studies.
Data Collected
Mahmood et al1 and Rasool et al3 performed studies in
2019 and 2017, respectively, and had the largest sample sizes,
84 and 60 children with CP, respectively (Table 1). Of the CP
types, spastic CP was included in all studies, but diplegic
children were included in only 5 studies.1,3,11,15,19 Only Nilsson
et al17 and Hernandez-Reif et al4 included other types of CP,
such as dyskinesia and ataxia.
GMFCS levels were presented in 6 studies,1,2,11,15,17,19 but
Macgregor et al’s19 study showed 2 children with 2 GMFCS
levels, I-II and III-IV and gave no additional information
about this unclear identification of levels. Furthermore, no
information was presented about the MACS levels of the
included children, especially for the studies that included
children possibly having affected upper limbs, such as those
having quadriplegic or hemiplegic CP (Table 1).
Güçhan Topcu—Massage for Children With Cerebral Palsy
Table 1. General Characteristics of the Studies

Sackett’s Number of
Research Level of Participants Characteristics of Participants
Studies by Year Design Evidence Treatment Control Age Range (y) Features of CP
Mahmood et al, 20191 Randomized II 42 42 • 2-10 years • Spastic diplegic CP
controlled • Intervention group mean: 7.05 • GMFCS I-III (n=54)
trial ± 2.47 years • GMFCS IV-V (n=21)
• Control group mean: 6.81 ±
2.31 years
Bingöl and Yılmaz, 20182 Randomized II 10 10 • 5-12 years • Quadriplegic (n=13), Diplegic
controlled • Intervention group mean: 6.6 ± (n=4) and Hemiplegic (n=3) CP
trial 1.3 years • GMFCS Level (I-IV)
• Control group mean: 9.7 ± 3.0
years
Kalantari et al, 201711 Case series IV 6 6a • 7 months-4 years • Spastic diplegic CP
• GMFCS level III (n=3), level IV
(n=2), and level V (n=2)
Rasool et al, 20173 Randomized II 30 30 • 3-9 years • Spastic diplegic CP on
controlled • Intervention group mean: 6.03 limbs involved
trial ± 1.73 years • Mild mental retardation
• Control group mean: 6.0 ± 1.85 • GMFCS not identified
years
Malila et al, 201515 Case series IV 17 17a • 6-18 years • Spastic diplegic CP
• Mean: 13.71 ± 3.62 years • GMFCS level I (n=8), level II (n=4),
level III (n=5)
Silva et al, 201216 Randomized II 16 9 • 0-4 years • Unilateral and bilateral spastic CP
controlled • GMFCS not identified
trial
Nilsson et al, 201117 Cohort stu- III 3 3 • 3-17 years • dyskinetic (n=2), unilateral spastic
dies (n=1), bilateral spastic (n=3) C
• GMFCS level IV (n=5) and level II
(n=3)
Alizad et al, 200918 Randomized II 13 14 • 1-7years • Spastic CP
controlled • Intervention group mean: 49.5 • GMFCS not identified
trial ± 15.7months
• Control group mean: 42.1 ±
11.8months
Alizad et al, 20078 Randomized II 13 14 • 1-7 years • Moderate spastic cerebral palsy and
controlled • Intervention group mean: cooperation
trial • 49.5 ± 15.7months • GMFCS not identified
• Control group mean:
• 42.1 ± 11.8months
Macgregor et al, 200719 Case series IV 5 5a • 12-15 years; mean: 14 years • Spastic diplegic
• GMFCS level I (n=2), level II (n=3),
level III (n=1), and level IV (n=1)
Hernandez-Reif et al, Randomized II 10 10 • Age range not identified • Spastic, athetoid, and ataxic CP
20054 controlled • Massage therapy mean: 29 ± 8 • Mobility level—ambulatory, no
trial months independent steps, no weight
• Reading therapy mean: 33 ± 10 bearing, no sitting
months • GMFCS not identified
a
Treatment group actedas its own control group

Abbreviations: CP, cerebral palsy; GMFCS, Gross Motor Function Classification System.

Under Sackett’s level of evidence, 7 studies1-4,8,16,18 showed
a level II, one study17 showed a level III, and 3 studies11,15,19
showed a level IV.
PEDro results indicated that the highest total scores
were found for questions 1, 9, and 10 (Table 2). The lowest
scores were seen for question 5, blinding of subjects, and 6,
blinding of therapists. Total scores showed that 5 studies had
high methodological quality; 5 studies had fair quality; and
one study had poor quality. All high-quality studies had a
level of evidence of II, with randomized, controlled study
designs. Bingöl and Yılmaz2 and Silva et al16 were found to be
randomized controlled trials with fair quality and only
Macgregor et al19 had poor quality among the 11 reviewed
studies.
Table 3 shows that massage was applied to all limbs of the
CP children in one study,17 only the lower limbs in 4

Güçhan Topcu—Massage for Children With Cerebral Palsy ADVANCES, SPRING 2020, VOL. 34, NO. 2 7
Table 2. PEDro Scores for Reviewed Studies. The PEDro scale has 11 questions covering: (Q1) the specification of eligibility
criteria; (Q2) the randomization of participants; in a crossover study, subjects must be randomly allocated in the order in
which treatments were received; (Q3) the concealment of allocations; (Q4) a similarity of groups at baseline regarding the
most important prognostic indicators; (Q5) the blinding of all subjects; (Q6) the blinding of all therapists who administered
massage; (Q7) the blinding of all assessors who measured at least one key outcome; (Q8) the acquisition of at least one key
outcome from more than 85% of the subjects initially allocated to the groups; (Q9) an intention-to-treat analysis; (Q10)
reporting of between-group statistical comparisons for at least one key outcome; and (Q11) both point measures and
measures of variability for at least one key outcome.

Scores on Questions
Studies by Year 1 2 3 4 5 6 7 8 9 10 11 Total
Mahmood et al, 20191 Y Y Y Y N N Y Y Y Y Y 8
Bingöl and Yılmaz, 20182 Y Y N Y N N N U Y Y Y 5
Kalantari et al, 201711 Y N N U N N N Y Y Y Y 4
Rasool et al, 20173 Y Y Y Y Y N Y Y Y Y Y 9
Malila et al, 201515 Y N N N N N Y Y Y Y N 4
Silva et al, 201216 Y Y N N N N N Y Y Y Y 5
Nilsson et al, 201117 Y Y Y N N U U Y Y Y N 5
Alizad et al, 200918 Y Y U Y N N Y N Y Y Y 6
Alizad et al, 20078 Y Y U Y N N Y N Y Y Y 6
Macgregor et al, 200719 Y N N N N N Y Y Y N N 3
Hernandez-Reif et al, 20054 Y Y U Y N Y Y Y N Y Y 7
Total score 11 8 3 6 1 1 7 8 10 10 8 62
Mean score 5.6

Abbreviations: Y, yes; N, no; U, unknown because not specified in a study.

studies,2,3,11,19 the lower back and both legs in one study,15 and
the whole body in 3 studies,1,4,18 whereas Silva et al16 and Alizad
et al (2007)8 didn’t mention the location of the massage. All
researchers gave the details of the massage used, with either
the type of massage or the manual movements and the type of
oils used in the massage mentioned in 4 studies.4,11,17,19
Moreover, massage was directly applied to the children
by trained massage therapists in 3 studies,4,15,17 and the
caregivers were trained in 2 studies to apply the massage.1,16
The massage duration ranged from 14 to 30 min and the
frequency ranged from 2 to 7 weekdays per week. Malila et
al15 investigated only the immediate effects of massage,
whereas Kalantari et al11 and Macgregor et al19 investigated
both immediate and long-term effects. Except for those 3
studies, the studies lasted a varying number of weeks and
months and investigated only long-term effects.
Routine therapy continued for both the intervention and
the control group in 6 controlled studies.1-4,17,18 Only 2
studies4,16 used other types of control techniques in the
control groups. First, Silva et al’s16 study compared massage
from trained therapists for intervention group and massage
by caregivers trained by the therapists for the control group.
Second, Hernandez-Reiz et al4 used a reading-attention
activity—30 min twice a week for 12 weeks—for the control
group and massage—30 min once a week for 12 weeks—for
the intervention group.
Effects of Massage
For the ICF domains, body structure and function was
assessed in all 11 studies, whereas the activity dimension was
measured in 5 studies (Tables 3 and 4). Only one study4
investigated the effects of massage on the participation of
children with CP. The ICF model was used to group the
studies’ results. Thus, outcome measures were identified as
body structure and function, activity, and participation.
Body structure and function. All reviewed studies
assessed the body structure and functions. The most common
outcome measure was muscle tone, which was assessed by
Mahmood et al,1 Bingöl and Yılmaz,2 Rasool et al,3 Hernandez-
Reif et al,4 Kalantari et al,11 Malila et al,15 and Alizad et al.18
Muscle tone showed a significantly greater decrease in
the intervention group than in the control group in Mahmood
et al’s1 study, with P = .04 after 6 weeks and P = .01 after 12
weeks, whereas no significant difference was found between
the massage and control groups in the studies by Bingöl and
Yılmaz2 and Rasool et al.3
Hernandez et al4 didn’t present the result between the
groups. Studies showed various results within groups for the
MAS scale: (1) Bingöl and Yılmaz2: for both intervention and
control groups—P = .005 for the hip adductor, hamstrings,
and calf muscles and P = .014 for the hip flexor change is for
intervention group only. (not within both groups); (2) Rasool
et al3: for intervention group only—P < .001; (3) Malila et al15:

8 ADVANCES, SPRING 2020, VOL. 34, NO. 2 Güçhan Topcu—Massage for Children With Cerebral Palsy
Table 3. Summary of Intervention and Outcomes of the Studies

Massage Massage Training of Person Intervention Massage and

Study Region Details Oil Type Applying Massage Control Procedures Assessments Outcome measures ICF Model Statistics Results
Mahmood et Whole Traditional NA • Physical • Intervention group: 30 Baseline and • MAS (muscle • Body • Independent Between groups:
al, 20191 body massage in therapist min traditional massage weeks 6 and 12 tone) structure/ Samples t test • MAS: More significant decrease in
Pakistan: intervention before 30 min • GMFM-88 function • Paired t test intervention group than control
gently rubbing group conventional physical • GMFCS • Activity group after 6 and 12 weeks (P < .05)
from proximal • Caregivers for therapy; 5 times per • No significant differences in GMFM
to distal, from control group week, 12 weeks and GMFCS between control and
center to • Control group: 30 min intervention groups (P > .05)
peripheral conventional physical Within groups:
therapy; 5 times per • Significant improvements in all
week, 12 weeks parameters for both intervention and
control group after 12 weeks (P < .05)
• No significant improvement in
GMFCS after 6 weeks for both
groups.
• Significant change in GMFM and
MAS scores after 6 weeks for both
groups (P < .05)
Bingöl and Lower Traditional NA NA • Intervention group: 20 Before and after • MAS (muscle • Body • Kolmogorov- • Improvements in GMFM for within
Yılmaz, 20182 limbs massage in min functional massage, 2 months tone) structure/ Simirnov/ Shapiro- both control and intervention group
Pakistan: then 25 min traditional • GMFM function Wilk’s test before and after the study (P < .05)
gently rubbing physiotherapy; 2 days • Activity • Paired Student’s t • Higher scores of GMFM in
from proximal per week for 8 weeks test intervention group than control group
to distal, from • Control group: 45 min • Independent after the study (P < .05)
center to traditional Samples t test • Improvements in spasticity of hip
peripheral physiotherapy; 2 days flexors on MAS within only
per week for 8 weeks intervention group (P < .05)
• Improvements in spasticity of hip
adductors, hamstrings and calf muscles
on MAS within both groups
• No significant difference in spasticity
between groups (P > .05)
Kalantari et Lower Swedish Olive oil and NA • Only Intervention group Baseline, at the • MAS (muscle • Body • Mann-Whitney U • Both oils effective in reducing
al, 201711 limbs massage camel hump available end of each tone) structure/ test muscle tone
oil • Study conducted in 10 massage session, function • Possibly Camel hump oil more
weeks in 5 phases: (1) and every week effective in some cases, no P value
baseline 2 weeks, during the 10
routine treatments; (2) weeks of the
massage with olive oil, 2 study = the
weeks, 30 min each outcome
session, 3 days per week; measures were
(3) wash-out, 2 weeks, recorded in these
routine treatments; (4) three times:
massage with camel starting, just
hump oil, 2 weeks, 3 after session,
days per week; (5) weekly
baseline 2 weeks, routine
treatments
• Both groups receiving
routine occupational
therapy during the 10
weeks
Rasool et al, Lower Cross-friction NA Therapist • Intervention group: Before and after • MAS (muscle • Body • Independent • No significant differences in MAS
20173 limbs massage: Soleus routine physiotherapy 6 weeks tone) structure/ Samples t test between groups (P > .05)
and treatment and cross- • 9-point scale for function • Paired t test • Significant improvement in MAS in
gastrocnemius friction massage, 5 times functional level • Activity intervention group only (P < .05)
along Achilles per week for 6 weeks • No change in functional level on
tendon • Control group: routine 9-point scale within or between
physiotherapy treatment, groups (P > .05).
5 times per week for 6
weeks
Malila et al, Lower back Traditional Thai NA Certified Thai • Only Intervention group Before and after • MAS (muscle • Body • Wilcoxon Signed Decrease in spasticity of quadriceps
201515 and both Massage: thumb massager available. the 30 min tone) structure/ Ranks Test femoris with Thai massage (P = .004)
legs pressure to every • Massage session of 30 session function
specific point. minutes
for 5-10 seconds
Silva et al, NA Qigong massage NA Parents trained by • Intervention group: Before and after • Abnormal • Body • Ancova Moncova t • Greater improvement in PGMS
201216 (manual Qigong Sensory weekly qigong massage 5 months and 5 sensory structure/ test object manipulation scores improved
techniques) Training therapists by trained therapist, month after responses function (P < .01) in intervention group versus
for applying with no frequency or study completion • Peabody Gross • Activity control group
massage to their duration identified, and Motor Scale • No significant change in sensory
children. special education responses
• Control group: daily
qigong massage by
parents, every day for 15
min, and special
education
Nilsson et al, All Limbs Longitudinal, Cold-pressed Trained massage • Intervention group: Before and after • Sleep quality • Body • Manne Whitney U • No difference in pain, well-being,
201117 transverse and vegetable oil therapists standardized massage 2 weeks • Wellbeing structure/ test and sleep quality (P > .05)
circular therapy for 30 min • Heart rate function • Wilcoxon • Decrease in heart rate with rest in
movements. before physiotherapy • Pain controls (P < .05), but no change in
session • Experiences of the massage therapy group (P > .05)
• Control group: resting both massage • Heart rate reduction not different
for 30 min before therapists and between groups (P > .05)
physiotherapy session physiotherapists
Alizad et al, Whole Swedish NA Trained • Intervention group: Before and after • MAS (muscle • Body • According to • After intervention, no significant
200918 body massage. occupational Swedish massage for 30 3 months tone) structure/ distribution of differences in MAS results (P > .05)
therapist; training minutes, 3 times a week, function variables, • Tone reduction in upper limbs and
area unclear and routine parametric (t test trunks greater in intervention group
occupational therapy and paired t test) than control group (P < .05)
(Rood and Bobath and non-
techniques) parametric (Mann
• Control group: Routine Whitney and
occupational therapy Wilcoxon) tests
(Rood and Bobat • Data analysis using
techniques) SPSS statistical
software, version 11.

Güçhan Topcu—Massage for Children With Cerebral Palsy ADVANCES, SPRING 2020, VOL. 34, NO. 2 9
Table 3. (continued)
Massage Massage Training of Person Intervention Massage and
Study Region Details Oil Type Applying Massage Control Procedures Assessments Outcome measures ICF Model Statistics Results
Alizad et al, NA Swedish Not Trained • Intervention group: Before and after • Reflex • Body • Parametric (t test No significant effects (P > .05)
20078 massage mentioned occupational Swedish massage for 30 3 months assessment structure/ and paired t test)
therapist (the minutes, 3 times a week, function and nonparametric
training area is and routine occupational • (Mann Whitney,
unclear) therapy (Rood and and Wilcoxon)
Bobat techniques)
• Control group: Routine
occupational therapy
(Rood and Bobat
techniques)
Macgregor et Lower Swedish Non- NA • Only intervention group One week before • Range of • Body No statistical test Improvements in the values of the
al, 200719 limbs massage allergenic available; 14 min the test period, passive and structure/ outcome measures.
grape seed massage conducted after every voluntary ankle function
oil twice a week for 5 weeks massage session, movement • Activity
in addition to curricular after massage • EMG from
activities session at week 5 soleus (muscle
and at session at activity)
week 12 for • GMFM-66
follow-up
Hernandez- Whole • Stroking, Unscented Licensed massage • Intervention group: 30 Before and after • Modified • Body • Paired sample t For the intervention group:
Reif et al, body Circular oil therapists min massage once a 12 weeks Ashworth scale structure/ tests • Reduced MAS (P < .05)
20054 movements week for 12 weeks (muscle tone) function • Wilcoxon signed • Less rigid muscle tone overall and in
• Kneading • Control group: 30 min • Arms, legs, and • Participation ranks related t arms (P < .05)
• Milking reading attention group, trunk muscle- tests • Improved fine- and gross-motor
• Wringing twice a week for 12 tone scale functioning (P < .05)
• Twisting weeks • Range of • Increased range of motion of hip
• Treatment for both motion extension (P < .05)
groups: regular preschool • Developmental • No change in hip abduction (P > .05)
activities such as finger programming • Improved cognition (P < .05), social,
painting and story time, for infants and and dressing scores
1-1.5 hours per week of young children • More positive facial expressions and
physical therapy, one • Videotaped less limb activity during face-to-face
hour per week of interactions play interactions (P < .05)
occupational therapy, and
one hour per week of
speech therapy.

Abbreviations: NA, not available; MAS, Modified Ashworth Scale; GMFM, Gross Motor Function Measure; GMFCS, Gross
Motor Function Classification System, PGMS: Peabody Gross Motor Scale

Table 4. ICF Domains Measured in the Studies. A plus sign indicates the study measured the domain; a minus indicates it
did not.

Body
Structure/
Studies by Year Function Activity Participation
Mahmood et al, 20191 + + -
Bingöl and Yılmaz, 20182 + + -
Kalantari et al, 201711 + - -
Rasool et al 20173 + + -
Malila et al, 201515 + - -
Silva et al, 201216 + + -
Nilsson et al, 201117 + - -
Alizad et al, 200918 + - -
Alizad et al, 20078 + - -
Macgregor et al, 200719 + + -
Hernandez-Reif et al, 20054 + - +

Abbreviations: ICF, International Classification of Functioning, Disability, and Health.

for intervention group only—P = .004 for the quadriceps control groups of the studies by Rasool et al3 and Hernandez
femoris, and (4) Hernandez et al4: for the intervention group et al.4 Muscle tone decreased in both massage groups in
only—P < .05 for the arm and P > .05 for the leg. Kalantari et al’s study,11 which compared 2 types of oils with
Looking at the MAS change within the control groups of wash-out periods.
the controlled studies, the tone of all muscle groups except Moreover, no significant MAS differences existed
the hip flexors decreased significantly in Bingöl and Yılmaz’s between or within the groups of Alizad et al’s study,18 but
study (P < .05), whereas no MAS change occurred in the tone reductions in the trunk and upper limbs were

10 ADVANCES, SPRING 2020, VOL. 34, NO. 2 Güçhan Topcu—Massage for Children With Cerebral Palsy
significantly higher for the massage group than the control
group, with P = .006 and P = .033, respectively. Hernandez-
Reif et al4 examined the arm, leg, and trunk muscle-tone
scale, and the overall tone and the tone for arms decreased
significantly in the massage group (P < .05), whereas no
significant change was seen in the control group. On the
other hand, the legs score decreased significantly in the
control group (P < .05), whereas no change was seen in the
massage group.
Nilsson et al17 found that heart rate decreased significantly
for the control group (P = .039), whereas no significant
change occurred for the massage group (P > .05). In the study
by Hernandez et al,4 the range of both the right and left hip
extensions significantly increased for the massage group
(P < .05), while no change was seen in the control group
(P > .05). Except for these mentioned parameters above, no
significant difference was found in sensory response,16 pain,17
reflexes,8 and muscle activity19 in favor of the massage groups
(P > .05).
Activity. Table 4 indicates that activity was measured
in 5 studies.1-3,16,19 The studies used the GMFM, the GMFCS,
a 9-point scale, and the Peabody gross motor scale. Two
randomized control trials2,16 indicated more improvements
in intervention groups versus control groups for this
dimension, whereas no significant change was found in 2
other studies1,3 (P > .05). Bingöl and Yılmaz2 showed that the
massage group had significantly higher GMFM (P = .002)
and GMFCS (P = .004) results than did the control groups.
According to Silva et al,16 all subscales of the PGMS showed
significant improvement within the massage group—
P = .042 for stationary body control, P = .02 for locomotion/
movement, and P = .027 for object manipulation, whereas
no change was seen within the control group (P > .05).
However, no significant treatment effect was found for
massage by Silva et al16 (P > .05). Macgregor et al’s study19
assessing activity showed no statistical change within or
between the groups.
Participation. WHO defined this domain of the ICF as
involvement in a life situation, such as studying at school or
playing with friends. Only Hernandez et al4 evaluated this
section of the ICF, using “Developmental programming for
infants and young children” and videotaped interactions.
They showed significant improvements in 5 variables which
are fine motor, gross motor, dressing, social, and cognition of
the outcome measure “Developmental programming for
infants and young children for the massage group (P < .05),
with no change in the control group (P > .05), while 2
variables which are language and significantly increased for
the control group (P < .05), with no change for the massage
group (P > .05). According to videotaped interactions, more
positive facial expressions during playtimes were observed
for the massage group after the 12-week study (P < .05), while
no significant change occurred for the control group in
playtime (P > .05). Hernandez et al4 presented no information
about the differences between the included groups.
Güçhan Topcu—Massage for Children With Cerebral Palsy
Discussion
Eleven studies with both low and high levels of evidence
were included in the current review of available literature on
the effects of massage for children with CP. Heterogenic
outcome measures and study designs limited data analysis
and prevented formation of a conclusion about the
effectiveness of massage.
The review found more variations in methods than the
current research team expected, and it was difficult to collect
and list the important factors that can affect results and to
categorize the outcomes.
The aims weren’t clearly explained for some studies.
Nilsson et al17 applied massage to children following lower-
limb surgery and investigated the effects of lower-limb
massage on pain, heart rate, sleep, and well-being. However,
the researchers didn’t identify any hypothesis to examine
regarding the mechanism of massage’s effects on these
parameters as background information of the studies
reviewed explained the cerebral palsy and the possible
benefits of massage in general, but there is no linkage
between these effects and the targets of massage in cerebral
palsy so the hypothesis is not clear in the papers. Lower-limb
surgeries usually aim to increase range of motion or manage
the tonus and optimize the gait of CP children, and massage
can be used to facilitate these goals of surgery20; nevertheless,
Nilsson et al17 didn’t mention examination the effects of
massage on these goals as part of their hypothesis. Similarly,
Alizad et al’s8 2007 study didn’t indicate which mechanism
within the massage concept might be effective in decreasing
abnormal infant reflexes, and they found no effect on these
reflexes.
The methodology of Alizad et al’s18 2009 study was
unclear. The researchers didn’t describe: (1) which muscles of
the upper and lower limbs they tested, (2) how the scores for
these limbs were acquired, or (3) how the neck and trunk
muscles were evaluated by MAS; MAS isn’t used to test these
regions.21 Moreover, the neck and trunk muscles are usually
weak and hypotonic in spastic-type CP. Thus, more details
are required about the methodology of any further studies.
Two studies offered confusing information about the
control groups. Silva et al16 compared the effects of massage
by trained therapists and caregivers trained by the same
therapists, and Hernandez-Reiz et al4 read books to children
at a different frequency than that of the massage in
intervention group. Thus, the results of Silva et al’s study16
may have been affected by bias that occurred during the
teaching of massage to the parents. The trained massage
therapist knew that the study would compare the results for
the therapist’s massages to those for the caregivers’ massages.
Moreover, Hernandez-Reiz et al4 used a reading activity
for control group. For the outcome measure of developmental
programming for infants and young children, some
parameters of participation measurement, such as for feeding
and language, improved more for the study’s control group
than for the massage group, which could possibly be related
to the reading activity.
ADVANCES, SPRING 2020, VOL. 34, NO. 2 11
 These kinds of control groups can affect the reliability of
results, so control groups with only routine therapies should
be preferred.
The details of the provided massage were presented in
the reviewed studies, and some of them also gave
environmental details, such as the use of warm rooms and
warm towels. However, the studies gave no information
about the correct timing of massage. Should it be applied
before or after exercises as an adjunctive intervention or
should occur in a different session. If massage was applied to
a child before the exercise, while it was applied to another
child after the exercise, it may probably cause different
effects. Thus, more details should be presented in the study to
indicate the effects of massage in this population.
In terms of oil types, according to the study by Rasool et
al3, oil isn’t required in friction massage, but no information
was given in other studies as to the use of oils, although oil is
one of the required tools of Swedish massage therapy.22
Also, the training of persons who apply massage to children
is important, but the information on training was limited for the
reviewed studies. Some studies identified the persons who
applied the massage as trained massage therapists, physical or
occupational therapists, or caregivers, but some studies gave no
information about the person who applied the massage.
Mahmood et al1 showed that massage administered by
mothers was effective in reducing spasticity in conjunction
with routine therapies. Similarly, Barlow and Cullen23 had
shown positive clinical effects of touching training for
parents of disabled children. Nilsson et al17 underlined some
children reacted to the massage applied by therapists.
Moreover, some children and adolescents can have negative
reactions to massage when it is applied, which could relate to
a child’s sense of security and reaction to touching. Thus,
they recommended that parents who are familiar with their
children should be trained for massage.
Similarly, according to IAIM,9 massage education should
be presented to caregivers on baby dolls by certified infant
massage instructors, because IAIM states that touching is a
special sensation and massage should be a special way of
communication and a high-quality time shared between the
baby or child and the parent or caregiver. Moreover, infants
especially can be afraid of and children and teenagers can feel
shame from being touched by unfamiliar people.9
Nevertheless, Malila et al15 also reported that children
enjoyed the massage sessions administered by a Thai
massager. Thus, more studies should investigate who can
better perform massage in children or adolescents with CP.
Most studies focused on muscle tone as an outcome
measure, since abnormal tone is the most commonly seen
symptom in CP. Mahmood et al,1 a study with an evidence
level of II and high methodological quality, reported significant
differences in the effects on muscle tone between the massage
and control groups, but the researchers gave no information
about the muscle groups that were tested by MAS in the study.
Bingöl and Yılmaz2 and Rasool et al,3 both with an
evidence level of II and with fair and high methodological
12 ADVANCES, SPRING 2020, VOL. 34, NO. 2
qualities, respectively, found significant improvements for
the massage group but not between groups. Although
Hernandez et al,4 with an evidence level of II and high
methodological quality, didn’t show differences between the
groups, the researchers found significant improvements for
the massage group. However, Hernandez et al4 included
athetoid and ataxic CP types in their study, and it isn’t clear
how they evaluated the outcome measures since not all
included children had spasticity.
The activity domain significantly improved in
2 studies 2,16 with an evidence level of II and fair
methodological qualities and in one study19 with an
evidence level IV and of poor quality, whereas no
significant improvement was shown in 2 studies1,3 with an
evidence level of II and high methodological quality.
Thus, since the studies by Mahmood et al1 and Rasool et
al3 provided a higher level evidence with higher quality, it
has been considered that massage has no effects on
activity in children with CP. Looking at the last domain,
participation of ICF, no recent study has investigated this
domain of ICF, although it has recently been an important
goal in practice to indicate the effects of interventions on
a multidisciplinary context.
No study has investigated all the ICF domains to
indicate the effects of massage with different aspects. When
all ICF domains are evaluated, many different health fields
can benefit from the results because the 3 domains examined
in the current review have presented information about not
only heath conditions but about factors that can exert
positive or negative influences on the human body’s
functioning.24 Only Hernandez-Reif et al assessed the
participation domain and found significant improvements
with use of massage. However, the control group also had
greater improvement in some dimensions of participation
because it group took a reading course in addition to routine
therapies. Further studies should focus on all ICF domains,
particularly participation, to reveal the biopsychosocial
effects of massage.
The current review study found promising results in
decreasing spasticity, with various evidence levels.
However, more randomized controlled studies with
standardized procedures are required to determine the
effects of massage on the activity and participation
domains as are some other outcome measures in addition
to body structure, such as range of motion, that can be
more relevant to CP children than many outcome measures
in the reviewed studies.
In future studies, the current research team generally
will examine changes in muscle tone through massage for
children with spastic CP, and it hopes to create some
standards for massage with this goal in mind and to show its
effects on other domains of ICF.
The limitations of small sample size and the lack of an
adequate control group, one without any intervention, were
stated in many studies.2,3,11,15,16,17
Güçhan Topcu—Massage for Children With Cerebral Palsy

Conclusions
This study is a first review in this area and can be an
important guide for professionals and caregivers who want to
properly use massage for children with CP. Massage as an
adjunct to traditional therapies should be used to reduce
muscle tone in spastic-type CP. More clear methods and
relevant outcome measures should be used in future studies.
Further studies with randomized controlled trials are
required to determine massage type, massage applier, and oil
for this population and to investigate immediate and long-
term effects of massage on all ICF’s domains.
22. Saunders G. Tools of the Trade: Massage Tables, Table Accessories, Linens,
Lubricants, Essential Oils, and the Treatment Room. Massage Therapy E-Book:
Principles and Practice. 2019 Feb 28:37.
23. Barlow J, Cullen L. Increasing touch between parents and children with
disabilities: Preliminary results from a new program. J Fam Med Dis Prev. 2002;
12:7-9.
24. Silva SM, Correa JC, Pereira GS, Correa FI. Social participation following a stroke:
An assessment in accordance with the international classification of functioning,
disability and health. Disabil Rehabil. 2019 Apr 10; 41:879-86.

Author’s disclosure statement

The research team received no funding for this study and had no conflicts of interest
related to it.

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