Healing the Autistic with the Power of Massage Therapy

By Shirley Vanderbilt

Originally published in Massage & Bodywork magazine, February/March 2003. Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.


Autism is on the rise, and with it comes more heartache for parents and higher costs for the school system. Statistics from a 1999 state report from California showed a nearly 300 percent increase in cases reported from 1987 to 1998.1 Researchers estimate as many as one in 200 children are affected by the disorder.2

Editor's note: Since this article was originally published, a study in the Archives of General Psychiatry (September 2006) revealed that babies born to men between the ages of 40 and 49 are nearly six times more likely to develop autism than children born to men under 30, regardless of the mother's age.

Researchers are scrambling to uncover causes and put a halt to this increase, along with addressing the symptoms of autism, including abnormal response to sensory stimuli, limited attention span, excessive off-task behavior and touch aversion.3

Autism is a brain disorder, usually diagnosed by age 2, in which the child fails to develop language and normal social interaction skills. Withdrawal from social contact and aberrant behavior are common. Within the classroom, educators have used behavior modification, structured settings and social skills conditioning with minimal effect. And in the home, some parents have tried the gamut of treatments, conventional and alternative, in an attempt to restore what many experts postulate may be a permanently damaged brain. Moderate success has been achieved with vitamin B6 supplements, sometimes resulting in improvement in speech, behavior and physiological measures.4

Clinical trials have also shown massage therapy as a viable complementary treatment positively impacting some of the characteristic behaviors of autism. Two important studies have emerged in this area within the past few years, both from the Touch Research Institute (TRI) in Miami, Fla.


Massage in the Classroom Setting
In 1997, a study team at TRI, led by Tiffany Field, Ph.D., published results of its first project involving autistic children. Building on the success of previous studies demonstrating anxiety reduction and increased attention span using massage therapy for children, the team surmised touch therapy may be beneficial in reducing the autistic behaviors of inattentiveness, touch aversion and withdrawal.5

The 22 autistic children included in this study were recruited from a special preschool they had been attending for two years. Averaging 4.5 years of age and from middle socioeconomic-level families, the 12 boys and 10 girls were randomly assigned to a touch therapy or touch control group. In a series of developmental assessments, it was determined the two groups were equivalent in intelligence, speech and language skills, and behavioral adaptation. Additionally, all of the students had been diagnosed as autistic by two independent clinicians.6

Several instruments were used on the first and last day of the study to determine effectiveness of the treatment. Classroom observation by psychology graduate students included notation of "touch aversion, off-task behavior, orienting to irrelevant sounds and stereotypic behaviors" over a 30-minute time period. Teachers, blinded to group assignment, documented their observations on the Autism Behavior Checklist (ABC), and the Early Social Communication Scales (ESCS) were administered by graduate students, also blinded to group assignment.7

A specific massage protocol, administered by a volunteer student, was followed for each child in the touch therapy group and included moderate pressure and smooth stroking movements to the head and neck, arms and hands, torso, and legs and feet. These 15-minute sessions were conducted twice weekly for four weeks. Within the same time protocol, children in the touch control group sat on the lap of a volunteer student who had her arms around the child, and were engaged in a game selecting toys of different color, shape and form.8

Given that autistic children have been reported to be averse to physical contact, one of the most interesting findings of the study is observation of improvement in touch aversion for both groups. Researchers said this response may be related to the one-on-one attention and predictability of the contact in the study, as compared to a more generalized social touch. Similarly, these factors may account for the improvement in off-task behavior noted in both groups. Overall, both groups seemed to benefit, but the touch therapy group exhibited more significant beneficial effects for orienting to irrelevant sounds and stereotypic behaviors, and scores on the ABC and ESCS. Researchers surmised these increased effects may be credited to the "more active physical contact and relaxation involved in the touch therapy." Additionally, activity to the vagus nerve (key cranial nerves) enhanced by touch therapy could also account for increased attentiveness in the classroom.9


Massage at Home
Expanding on encouraging results from the 1997 study, researchers at TRI embarked on a second trial of massage therapy for autistic children, this time using parents to administer massage at home. This way children could receive daily treatments at no cost. The study team surmised greater improvements might be seen with more frequent massage administered by a familiar person. In addition to benefits previously documented, it was hoped nightly massage could improve sleep disturbances common to autistic children.10

Twenty children between the ages of 3 and 6 were recruited from a school for autistic children. All had been diagnosed within one to three years previously and were determined, through a series of assessments, to be homogeneous with regard to adaptive behavior and language skills. In addition, they came from the same developmental-level classrooms. The children were randomly assigned to either a massage group or attention control group, and parents were told that "reading stories and massaging might increase relaxation and sleep in children."11

Treatment in both groups was conducted over a one-month period, with the protocol being administered for 15 minutes just prior to bedtime. Parents in the massage group were trained by a massage therapist to use the same procedure outlined in the 1997 study. In the control group, parents were asked to read a Dr. Seuss story during the 15-minute evening period. It's important to note that on conclusion of the study, these parents were also offered instruction in massage therapy, affording their children an opportunity to experience the same benefits as the massage group.12

As with the 1997 study, assessments were made on the first and last days of treatment using much the same measures, but with the addition of sleep diaries completed by the parents. Parents and teachers recorded observations on five sub-scales of the revised Conners Scales which rated such factors as hyperactivity, attentiveness, restless-impulsive behaviors and emotional state. Teachers were blinded to group assignment, as were other behavioral observers in the classroom and on the playground. Sleep diaries included a record of fussing and restlessness, crying, self-stimulating behaviors and number of times the child attempted to leave the bed.13

The massage group showed a clear benefit in sleep as reported by parents, with the above behaviors diminishing during the treatment period. However, as noted by researchers, the parents were obviously not blinded to group assignment and their response to providing massage for their children was enthusiastic and positive. Despite this non-blinding, the ratings may hold true. In a previous study of depressed children, TRI researchers using videotape rather than parent ratings documented improvement in sleep following massage therapy. Whether or not improved sleep patterns also influenced a significant finding of improved classroom performance is unknown. But the team did find the massage group became more attentive at school, showed increased on-task behavior and were observed to have a decrease in stereotypical behaviors both in the classroom and on the playground.14


Touch and Autism
Researchers from the United Kingdom, in a study published in 2002, used a similar format to that of the TRI parent study. In this trial, a group of parents with autistic children was trained to administer touch therapy to their children. When interviewed prior to the program, the parents (primarily mothers) reported feeling "hurt in response to the aloof nature of autism" and also felt hindered in their spontaneous parenting instincts, such as cuddling. The Touch Therapy project, which included 12 children, was conducted for an eight-week period.

Not only did the children accept their parents' touch, parents also reported more cooperative behavior with daily tasks such as dressing and a higher level of relaxation in their children overall. At the conclusion, the study team noted, "Parents reported feeling closer to their children and felt that the touch therapy had opened a communication channel between themselves and their children."15

These are exciting results, given the tremendous challenge autism presents to both parents and teachers. Autism, as we now know it, is incurable and the behaviors associated with the disorder are pervasive throughout the individual's lifetime. One of the most heartbreaking aspects of this disorder is the block in communication between parent and child. The most basic of intimate human interactions -- hugs, words of love and facial responses of pleasure -- typically do not emanate from an autistic child. Recent research has debunked the long-held belief that autistic children are incapable of forming attachment. We now know they do attach to their parents and show a preference for interaction with their family. But they remain incapable of acting on that attachment or responding appropriately to the interaction. The results of these studies show promise that massage and other touch therapies will emerge as a building block in bridging that gap.

Shirley Vanderbilt is a staff writer for Massage & Bodywork magazine.

References
1. Ostrov, Barbara Feder. "Alarming rise in autism in state is genuine, researchers conclude," Mercury News. www.bayarea.com/mid/mercurynews/news/4312756.thm.
2. "Autism rise blamed on environment," BBC News, 29 August, 2002, http//:news.bbc.co.uk/1/hi/
programmes/newsnight/2224126.stm.
3. Field, T., Lasko, D., Mundy, P., Henteleff, T., Kabat, S., Talpins, S. and Dowling, M., "Brief Report: Autistic Children's Attentiveness and Responsivity Improve After Touch Therapy," Journal of Autism and Developmental Disorders, 27, 3 (1997): 333.
4. Rimland, Bernard and Baker, Sidney, "Brief Report: Alternative Approaches to the Development of Effective Treatments for Autism," Journal of Autism and Developmental Disorders, 26, 2 (1996): 237-238.
5. Field, 333.
6. Ibid., 334-336.
7. Ibid., 336.
8. Ibid., 334-335.
9. Ibid., 336-338.
10. Escalona, A., Field, T., Singer-Strunck, R., Cullen, C. and Hartshorn, K., "Brief Report: Improvements in the Behavior of Children With Autism Following Massage Therapy," Journal of Autism and Developmental Disorders, 31, 5 (2001): 513.
11. Ibid., 514.
12. Ibid.
13. Ibid.
14. Ibid., 515.
15. Cullen, L. and Barlow, J., "'Kiss, cuddle, squeeze': The experiences and meaning of touch among parents of children with autism attending a Touch Therapy Programme," Journal of Child Health Care 6, 3 (Sept. 2002): 171-181.

Sports Massage and Recovery Time

Sports Massage & Recovery Time
Re-examining the Role of Lactic Acid

By Shirley Vanderbilt

Originally published in Massage & Bodywork magazine, October/November 2001.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.


Sometimes a "truth" is not what it seems. Take lactic acid. For years, many massage therapists have been taught that lactic acid can and should be flushed from the muscles of athletes after intense activity. This truism has been passed on to clients who have also accepted it as fact. Both therapist and client thus have established and perpetuated a mutual belief system that purging of lactic acid is not only necessary, but also efficiently accomplished with the assistance of massage. Some beliefs die hard. This one and others related to lactic acid have been holding their own, not only in some massage schools and practices, but also in the community at large, despite emerging research to the contrary. Pass the word. There's no need to mess with Mother Nature.

Lactate accumulated from intense exercise actually fuels the body, according to Dr. Owen Anderson, exercise physiologist and editor of Running Research News. In a recent interview from his office in Michigan, Anderson explained the facts.

Lactic acid levels will return to homeostasis quickly post-exercise without any "hands-on" assistance. "Muscles don't need help from massage in removing lactate," said Anderson. "Massage will probably have the biggest effect on venous blood," and by the time massage is administered, lactate has already left the muscle. This is not to say massage isn't beneficial to the athlete. "Massage is good for relaxing," said Anderson, "and provides help increasing flexibility of muscles."

Whitney Lowe, owner and director of Orthopedic Massage Education and Research Institute and author of Functional Assessment in Massage Therapy concurs with Anderson's statements.

"Lactic acid is a natural by-product of any muscular activity. There are elevated levels of lactic acid in muscle tissues after exercise, but that is going to subside either with time or with any type of movement activity, even just walking around the room."

In addition, lactic acid does not cause muscle soreness, fatigue or the "burn" of intensive exercise, noted Anderson. His comments and those of Lowe are backed by valid scientific research. Several studies conducted in the 1980s by exercise physiologist Dr. George A. Brooks ushered in a new perspective on this supposed "demon." Brooks noted that lactic acid is a key substance for providing energy, disposing dietary carbohydrate, producing blood glucose and liver glycogen and promoting survival in stress situations.1


Nature's Magic Tricks
Just as the body's intelligence keeps our hearts pumping and our intestines digesting without any intervention on our part, in like manner it maintains the chemical process of glycolysis to provide energy on a 24-hour basis. In Anderson's book, Lactate Lift-off, he writes, "Glycolysis is actually a series of 10 different chemical reactions...that break down glucose, the simple six-carbon sugar which is your body's most important source of carbohydrate fuel, into something called pyruvic acid."2 From pyruvic acid, with the help of the enzyme lactate dehydrogenase, we get lactic acid. But it's not quite that simple.

The process of glycolysis converts each glucose molecule into two pyruvic acid molecules, releasing energy in the form of adenosine triphosphate (ATP). From there, pyruvic acid enters the mitochondria, where more ATP is produced through the Krebs cycle.3 "In addition to 'handling' the pyruvic acid produced from glucose," states Anderson, "the Krebs cycle also metabolizes fats, over all, it furnishes more than 90 percent of the energy you need to exercise in a sustained manner."4

As exercise intensity increases, glycolysis speeds up and pyruvic acid is produced at an increasing rate. When it can no longer be processed through the Krebs cycle as quickly as it is generated, some of the pyruvic acid is converted to lactic acid, which rapidly dissociates into a lactate anion and a free hydrogen ion (H+). Lactate can then be quickly transported from the muscle into the blood, where it is circulated throughout the body. If an excessive amount of pyruvic acid were allowed to build up, glycolysis would come to a halt, thus blocking energy production. The conversion to lactic acid allows the body to continue its exertion of energy. Once the lactate enters other tissues, it can be converted to pyruvate, which is processed by the Krebs cycle into ATP for even more energy. Lactate can also be converted by the liver and other tissues into glucose, boosting depleted stores of glycogen needed for future activity.5,6,7

Although the focus here is to examine excessive lactic acid accumulation during intensive activity, it's important to clarify that lactic acid production is a normal and continuous part of the body's energy cycle. According to Anderson, lactate is produced even at rest and "...its concentrations can rise rather dramatically whenever you take in a carbohydrate-containing meal." Lactate plays an important role in processing carbohydrate and facilitating its availability to the liver and muscles.8

Lactic acid reaches excessive levels when the body can no longer clear it as quickly as it is being produced. "When you begin a moderate to difficult workout," states Anderson, "lactate levels in your blood initially rise, simply because glycolysis is working away to provide quite a bit of the energy you require." At this point, there is minimal blood and oxygen flow to the muscles. This limits the breakdown of pyruvate in the Krebs cycle and increases its conversion to lactate. With continued activity, heart rate increases and oxygen becomes more readily available to the muscle cells, allowing pyruvate and lactate to be oxidized for energy. The entry and exit rates of lactate then become stabilized and will remain so even with gradually intensified activity.9

"However," states Anderson, "once you get up to a point (actually a speed) at which glycolysis is tearing along so fast that your leg muscles have problems converting most of the pyruvate and lactate being formed to carbon dioxide and water, the lactate-spilling process may accelerate so much that lactate levels in the blood may really begin to lift off." This can be a result of oxygen debt inside the muscle cell, inadequate concentrations of enzymes necessary for oxidation at high rates or a lack of sufficient cell-mitochondria, where the Krebs cycle takes place. The point at which this occurs is referred to as the lactate threshold (LT). According to Anderson, the LT is simply an indicator of how effectively your tissues utilize lactate as an energy source. For athletes, a high LT means increased endurance - the longer the athlete can perform before reaching this point, the longer lactate production and extraction is kept in balance and energy is maintained.10

At the completion of exercise, lactate levels will return to normal within 30-60 minutes, being quickly converted back to pyruvate or glucose.11 Research supports the claim that active recovery (light exercise) is the most effective approach to speed up this process,12,13 and that massage is no more effective than passive rest.14 This does not discount other potential benefits of massage in sports recovery. A study by Monedero and Donne showed while active recovery proved best in removing lactic acid, a combined approach (active recovery and massage) did increase recovery rate during short intervals between maximal efforts and was most efficient for maintaining maximal performance time in subsequent performance. Recovery rate was determined by blood lactate levels and heart rate during recovery, and performance times in tests of maximal efforts.15

For post-exercise recovery, Anderson recommends a cool-down of about 10 minutes or running a few miles followed by stretching and strengthening exercises, nutrition (carbohydrates) to restock energy and a good night's sleep. Improving the body's ability to break down pyruvate, use oxygen and extract lactate from the muscle during activity will raise the LT and increase an athlete's endurance. This can be accomplished with proper training, such as methods recommended in Lactate Lift-off.16 An effective training approach can increase the supply of mitochondria, enzymes and capillaries needed to enhance the body's ability to rapidly use lactate as an energy source.17


Soreness, Fatigue and the 'Burn'
Is lactic acid to blame? "There has been a strong suggestion," said Lowe, "that delayed onset muscle soreness (DOMS) occurring 12-24 hours after exercise is caused by excess levels of lactic acid, but the onset of soreness does not at all coincide with the levels of lactic acid. This is still a very rampant misconception."

Anderson indicates there are two likely causes of muscle soreness: tears in the muscle associated with the stress of exercise and free radical attack on the muscle membranes. According to physician Dr. Gabe Mirkin,"Next-day muscle soreness is caused by damage to the muscle fibers themselves. Muscle biopsies taken on the day after exercising show bleeding and disruption of the z-band filaments that hold the fibers together as they slide over each other during a contraction." Mirkin suggests ceasing exercise when muscles start to burn and hurt as this is likely an indication that DOMS will occur.18

The free hydrogen ions produced in dissociation of lactic acid can present a problem. Biscarbonate buffers H+ to maintain homeostasis in pH, but an increase of H+ during intensive exercise can overwhelm the buffering system, resulting in acidity (low pH) of muscle and blood. If the pH goes below 7.00, the athlete may experience nausea, headache, dizziness and pain in the muscles. But with cessation of exercise the pH, like lactate, returns to normal.19 "The muscle will slow down if there is a great enough lowering of pH," said Anderson, "and this may cause fatigue." He noted there can be a lowering of pH in muscles even while sedentary. "We don't know if it can cause burn," he added, "but burn is the nervous system's way of telling you you're exercising at too high intensity and you need to cut back. There is nothing wrong. It's just a message."

Heavy legs or fatigue can occur in an all-out sprint, said Anderson, but if it occurs at the 20-mile point in a marathon, it's a sign the muscles are running out of energy. To combat these problems, Anderson emphasizes the importance of training. "If you are really strong," he said, "you have less stress and damage."


So What About Massage?
Although the effectiveness of massage to flush out lactic acid after exercise has been disproven, there are benefits to validate its use in sports. "In my own experience," said Keith Grant, head of Sports and Deep Tissue Massage Department at McKinnon Institute, "I've seen that massage is effective. How our body reacts to things depends on both the state our body is in (state of memory), as well as the input." Grant combines his knowledge as a scientist with personal experience as a massage instructor and runner to support his conclusions.

Pointing to a study by Tiitus and Shoemaker (1995) in which effleurage did not increase local blood flow, Grant said, "This is a mechanistic way of looking at what's going on." The difficulty, he noted, in interpreting research results comes from looking for direct, mechanical effects. "Clinically, we see a different story," he said. "Through our techniques we work with the nervous system to relax muscles, but that's not a direct mechanical effect. "I believe the effects of massage also involve the neurological and emotional. My reason for that is the neurological side controls the current (base) state of the muscle activation. The emotional controls the chemical messengers that affect the immune system. What seems likely is massage acts as a new input to a system with a memory. Massage stimulates the mechanoreceptors and can gate off pain receptors. It floods the body with new sensory input. We are using the nervous system to reset the muscle to greater relaxation.

"In my observation, fatigued muscles tend to remain hypertonic and shortened. When we cajole specific muscles to relax and lengthen via mechanical and neurological input, we reduce their metabolic activity. When the muscle relaxes, it's not using energy as much, not metabolizing as fast, not producing waste products and because it's more relaxed, it's not compressed and not exerting pressure on surrounding tissues. This means circulation is better. It's not because we're pushing fluid around. It's because we've put the body in a more optimum state, so the body naturally increases circulation on it's own. By massaging muscles and adding input to the nervous system, we are facilitating the body in recovering faster from exercise. It's not the massage that's doing the healing, it's the person's body."

In a British study of boxers, massage was reported to have a significantly positive effect on perception of recovery, giving scientific credence of its benefits as a recovery strategy. According to the authors, their results support arguments by some researchers that "the benefits of massage (in sports recovery) are more psychological than physiological."20 Grant takes that a step farther. "As a trained scientist, I use what I observe and what I know about physiology to come with a hypothesis. From my own experience in running, when you exert to the point of substantial fatigue, you come back feeling more fragile, in an emotionally vulnerable spot. To have the sense that someone is nurturing, in a sense taking care of you, is a very psychologically emotional thing. In supporting the person, we improve their immune function and their ability to heal, by influencing the chemical environment of their body. It has to do with psychoneuroimmunology, the whole chemical homeostasis of their body -- neurochemicals and the relationship between mood, or feelings, and the immune system.

"There is some evidence that following heavy exercise, both L-glutamine (an amino acid manufactured by the body) and the immune system take a dip. I look at the healing effect of massage as, in some way, counteracting that dip. When you provide support it has a positive effect on immune function. If the person doesn't feel supported and nurtured, it will have a negative effect on the chemical environment, opening them more to catching colds, not healing as fast and decreasing their ability to train. It ties into the whole emotional state of a person. The athlete has to stay healthy in order to continue training. With massage, they can train harder because they are able to recover faster."


Facts vs. Myths
Remember the old theory about the earth being flat? The more we learn, the more we realize how much we don't know. That's why research in massage is so important. "These concepts and ideas are firmly entrenched in our early training, and in the medical profession, said Lowe. "Things that have been disproved continue to persist. It takes a long time to trickle down. If we say there is no research that supports massage works for inflammation, there may not be research - or it may not be true. We don't really know yet and we need to investigate that further. This lactic acid concept illustrates the perpetuation of misinformation that can happen if we don't have the research base. When we are looking for credibility with others in health care, they want to know on what we base our opinions. A lot is passed along on hearsay, not on scientific information. What we need to keep our eyes on is how to reduce that as much as possible so we do have accurate information."

Shirley Vanderbilt is a staff writer for Massage & Bodywork magazine.





References
1. Vannatta, Dan. "Lactic Acid: Friend or Foe?" http://sportsmedicine.about.com/library/weekly/aa053101a.htm.
2. Anderson, Owen, Lactate Lift-off (Lansing, Mich.: SSS Publishing, 1998),16.
3. Vannatta.
4. Anderson, 16.
5. Vannatta.
6. Anderson, 16-24.
7. Grant, Keith. "Lactating Mythers." www.mckinnonmassage.com/articles/lactating_mythers.html.
8. Anderson, 20-21.
9. Ibid., 25-26.
10. Ibid., 26-30.
11. Grant.
12. Ibid.
13. Vannatta.
14. Hemmings, B., Smith, M., Graydon, G. and Dyson, R., "Effects of massage on physiological restoration, perceived recovery, and repeated sports performance," British Journal of Sports Medicine 34 (2000): 113.
15. Monedero, J. and Donne, B., "Effect of recovery interventions on lactate removal and subsequent performance," International J. of Sports Medicine 21, 8 (Nov. 2000): 593-597.
16. Anderson, 30-35.
17. Grant.
18. Mirkin, Gabe. "What causes muscle soreness?" Report #6386. www.drmirkin.com/archive/6386.html.
19. Grant.
20. Hemmings, 113.