Assignment topic: Choose an article listed below and write a critique of that article.
Nilsson, S., Johansson, G., Ensk?r, K., & Himmelmann, K. (2011). Massage therapy in post-operative rehabilitation of children and adolescents with cerebral palsy - a pilot study. Complementary Therapies in Clinical Practice, 17(3), 127-131. [see http://ezproxy.csu.edu.au/login?url=http://dx.doi.org/10.1016/j.ctcp.2010.11.003]
Your critique should address, but need not be restricted to, the following issues:
What is the research problem or hypothesis? Has it been stated clearly and the importance explained?
Has the author used the literature to provide a sound and logical basis for the study?
Has the context of the study been given?
Are the references appropriate, comprehensive and current?
What type research methodology is used? Are the methods used consistent with the methodology?
Was the research design appropriate for answering the research question?
Do the authors clearly explain how they conducted their study? Is there sufficient information for the study to be independently repeated?
Are data collection procedures clearly described?
Do the authors explicitly discuss ethical considerations? Are there any issues of concern?
Have all threats to internal validity been controlled?
What data analysis methods were used? Were these appropriate for the type of data collected?
For quantitative studies, irrespective of statistical significance are the results clinically significant?
Are tables and figures presented clearly and accurately?
Do the findings support the conclusions made by the authors? Do these conclusions address the research question/hypothesis?
Have the authors discussed limitations of their study, and do they present suggestions for future studies?
DO NOT use the above questions as headings within your work because they are provided as guidance when preparing your work. If you wish to use sub-headings in your work then it is suggested that you group responses about similar issues (e.g. data analysis) under a single sub-heading.
An important skill when reading research reports is the ability to determine whether the findings will be useful for clinical practice. The purpose of this assignment is to introduce you to the process of critiquing research reports. A research critique is not just a summary of a study but an evaluation of its strengths and weaknesses.
Critique will be marked using the following criteria and the the level descriptors previously described in the Subject Outline:
Knowledge Development - Understanding of the material presented in the paper
being critiqued and ability to correctly apply factual information from the set text and readings to the assignment task (e.g. correct identification of type of research e.g. qualitative v quantitative, action research v ethnography). 10
Critique - Ability to provide a balanced critique of the strengths and weaknesses of the paper
including the research problem, methodology, data collection and analysis, and interpretation. 10
Presentation - while there are no marks allocated for this area marks will be deducted (max 3 marks) for failure to following the assignment instructions regarding presentation standards.
Spelling and other grammatical errors will incur a 0.5 mark penalty for each instance up to a maximum of 3 marks.
Up to 3 marks will also be deducted for failure to adhere to the APA guidelines for referencing.
Article Below included
Complementary Therapies in Clinical Practice
Volume 17, Issue 3, August 2011, Pages 127?131
Massage therapy in post-operative rehabilitation of children and adolescents with cerebral palsy ? a pilot study
Stefan Nilssona, b, , , Gunilla Johanssonc, Karin Ensk?rb, Kate Himmelmannc
a Department of Paediatric Anaesthesia and Intensive Care Unit, The Queen Silvia Children?s Hospital, Sahlgrenska University Hospital, G?teborg, Sweden
b Department of Nursing Science, School of Health Sciences, J?nk?ping University, Sweden
c The Queen Silvia Children?s Hospital, Sahlgrenska University Hospital, G?teborg, Sweden
Available online 15 December 2010
http://dx.doi.org.ezproxy.csu.edu.au/10.1016/j.ctcp.2010.11.003, How to Cite or Link Using DOIPermissions & Reprints
The purpose of this pilot study was to explore the use of massage therapy in children with cerebral palsy undergoing post-operative rehabilitation.
Material and method
Three participants were randomized to massage therapy and another three participants to rest. All children had undergone surgery in one or two lower limbs. Pain, wellbeing, sleep quality, heart rate and qualitative data were collected for each child.
The scores of pain intensity and discomfort were low in all participants. Heart rate decreased in participants who were randomized to rest, but no change was found in the massage therapy group.
The lack of decrease in heart rate in the study group of massage therapy may imply an increased sensitivity to touch in the post-operative setting. Further research with larger study populations are needed to evaluate how and when massage therapy is useful for children with cerebral palsy.
Cerebral palsy; Pain; Physiotherapy; Post-operative; Wellbeing
McGrath and colleagues have reported that pain is a common problem among children with disabilities,1 more frequent than in normally developing peers. 2 Several reports have shown frequent and chronic pain in children with cerebral palsy (CP). ,  and  Musculoskeletal and gastrointestinal pain is common.  and  It is known that untreated pain in childhood give a pain sensitization.5 This pain sensitization is dependent on genetically determined neural programmes and past experiences of similar procedures.6 Pain behaviour occurs mainly after the inputs have been analysed and synthesized sufficiently to produce a meaningful experience for the child.7 Pain is particularly hard to assess in severely impaired children, although they have more frequent life events and incidents associated with pain and discomfort. Thus, pain is often underestimated or not sufficiently evaluated and treated.8 Prejudice regarding pain in children with cognitive impairment in both the caregivers and health care professionals may affect the children?s care.  and  Nonverbal assessment tools have proven valuable in understanding pain in children with cognitive impairments. One of these tools, The Non-Communicating Children?s Pain Checklist-Postoperative Version (NCCPC-PV), is validated in children with cognitive impairments. It has been useful to measure procedural pain in children with CP, and translated into Swedish.10
Pain affects the possibilities of participation, quality of life and has social and educational consequences.  and  Quality of life (QOL) in moderate and severe CP was worse compared to children without CP in a study by Liptak et al., using Child Health Questionnaire (CHQ) which is one of the most common instruments.12 Parents of children with CP report a reduced QOL related to the motor severity of CP.13 The ratings seem stable over time.14 In the population-based multicenter study SPARCLE (Study of PARticipation of Children with cerebral palsy Living in Europe) more than 800 children and their parents across nine countries in Europe were interviewed.15 A striking finding was that pain affected quality of life, regardless of domain.
A literature review was conducted January 2008 in Pubmed and Cinahl to get an overview of current research in the area of massage therapy. The keywords were children (0?18 years) and cerebral palsy and massage or tactile stimuli. Only English papers
were included, review articles and educational reports were excluded. Nine papers
were found (Table 1). Three papers
surveyed the use of massage therapy in children with CP ,  and  while six papers
evaluated the effects of massage therapy. , , , ,  and  None of these studies were randomized clinical trials and most of the results reported beneficial effects of massage therapy. No study evaluated massage therapy in post-operative rehabilitation of children with CP.
Table 1. Literature review.
Authors Year N= Results
Use of massage therapy
Samdup DZ, Smith RG, Song SI. 2006 194 children Within the CP group, greater disease severity was associated with higher use. The main reason for complementary and alternative medicine (CAM) use was to complement conventional medicine
Sanders H, Davis MF, Duncan B, Meaney FJ, Haynes J, Barton LL. 2003 Families of 376 children Use of CAM for children with special health care needs was common
Hurvitz EA, Leonard C, Ayyangar R, Nelson VS. 2003 Families of 213 children Parents who used CAM for themselves were more likely to try CAM for their child and were more pleased with the outcome
Effects of massage therapy
Barlow J, Powell L, Cheshire A. 2007 70 parents 67 children Training and support programme (TSP) showed improvements over time in terms of parental anxious and depressed moods, perceived stress, generalized self-efficacy, self-efficacy for managing their children?s psychosocial wellbeing and satisfaction with life. Parental perceptions? of children?s sleeping, mobility, and eating had significantly improved
Powell L, Swaby L. Barlow J. 2007 4 children Many children found TSP relaxing and helpful in reducing stiffness
Macgregor R, Campbell R, Gladden MH, Tennant N, Young D. 2007 5 children Participants in Gross Motor Function Classification System (GMFCS) Levels I and II made improvements. One participant in GMFCS Level III improved significantly only after massage of all leg muscles for 30 weeks
Powell L, Barlow J, Cheshire A. 2006 70 parents 67 children Parents reported a number of improvements in their own emotional wellbeing and had noted various improvements in their children
Zhou XJ, Zheng K. 2005 140 children The majority of the children improved greatly in motor and social adaptation capacities after treatment. This combined therapy method, based on traditional Chinese medicine and western medicine plus family supplemental therapy, was an effective and practical treatment strategy for CP children in China.
Barlow J, Cullen L. 2002 42 parents TSP showed improvements over time, for example sleep patterns and better response to physiotherapy
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The effect of complementary therapies is insufficiently known in CP.25 Children with chronic pain have shown decreased distress and pain when they used massage therapy.26 In children with CP there is still insufficient evidence about how and when massage therapy should be applied. In addition to pharmacological therapy, physical therapy has its place by tradition and by emerging evidence in this group of children in post-operative rehabilitation.27
The aim of this study was to explore the use of massage therapy on pain and distress in conjunction with physiotherapy in children with CP undergoing post-operative rehabilitation.
2. Material and methods
This pilot study has a concurrent mixed-method design, i.e. quantitative and qualitative data in the same data collection. Both methods in this data collection are of equal importance in answering the research question.28
Children with CP, aged 3?17 years, and scheduled for orthopaedic surgery were recruited from a paediatric unit at the Queen Silvia Children?s hospital, Gothenburg, Sweden. All children had undergone surgery in one or two lower limbs. The children came postoperatively, after removal of the cast, to a regional centre for rehabilitation for approximately two weeks. The health related QOL was examined in each child by using CHQ. Demographic data are shown in Table 2.
Table 2. Baseline data and intervention (MT = Massage therapy; C = Control (rest)).
Participant Age Diagnosis GMFCSa Intervention CHQ-PF50b
1 8 year Dyskinetic CP 5 MT Parents reported that the child has had pain a few times during the last 4 weeks. The parents were very emotionally affected by the child?s pain. It also had a great impact on the family activities.
2 13 year Unilateral spastic CP 2 C Parents reported that the child has had pain a few times during the last 4 weeks. The parents were emotionally affected by the child?s pain. It also had an impact on the family activities.
3 10 year Bilateral spastic CP 2 C Parents reported that the child has had a lot of pain and often during the last 4 weeks. The parents were emotionally affected by the child?s pain. It also had a great impact on the family activities.
4 16 year Bilateral spastic CP 2 MT Parents reported that the child has had pain a few times during the last 4 weeks. The parents were emotionally affected by the child?s pain. It also had a great impact on the family activities.
5 14 year Dyskinetic CP 5 MT Parents reported that the child has had pain every day during the last 4 weeks. The parents were very emotionally affected by the child?s pain. It also had a great impact on the family activities.
6 3 year Bilateral spastic CP 5 C Parents reported that the child has had a lot of pain and often during the last 4 weeks. The parents were very emotionally affected by the child?s pain. It also had a great impact on the family activities.
aGross Motor Function Classification System.
bChild Health Questionnaire Parent Form 50.
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The therapists were trained massage therapists and they were proficient in this subject area. The massage therapist hung up a ?do not disturb? sign on the door. One parent had the possibility to be in the room, but it was the massage therapist who carried out all treatment. The light was subdued in the room and the bed was prepared with blankets, sheets and pillows. The child lied on its back and warm wheat pillows wrapped in towels were placed on his or her upper body. A light massage therapy was performed and this form of massage is equal with tactile massage. The massage therapy was conducted in the same order at each intervention. The massage therapist used cold-pressed vegetable oil and used longitudinal, transverse and circular movements. The massage therapy started with the right leg, and continued with foot, right arm, hand, left arm, hand and finally the left leg and foot.
2.4. Data collection
The data were consecutively collected in conjunction with massage therapy/rest and one of the children?s physiotherapy session each day. Three participants were randomized to the intervention group and another three participants to the control group. The six protocols were blindly randomized and distributed in a predetermined order. All families and children got equal information preoperatively about the study. The children in the intervention group underwent standardized massage therapy for 30 min before the physiotherapy session. The control group rested for 30 min before the physiotherapy session.
2.4.1. Sleep quality
The quality of sleep was measured by numbers of times each night that the child had a disturbed sleep, based on the parent?s report.
The parents rated their child?s wellbeing on a 0?10 Visual Analogue Scale (VAS). Two questions were asked before and after massage therapy/rest and after the physiotherapy, How much physical discomfort has the child right now? (0 = none, 10 = constantly) and How is the child feeling right now? (0 = excellent, 10 = terrible). These questions were modified from an earlier study that also used VAS to measure wellbeing.29
2.4.3. Heart rate
The heart rate was measured before and after the massage therapy/rest and after the physiotherapy. The heart rate was measured with a pulseoxymeter on the second finger of the left hand.
2.4.4. Pain assessment
In non-communicating children NCCPC-PV was used before and after the massage therapy/rest and after the physiotherapy. Children who had the ability to manage a self-reported pain scale used the Coloured Analogue Scale (CAS) for scoring pain intensity on a scale from zero to ten.30 CAS was used before and after the massage therapy/rest and after the physiotherapy.
2.4.5. Qualitative reports
In addition, each massage therapist and physiotherapist described his or her experiences of the therapy sessions (massage therapy and physiotherapy, respectively). Each therapist documented his or her experiences after each session.
2.5. Data analysis
2.5.1. Quantitative data
The power was insufficient for statistical calculations. However, due to the limited experience of massage therapy in the literature, it was important to start with a small number of participants to evaluate the intervention and the study design. To get a guidance for further studies, non-parametric statistics were used.31 Statistical significance was set at p < 0.05. Comparisons of data between the intervention group and the control group were made by the Mann?Whitney U test. The Wilcoxon signed ranks test was used for comparing changes before and after the massage therapy/rest and after the physiotherapy.
2.5.2. Qualitative data
All texts from the massage therapists and physiotherapists were read and analysed by using a qualitative content analysis.32 All data were read and reread until a sense of totality was obtained, the unit of analysis was identified, and transcripts were broken down into phrases and sentences, giving meaning to units of information. The meaning units were sought and organized into categories. In categorizing the data, issues denoting the same feature were grouped into categories and labelled.33 Finally, all categories were compared to maximize their unique and non-overlapping quality.
2.5.3. Ethical considerations
The study was approved by the Regional Medical Ethics Review Board of Gothenburg. An oral informed consent was obtained from all participants and a written consent was collected from all parents. The children and their parents knew that they could withdraw this study at any time.
The study was conducted between May 2008 and January 2010. Seven children were consecutively asked for participation in this study. One child declined to participate and data was finally recorded on six children, aged three to 17. Each participant underwent in median either seven massage therapy sessions (range 5?9) or eight rest sessions (range 5?9) during the rehabilitation period. In Table 2 baseline data and randomisation are presented. In Table 3 surgical intervention and pain medication are presented.
Table 3. Orthopaedic surgery, cast duration and pain medication.
Participant Surgery Cast duration Pain medication during post-operative training
1 (MT) Tenotomies of the adductors and hamstrings, Osteotomy of the femur 6 weeks Intrathecal baclofen, paracetamol
2 (C) Osteotomy of the femur, tenotomies of the adductors, iliopsoas, hamstrings and gastrocnemius 6 weeks Paracetamol, diklofenac
3 (C) Tenotomies of the hamstrings and Achilles tendons 6 weeks Botulinum toxin in conjunction with operation
4 (MT) Osteotomy of the femur, derotation of the tibia, tendon transfer of rectus femoris, tenotomy of gastrocnemius 10 weeks Botulinum toxin in conjunction with operation
5 (MT) Tenotomies of the adductors and iliopsoas subtalus arthrodesis, tenotomies of peroneus and Achilles tendons 6 weeks Intrathecal baclofen, diklofenac
6 (C) Tenotomies of the adductors and iliopsoas 8 weeks Paracetamol, diklofenac
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The scores of pain intensity and discomfort were low in all participants. It was rare that children woke up during the nights, median zero (range 0?7) in the massage therapy group and median zero (range 0?4) in the control group. There were no statistical significant differences between the study groups concerning pain intensity, wellbeing or sleep quality.
There was no difference in heart rate between before and after massage therapy in the intervention group, while the heart rate decreased significantly in the control group after 30 min of rest (p = 0.039). Heart rate decreased more in the children who rested (median ? 4 heartbeats) than in the children who received massage therapy (median + 0.2 heartbeats), but this difference was not statistical significant (p = 0.182). There was no difference between after massage therapy and after physiotherapy in the intervention group, while a significant increase of heart rate was seen in the control group between after rest and after physiotherapy (p 0.023).
From the massage therapist?s descriptions two categories emerged, ?You need to be attentive to the child?s response to touch? and ?Massage therapy is often appreciated by the child?. The massage therapists stated that the children often felt that the massage was pleasant, but when the children were massaged, they could also have negative reactions.
From the physiotherapists? one category emerged ?Massage relaxes the muscles in the child?.
The management of pain in children with cerebral palsy is a challenge for the staff and caregivers to assess and treat, and many treatment modalities, traditional pharmacological therapy and physical therapy as well as complementary methods maybe explored. ,  and  There is some evidence regarding the value of massage therapy in children with CP.34 This pilot study on children with CP who had undergone orthopaedic surgery did not show any differences on wellbeing, sleep quality or pain intensity between those who had received massage therapy and those who were randomized to rest. All the children underwent intensive physiotherapy repeatedly for approximately two weeks, and managed this period well, showing low scores of pain intensity and discomfort. The latter may explain the absence of differences between the study groups, and may indicate that post-operative rehabilitation is beneficial for these children even without the use of complementary treatment, i.e. massage therapy. Children who underwent massage therapy did not decrease their heart rate compared to the control group, in contrast to a study on children with cancer, where heart rate decreased more with massage therapy compared with rest in the control group.35 However, it is known that sensation and perception often is disturbed in CP, and behavioural response to tactile stimuli maybe negative.36 It seems to be important for the massage therapist in children with CP to carefully evaluate the child?s reaction to tactile stimuli and reaction to the massage therapy. The massage therapists in this study were aware of the children?s resistance to some of the massage therapy sessions, ?You need to be attentive to the child?s response to touch?. This qualitative result is in consistence with the quantitative data, that showed no difference in heart rate between before and after the intervention.
It is also likely that this pilot study would have been different if the parents conducted the massage therapy. At least one study has found positive responses from children with CP when their parents performed the massage.34 Since parents are familiar with their child this can lead to an increased sense of security and maybe positive outcomes.
The major limitation in this pilot study is the sample size. Although there arises a hypothesis about massage therapy the result must be repeated and confirmed in a larger sample size. The low scores on discomfort and pain intensity in this study suggested a positive management of the post-operative rehabilitation. However, it may also indicate that there are effects not shown by the chosen assessment tools. In further studies probably other data should be collected as well. S-oxytocin and cortisol have been valuable in adults who underwent complementary therapy, with conflicting results.  and  The classification system International Classification of Functioning, Disability and Health in Children and Youth (ICF-CY)39 may enable researchers to move beyond quantifying the character of pain and help them to identify the functional consequences of pain, and assess its functional impact in the broader context of the life of a child with CP. ICF-CY is useful to improve the aims and the outcomes of which interventions are applied.40 Core sets based on ICF have been presented in other contexts of pain, such as low back pain41 and widespread pain.42 It maybe of interest to use ICF-CY to create a core set of assessment tools.
The recommendations for a larger study are:
?Use a core set out of ICF-CY to get a validated and holistic data collection
?Evaluate if children with CP are more vulnerable to touch in comparison with other child populations
The lack of difference in heart rate in conjunction with massage therapy in this study, while the children assigned to resting had a decrease in heart rate, may indicate an increased sensitivity to touch in the children who got massage therapy. There is a need for the massage therapist to use of this method with care in children with CP. However, massage therapy is still a common used and appreciated method in clinical settings. It is important with further research to evaluate how and when massage therapy is useful for children with CP.
Conflict of interest
The authors report no conflict of interest.
We thank the children and parents who participated in the study, generously gave their time and shared their experiences. We would also like to thank the staff at the Regional Rehabilitation Centre for data collection. Finally, we would like to thank Marita Hild?s and Kerstin Uvn?s-Moberg for sharing their knowledge about massage therapy. The Mayflower Charity Foundation and the Petter Silfverski?ld Foundation funded this research project.
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Corresponding author. Department of Paediatric Anaesthesia and Intensive Care Unit, The Queen Silvia Children?s Hospital, Sahlgrenska University Hospital, 416 85 G?teborg, Sweden. Tel.: +46 (0)31 343 6688; fax: +46 (0)31 343 5880.
Copyright ? 2010 Elsevier Ltd. All rights reserved.
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