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presents: presents: A Neuro-Endocrine Approach to A Neuro-Endocrine Approach to The Obstetric and Pediatric The Obstetric and Pediatric Applications Applications of Tactile-Kinesthetic Stimulation of Tactile-Kinesthetic Stimulation Therapy Therapy questions/complaints: [email protected] slide show: www.uvm.edu/~jstaylor/TKST.ppt notes and citations: www.uvm.edu/~jstaylor/TKST.doc

Steele Taylor presents: A Neuro-Endocrine Approach to The Obstetric and Pediatric Applications of Tactile-Kinesthetic Stimulation Therapy questions/complaints:

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Steele TaylorSteele Taylorpresents:presents:

A Neuro-Endocrine Approach to A Neuro-Endocrine Approach to The Obstetric and Pediatric The Obstetric and Pediatric

ApplicationsApplicationsof Tactile-Kinesthetic Stimulation of Tactile-Kinesthetic Stimulation

TherapyTherapy

questions/complaints: [email protected] show: www.uvm.edu/~jstaylor/TKST.ppt

notes and citations: www.uvm.edu/~jstaylor/TKST.doc

The Touch Research InstituteThe Touch Research Institute

• Research designs explore the following benefits that might be derived from Research designs explore the following benefits that might be derived from massage:massage:– Alleviation of depression and anxietyAlleviation of depression and anxiety– Improved quality of sleepImproved quality of sleep– Pain reduction on neurological and soft-tissue levelsPain reduction on neurological and soft-tissue levels– Prevention of premature deliveryPrevention of premature delivery– Weight gain and cognitive/behavioral advances in premature infantsWeight gain and cognitive/behavioral advances in premature infants– Improved immune function and reduction of symptoms in auto-immune disordersImproved immune function and reduction of symptoms in auto-immune disorders– Alleviation of eating disorders and dissonant body-perceptionsAlleviation of eating disorders and dissonant body-perceptions– Reduced anxiety and sense of empowerment in the practitioner or parentReduced anxiety and sense of empowerment in the practitioner or parent– Improved social dynamic between practitioner and recipient (mother-infant, etc.)Improved social dynamic between practitioner and recipient (mother-infant, etc.)

• Studies that compare massage to general relaxation methods demonstrate that Studies that compare massage to general relaxation methods demonstrate that tactile-kinesthetictactile-kinesthetic pathwayspathways are somehow involved to produce an effect that is are somehow involved to produce an effect that is beyond that of relaxationbeyond that of relaxation

• Inadequate elucidation of the physiological underpinnings, yet valuable information such as changes Inadequate elucidation of the physiological underpinnings, yet valuable information such as changes in hormone and neurotransmitter levels in response to massage so that outsiders may produce their in hormone and neurotransmitter levels in response to massage so that outsiders may produce their own hypotheses and interpretations as to the underlying mechanismsown hypotheses and interpretations as to the underlying mechanisms

http://www.miami.edu/touch-research/ http://www6.miami.edu/touch-research/research.htm

Some Complicating Endocrine Some Complicating Endocrine ConsiderationsConsiderations• Receptor Type+Expression+Signal Cascades Determine the Receptor Type+Expression+Signal Cascades Determine the

ResponseResponse– Selective Estrogen Receptor ModulationSelective Estrogen Receptor Modulation– Cardiovascular Epinephrine ReceptorsCardiovascular Epinephrine Receptors

• Duration of the Signal Can Alter Feedback and ResponseDuration of the Signal Can Alter Feedback and Response– Estrogen feedback to hypothalamus becomes positive to initiate ovulationEstrogen feedback to hypothalamus becomes positive to initiate ovulation– Clearance of steroid hormonesClearance of steroid hormones

• Genomic Versus Non-Genomic EffectsGenomic Versus Non-Genomic Effects– Non-genomic: Open/ close ion channels, activate/deactivate enzymes, perform Non-genomic: Open/ close ion channels, activate/deactivate enzymes, perform

exocytosisexocytosis– Genomic: protein synthesis, cellular proliferation, cellular differentiationGenomic: protein synthesis, cellular proliferation, cellular differentiation

• Inter-Hormonal InteractionsInter-Hormonal Interactions– Glucocorticoid (GC) permissive effects @ epinephrine binding sitesGlucocorticoid (GC) permissive effects @ epinephrine binding sites– Action of estriol to influence oxytocin receptor expression during parturitionAction of estriol to influence oxytocin receptor expression during parturition

• Temporary Endocrine GlandsTemporary Endocrine Glands– Fetal-Placental unit: substrates, precursors, active hormonesFetal-Placental unit: substrates, precursors, active hormones– Levels are difficult to measure because activity is primarily localLevels are difficult to measure because activity is primarily local

• Behavioral/Environmental ActivatorsBehavioral/Environmental Activators– Stress responses and coping behaviorsStress responses and coping behaviors– Placebo and somatoform phenomenaPlacebo and somatoform phenomena

• Endocrine Regulation of Brain/BehaviorEndocrine Regulation of Brain/Behavior– Thyroid, Adrenal Cortex, and Gonads profoundly impact brain development and Thyroid, Adrenal Cortex, and Gonads profoundly impact brain development and

functionfunction– Might be considered as peripheral-diffuse-modulatory-systemsMight be considered as peripheral-diffuse-modulatory-systems– Adipose, GI, and other tissues also hormonally regulate behaviorAdipose, GI, and other tissues also hormonally regulate behavior

Obstetric/Pediatric Complications Obstetric/Pediatric Complications Treatable with Massage andTreatable with Massage and

Explainable via Neuro-Endocrine PrinciplesExplainable via Neuro-Endocrine Principles

1)1) Back Pain / general discomfort during pregnancyBack Pain / general discomfort during pregnancy2)2) Depression/anxiety/stress during and/or after pregnancyDepression/anxiety/stress during and/or after pregnancy3)3) Premature or low birth weight deliveryPremature or low birth weight delivery

Alex Grey www.alexgrey.com

Pain During Pregnancy:Pain During Pregnancy:• Back pain affects over half of all pregnant women and may Back pain affects over half of all pregnant women and may

significantly impact outlook, mood, daily activities, and significantly impact outlook, mood, daily activities, and sleepsleep

• Back Pain: Two TypesBack Pain: Two Types

1)1) Lower BackLower Back

• Center of gravity moves anteriorlyCenter of gravity moves anteriorly

• Loss of abdominal toneLoss of abdominal tone→ lumbar lordosis and spasm→ lumbar lordosis and spasm

• Increased pressure on intervertebral discsIncreased pressure on intervertebral discs

2)2) PelvicPelvic

• Relaxin - induced softening of pelvic ligaments and Relaxin - induced softening of pelvic ligaments and pubic symphysis to produce pelvic wideningpubic symphysis to produce pelvic widening• Crucial for successful delivery, not very convenient Crucial for successful delivery, not very convenient

otherwiseotherwise• Walking, lifting, rotating can become painfulWalking, lifting, rotating can become painful

• Referred pain from inferior vena cavaReferred pain from inferior vena cava• Proper positioning to alleviate pressureProper positioning to alleviate pressure

Mechanisms of Referred Mechanisms of Referred PainPain

• Visceral and cutaneous nociceptor Visceral and cutaneous nociceptor axons converge on the same axons converge on the same interneurons in the spinal cordinterneurons in the spinal cord

• Signal becomes mixed and visceral Signal becomes mixed and visceral pain is perceived as cutaneouspain is perceived as cutaneous

• Important warning sign/diagnostic Important warning sign/diagnostic tooltool

• Angina pectoralis is the classic Angina pectoralis is the classic exampleexample

• During pregnancy, pressure on the During pregnancy, pressure on the inferior vena cava produces inferior vena cava produces referrals to the pelvic region and referrals to the pelvic region and lower backlower back– Immediate relief: positioning (left-Immediate relief: positioning (left-

side-lying)side-lying)– Long term relief: yoga, chi gung, etc.Long term relief: yoga, chi gung, etc.– Ultimate relief: delivery!Ultimate relief: delivery!

http://www.mona.uwi.edu/fpas/courses/physiology/neurophysiology/ReferredPainMech.gif

Pain Regulation in the Spinal Cord:Pain Regulation in the Spinal Cord:The Gate TheoryThe Gate Theory

• Cutaneous nociceptors (pain) and Cutaneous nociceptors (pain) and mechanoreceptors (touch, mechanoreceptors (touch, pressure) interact with ‘gating’ pressure) interact with ‘gating’ interneurons in the dorsal hornsinterneurons in the dorsal horns

• Mechanical stimulation at the site Mechanical stimulation at the site of pain may override/inhibit the of pain may override/inhibit the projection of a pain signal up the projection of a pain signal up the spinothalamic tractspinothalamic tract– Instinctively rubbing/compressing Instinctively rubbing/compressing

bruised tissuebruised tissue– Broad gliding, friction, and Broad gliding, friction, and

vibrating massage strokesvibrating massage strokes

www.burtonreport.com/images/GateTheory432GIF.gif

http://www.nursece.com/onlinecourses/imagesPain/Fig2.gif

Pain Regulation in the Brain:Pain Regulation in the Brain:The Mother’s Kiss and Placebo The Mother’s Kiss and Placebo

MechanismsMechanisms

• Cross-talk occurs between higher emotional regions, ascending pain-signals, ascending pressure signals, pain-localization regions, Cross-talk occurs between higher emotional regions, ascending pain-signals, ascending pressure signals, pain-localization regions, pain-anticipatory and avoidance regions, analgesia anticipatory regions (placebo regulators), and pain regulating pathwayspain-anticipatory and avoidance regions, analgesia anticipatory regions (placebo regulators), and pain regulating pathways

• Emotional status powerfully influences the degree of pain that is perceivedEmotional status powerfully influences the degree of pain that is perceived

• Sympathetically maintained pain = centrally produced hyperalgesiaSympathetically maintained pain = centrally produced hyperalgesia– Nociceptors become sensitive to and activated by norepinephrine due to prolonged exposureNociceptors become sensitive to and activated by norepinephrine due to prolonged exposure

• Periaqueductal gray matter (PAG) of the midbrain, appears to be a critical mechanism in pain regulation, and may be innervated by Periaqueductal gray matter (PAG) of the midbrain, appears to be a critical mechanism in pain regulation, and may be innervated by endorphin producing neurons of the hypothalamus, as well as other regionsendorphin producing neurons of the hypothalamus, as well as other regions– Electrical stimulation of the PAG produces remarkable analgesic effectsElectrical stimulation of the PAG produces remarkable analgesic effects– Top-Down Effect:Top-Down Effect: PAG activates serotonergic cells in the rostral ventral medial nuclei (RVM) of the brainstem, which projects PAG activates serotonergic cells in the rostral ventral medial nuclei (RVM) of the brainstem, which projects

axons down the spinal cord that can effectively stifle pain signalsaxons down the spinal cord that can effectively stifle pain signals

• Distracting tasks are highly effective analgesic toolsDistracting tasks are highly effective analgesic tools– Lamaze breathing, visualization, massage, otherLamaze breathing, visualization, massage, other

http://www.annkullberg.com/Shows/2003/Hild.jpg

http://www.sciencemag.org/cgi/content/full/288/5472/1769

Pain Regulation at the Soft Tissue Pain Regulation at the Soft Tissue LevelLevel

• Muscle tightness/spasm may compress nerves or obstruct vascular supplyMuscle tightness/spasm may compress nerves or obstruct vascular supply

• Hypoxia / ischemia triggers pain pathways via vascular signals and irritating waste products from anaerobic muscle metabolismHypoxia / ischemia triggers pain pathways via vascular signals and irritating waste products from anaerobic muscle metabolism– Inflammation may also occur as a result, causing local hyperalgesiaInflammation may also occur as a result, causing local hyperalgesia

• Massage therapy shuts off spasm/holding patterns on a neurological levelMassage therapy shuts off spasm/holding patterns on a neurological level

• Golgi tendon organs reflexes inhibit muscle contractionGolgi tendon organs reflexes inhibit muscle contraction

• Disruption of holding patterns generated beneath the awareness of the brainDisruption of holding patterns generated beneath the awareness of the brain– Massage therapy improves local circulation thus alleviating local ischemiaMassage therapy improves local circulation thus alleviating local ischemia

• Performed gradually and over a series of treatments to avoid reperfusion injuryPerformed gradually and over a series of treatments to avoid reperfusion injury

• Massage, stretching, and strengthening all help to stabilize and maintain normal joint position and function, especially in the Massage, stretching, and strengthening all help to stabilize and maintain normal joint position and function, especially in the lower back and pelvic regionslower back and pelvic regions

www.amazingbirths.com/images/massage.jpg www.yogaretreats.ie/images/Nataraj2.jpgwww.yogaretreats.ie/images/Nataraj2.jpg

Potential Factors Promoting and Alleviating Potential Factors Promoting and Alleviating Stress During PregnancyStress During Pregnancy

STRESSORSTRESSOR1)1) Uncertainty, lack of control, Uncertainty, lack of control,

inadequacy (perceived): inadequacy (perceived): • labor (acute) labor (acute) • motherhood (perpetual)motherhood (perpetual)

2)2) Frustration: inability to Frustration: inability to perform tasks previously perform tasks previously capable of performingcapable of performing• Movement, consumption, Movement, consumption,

career, travel, etc.career, travel, etc.3)3) Environmental withdrawal Environmental withdrawal

and/or exposure to novel and/or exposure to novel settingssettings• Workplace withdrawal, new Workplace withdrawal, new

dwelling, new community, etc.dwelling, new community, etc.4)4) Social withdrawal, low social Social withdrawal, low social

support, novel social settingssupport, novel social settings• Spouse/father, family, friends, Spouse/father, family, friends,

colleaguescolleagues5)5) Pain and discomfortPain and discomfort

COUNTER-STRESSORCOUNTER-STRESSOR1)1) Gain mastery of situationGain mastery of situation

• Education, planning, birthing Education, planning, birthing classes, strategizing, networking, classes, strategizing, networking, nesting, etc.nesting, etc.

2)2) Find new rewarding tasks, future Find new rewarding tasks, future oriented versus prisoner of the oriented versus prisoner of the pastpast• Walking, yoga, swimming, etc.Walking, yoga, swimming, etc.• Consume flavorful, colorful, and Consume flavorful, colorful, and

intriguing foods and beverages: intriguing foods and beverages: 3)3) Embrace and network in new env.Embrace and network in new env.

• Nesting behavior: prepare Nesting behavior: prepare dwelling for amazing new dwelling for amazing new occupantoccupant

4)4) Embrace and pursue supportive/ Embrace and pursue supportive/ rewarding relationshipsrewarding relationships• Fetus, family, spouse, friends with Fetus, family, spouse, friends with

childrenchildren5)5) Go Shopping…Go Shopping…

Psychoendocrinological research cites the following factors as activators and deactivators of stress responses, Psychoendocrinological research cites the following factors as activators and deactivators of stress responses, as determined by GC levels, skin conductance response, sympathoadrenal activity, etc. as determined by GC levels, skin conductance response, sympathoadrenal activity, etc.

(many of these stimuli/stressors are non-removable and beyond our scope as health (many of these stimuli/stressors are non-removable and beyond our scope as health care practitioners…treatment must occur on the level of adaptation and coping)care practitioners…treatment must occur on the level of adaptation and coping)

Fetal Consequences of Traditionally Fetal Consequences of Traditionally Prescribed Prescribed

Anti-Depressant and Anxiolytic AgentsAnti-Depressant and Anxiolytic Agents• Benefits/risks must be weighed before use during pregnancyBenefits/risks must be weighed before use during pregnancy• Tricyclic antidepressants, SSRI’s, MAOI’s, benzodiazepenes, etc.Tricyclic antidepressants, SSRI’s, MAOI’s, benzodiazepenes, etc.• Most are not likely teratogens, yet most are grade C or lower and cross Most are not likely teratogens, yet most are grade C or lower and cross

placentaplacenta• Neonatal-withdrawal is a common result of fetal exposureNeonatal-withdrawal is a common result of fetal exposure

– Inconsolable crying, irritability, feeding difficulties, tachycardia, blood sugar Inconsolable crying, irritability, feeding difficulties, tachycardia, blood sugar abnormalitiesabnormalities

– May last weeks to monthsMay last weeks to months• Tricyclic antidepressants: Grade B-DTricyclic antidepressants: Grade B-D

– Growth Malformations (imipramine, amitriptyline and relatives)Growth Malformations (imipramine, amitriptyline and relatives)– Neonatal WithdrawalNeonatal Withdrawal

• MAOI’s: Grade CMAOI’s: Grade C– Growth Malformations (tranylcypromine, isocarboxazid)Growth Malformations (tranylcypromine, isocarboxazid)

• SSRI’s: Grade B (fluoxetine, sertraline, etc.), C (fluvoxamine)SSRI’s: Grade B (fluoxetine, sertraline, etc.), C (fluvoxamine)– More research necessary, caution recommendedMore research necessary, caution recommended

• Benzodiazepenes: Grade DBenzodiazepenes: Grade D– Neonatal Withdrawal SymptomsNeonatal Withdrawal Symptoms– Cleft-Palate and other malformations (diazepam, chlordiazepoxide)Cleft-Palate and other malformations (diazepam, chlordiazepoxide)

• Barbiturates: just don’tBarbiturates: just don’t– May be necessary if severe epilepsy or severe anxiety prior to laborMay be necessary if severe epilepsy or severe anxiety prior to labor– Minor congenital defectsMinor congenital defects– Fetal hemorrhageFetal hemorrhage– Neonatal withdrawalNeonatal withdrawal

General Adaptation Syndrome ModelGeneral Adaptation Syndrome Model

AlarmAlarm → → MaintenanceMaintenance →→

ExhaustionExhaustion

SympathoadrenSympathoadrenal Activational Activation

• (Occurs via brainstem and (Occurs via brainstem and amygdala input to amygdala input to hypothalamus)hypothalamus)

• Glycogenolysis and Glycogenolysis and gluconeogenesis (without gluconeogenesis (without muscle proteolysis)muscle proteolysis)

• Increased heart rateIncreased heart rate

• Shunting of blood to brain, Shunting of blood to brain, lungs, and skeletal musclelungs, and skeletal muscle

• Bronchial dilationBronchial dilation

• Inhibition of enteric Inhibition of enteric division of ANSdivision of ANS

• Pupil dilationPupil dilation

Glucocorticoid Glucocorticoid ActivationActivation

• Sustained catecholamine Sustained catecholamine actionaction

• Continued gluconeogenesis Continued gluconeogenesis with additional muscle with additional muscle proteolysisproteolysis

• Continued lipolysisContinued lipolysis

• Reduced inflammationReduced inflammation

•(stabilize lysosomal (stabilize lysosomal membranes)membranes)

•(inhibit leukocyte migration (inhibit leukocyte migration to affected tissue)to affected tissue)

• Behavioral/emotional Behavioral/emotional adaptationsadaptations

Prolonged Prolonged Exposure Exposure

(Or inability to either accept (Or inability to either accept (habituate/cope) or take (habituate/cope) or take control over a non-control over a non-removable stimuli)removable stimuli)

• Muscle wastingMuscle wasting

• Hyperglycemia and Hyperglycemia and diabetogenesisdiabetogenesis

•Immuno-atrophyImmuno-atrophy

•Vascular derangementVascular derangement

• GI ulcerationsGI ulcerations

•Depression / anxietyDepression / anxiety

• Excess/inappropriate Excess/inappropriate sympathoadrenal activationsympathoadrenal activation

•PolyuriaPolyuria

• Hippocampal atrophyHippocampal atrophy

• Gonadal suppressionGonadal suppression

Factors Promoting Excess GC Factors Promoting Excess GC OutputOutput

• GC’s are a reliable indicator of the degree of stress that is experienced GC’s are a reliable indicator of the degree of stress that is experienced by the organism in environmental settingsby the organism in environmental settings

• Prolonged exposure and/or failure to cope will produce over-stimulation Prolonged exposure and/or failure to cope will produce over-stimulation of the hypothalamic-pituitary-adrenal axisof the hypothalamic-pituitary-adrenal axis

• GC’s are lipid soluble and readily diffused across blood-brain-barrierGC’s are lipid soluble and readily diffused across blood-brain-barrier• Widespread receptors in brain account for GC’s ability to influence Widespread receptors in brain account for GC’s ability to influence

behaviorbehavior• Slow clearance from cerebrospinal fluid causes prolonged exposure in Slow clearance from cerebrospinal fluid causes prolonged exposure in

brain brain • Delicate feedback loop increases susceptibility to hypercortisolemiaDelicate feedback loop increases susceptibility to hypercortisolemia::

– Feedback regulation of hypothalamic CRH secretions is heavily dependent on Feedback regulation of hypothalamic CRH secretions is heavily dependent on inhibition from the hippocampus, which heavily expresses GC receptorsinhibition from the hippocampus, which heavily expresses GC receptors

– Ironically, although hippocampal cells rely on GC’s for their development, Ironically, although hippocampal cells rely on GC’s for their development, repeated exposure can cause hippocampal atrophy and apoptosisrepeated exposure can cause hippocampal atrophy and apoptosis

• Reduced feedback causes out of control GC production and vicious cycleReduced feedback causes out of control GC production and vicious cycle• Hypercortisolemia produces a cascade of physiological impairments and Hypercortisolemia produces a cascade of physiological impairments and

neurological/behavioral alterations as demonstrated on previous slideneurological/behavioral alterations as demonstrated on previous slide

• Infants born to depressed mothers tend to mimic the maternal Infants born to depressed mothers tend to mimic the maternal biochemical and physiological constitution, including elevated biochemical and physiological constitution, including elevated glucocorticoid levels, reduced serotonin and dopamine levels, and glucocorticoid levels, reduced serotonin and dopamine levels, and behavioral dysfunctionbehavioral dysfunction

Can Stress-Related Maternal Can Stress-Related Maternal Hypercortisolaemia Contribute to the Hypercortisolaemia Contribute to the

Premature Onset of Parturition?Premature Onset of Parturition?

• IF… IF… Stress and depression during pregnancy produce an Stress and depression during pregnancy produce an increased risk for increased risk for premature deliverypremature delivery, and associated , and associated complicationscomplications

• AND…AND… Massage therapy is a highly effective drug-free Massage therapy is a highly effective drug-free treatment for the alleviation of stress and depression treatment for the alleviation of stress and depression

• THEN…THEN… Regular massage during pregnancy can Regular massage during pregnancy can dramatically reduce the occurrence of premature delivery dramatically reduce the occurrence of premature delivery and associated complicationsand associated complications– To support this we must establish:To support this we must establish:

1)1)The role of stress hormones in the onset of parturitionThe role of stress hormones in the onset of parturition

2)2)The pathways through which massage may alleviate stress The pathways through which massage may alleviate stress hormone activityhormone activity

Endocrinology of ParturitionEndocrinology of Parturition

• Considerable evidence suggests that the fetal lungs and brain are Considerable evidence suggests that the fetal lungs and brain are responsible for the initiation of labor, and that children continue to control responsible for the initiation of labor, and that children continue to control their parents throughout life…their parents throughout life…

• Late in gestation, the fetal adrenal cortex grows considerably, and under Late in gestation, the fetal adrenal cortex grows considerably, and under the influence of the CRH-ACTH axis, produces large amounts of GC’s and the influence of the CRH-ACTH axis, produces large amounts of GC’s and DHEASDHEAS

– Fetal GC’s stimulate maturation of organs, particularly the lungsFetal GC’s stimulate maturation of organs, particularly the lungs– Fetal GC’s stimulate the placenta to increase the conversion of progesterone to Fetal GC’s stimulate the placenta to increase the conversion of progesterone to

estrogens, particularly to estriol or Eestrogens, particularly to estriol or E3 3 , ( the fetal adrenal supplies 90% of the , ( the fetal adrenal supplies 90% of the precursor: DHEAS)precursor: DHEAS)

– Estriol acts on the uterus to:Estriol acts on the uterus to:1)1) Increase the output of prostaglandins, which prime the contractile proteinsIncrease the output of prostaglandins, which prime the contractile proteins2)2) Promote the formation of gap junctions within the uterus, which help to effectively Promote the formation of gap junctions within the uterus, which help to effectively

coordinate expulsion of the fetuscoordinate expulsion of the fetus3)3) Promote the expression of oxytocin receptors, which help maintain contractionsPromote the expression of oxytocin receptors, which help maintain contractions4)4) Promote collagenase enzymes that ripen the cervix by degrading fibrous connective Promote collagenase enzymes that ripen the cervix by degrading fibrous connective

tissuetissue

– Oxytocin, normally antagonized by progesterone, can now operate on uterusOxytocin, normally antagonized by progesterone, can now operate on uterus• Positive feedback loop is generated as uterine proprioceptors prompt the release of more Positive feedback loop is generated as uterine proprioceptors prompt the release of more

oxytocinoxytocin

• Fetal protection from maternal glucocorticoids:Fetal protection from maternal glucocorticoids:– Placenta deactivates 85% before they reach fetusPlacenta deactivates 85% before they reach fetus– ALL fetal tissue expresses enzymes that deactivate maternal cortisolALL fetal tissue expresses enzymes that deactivate maternal cortisol

• (11-hydroxysteroid dehydrogenase)(11-hydroxysteroid dehydrogenase)

– Fetus maintains high levels of progesterone, which have a stronger binding Fetus maintains high levels of progesterone, which have a stronger binding affinity for GCR’saffinity for GCR’s

Preterm Labor EpidemiologyPreterm Labor Epidemiology

• Stress, depression, infection,Stress, depression, infection, preeclampsia,preeclampsia, fetal/placental hypoxia, diabetesfetal/placental hypoxia, diabetes, previous PTL, , previous PTL, anemia, hyperthyroidism, smoking, and acute emergency anemia, hyperthyroidism, smoking, and acute emergency conditions (hemorrhage, etc.) all contribute to PTLconditions (hemorrhage, etc.) all contribute to PTL

• In acute cases, it is contraindicated to prevent PTLIn acute cases, it is contraindicated to prevent PTL

• Preventative strategies should be observed by all women, Preventative strategies should be observed by all women, since only 50 % of PTL’s exhibit identifiable risk factorssince only 50 % of PTL’s exhibit identifiable risk factors

• USA has a higher PTL rate than most industrialized USA has a higher PTL rate than most industrialized countriescountries– Over 10% of pregnancies, with occurrence still risingOver 10% of pregnancies, with occurrence still rising– Responsible for 75% of neonatal morbidity and mortalityResponsible for 75% of neonatal morbidity and mortality– Neonatal Intensive Care = $5 billion annuallyNeonatal Intensive Care = $5 billion annually

• Emotional hardship, economic drain, long-term Emotional hardship, economic drain, long-term complicationscomplications

Preterm Labor OnsetPreterm Labor Onset

1)1) Infection (vaginal, uterine, intraamniotic)Infection (vaginal, uterine, intraamniotic)• May cause up to 30% of preterm deliveriesMay cause up to 30% of preterm deliveries• Cytokines released from leukocytes fighting infection may prompt prostaglandin Cytokines released from leukocytes fighting infection may prompt prostaglandin

(PG) release(PG) release• Bacterial phospholipases may also increase free PG levelsBacterial phospholipases may also increase free PG levels• Concurrent reduction in levels of PG dehydrogenase (PGDH), an enzyme that Concurrent reduction in levels of PG dehydrogenase (PGDH), an enzyme that

deactivates PG’s and that is normally maintained at high levels during gestationdeactivates PG’s and that is normally maintained at high levels during gestation• Glucocorticoids may also reduce the expression of PGDHGlucocorticoids may also reduce the expression of PGDH• Infection may ultimately be linked to general immunosuppression Infection may ultimately be linked to general immunosuppression

resulting from hypercortisolaemia associated with stress and resulting from hypercortisolaemia associated with stress and depressiondepression

2)2) Preeclampsia and Fetal-Placental HypoxiaPreeclampsia and Fetal-Placental Hypoxia• Fetal CRH increases which stimulates increase in placental CRHFetal CRH increases which stimulates increase in placental CRH• Placental CRH operates as a vasodilatorPlacental CRH operates as a vasodilator• If the attempt to restore blood flow fails, CRH stays highIf the attempt to restore blood flow fails, CRH stays high• Fetal adrenal response to CRH-ACTH triggers placenta to initiate laborFetal adrenal response to CRH-ACTH triggers placenta to initiate labor

3)3) Disruption of Feedback Systems From Chronic GC ExposureDisruption of Feedback Systems From Chronic GC Exposure

4)4) Other Adverse Fetal EnvironmentsOther Adverse Fetal Environments

Mechanisms Involved In Mechanisms Involved In Physiological Responses to Physiological Responses to

MassageMassage

• Tactile - kinesthetic pathways, including oral, apparently Tactile - kinesthetic pathways, including oral, apparently interact with the brain and particularly the hypothalamus to: interact with the brain and particularly the hypothalamus to: – Diminish stress responses and reduce mobilization of energy Diminish stress responses and reduce mobilization of energy

reservesreserves– Increase levels of serotonin, dopamine, and norepinephrineIncrease levels of serotonin, dopamine, and norepinephrine– Improve sleep patternsImprove sleep patterns– Shift relative EEG activity from right frontal cortex to left frontal Shift relative EEG activity from right frontal cortex to left frontal

cortexcortex– Activate pain-reduction pathways and reduce pain at its originsActivate pain-reduction pathways and reduce pain at its origins– Release growth-hormone releasing hormone (infants)Release growth-hormone releasing hormone (infants)– Strengthen vagal activityStrengthen vagal activity

• Improved gastric motilityImproved gastric motility

• Increased digestive and absorptive hormones such as gastrin and insulinIncreased digestive and absorptive hormones such as gastrin and insulin

• Reduce heart rateReduce heart rate

• Anatomical interactions between touch receptors and the Anatomical interactions between touch receptors and the hypothalamus via the thalamus and somatosensory cortex are hypothalamus via the thalamus and somatosensory cortex are necessary to enable such dramatic physiological alterationsnecessary to enable such dramatic physiological alterations

Tactile-Kinesthetic Stimulation Benefits viaTactile-Kinesthetic Stimulation Benefits via Nonnutritive Suckling, Kangaroo Care and Nonnutritive Suckling, Kangaroo Care and

MassageMassage

• Nonnutritive SucklingNonnutritive Suckling: the first coping mechanism (98% of NICU’s): the first coping mechanism (98% of NICU’s)– Powerful instinct upon birth also occurring in womb as early as 5 months Powerful instinct upon birth also occurring in womb as early as 5 months

gestationgestation– Analgesic effect reduces fussiness during painful proceduresAnalgesic effect reduces fussiness during painful procedures– Improved sleep patterns (REM), growth rates, and Improved sleep patterns (REM), growth rates, and shorter hospital staysshorter hospital stays

• Kangaroo CareKangaroo Care: tactile, kinesthetic, vestibular, and thermal stimulation : tactile, kinesthetic, vestibular, and thermal stimulation (97% of NICU’s)(97% of NICU’s)– Improved breastfeeding habits, reduced infections,Improved breastfeeding habits, reduced infections, andand shorter hospital shorter hospital

staysstays

• Massage TherapyMassage Therapy: Dynamic tactile – kinesthetic stimulation (39% of : Dynamic tactile – kinesthetic stimulation (39% of NICU’s)NICU’s)– Deeper pressure is important: light touch may be perceived as aversiveDeeper pressure is important: light touch may be perceived as aversive– Enhanced growth, social responsiveness, motor behavior, habituation, Enhanced growth, social responsiveness, motor behavior, habituation,

parental interaction, and parental interaction, and shorter hospital staysshorter hospital stays – (in rats, maternal tongue licking is essential for normal growth and behavior)(in rats, maternal tongue licking is essential for normal growth and behavior)

A Neonatal Massage Sequence A Neonatal Massage Sequence Utilized In A TRI Experimental Utilized In A TRI Experimental

DesignDesign• Experimenters treated 40 infants delivered on average 9 weeks preterm and Experimenters treated 40 infants delivered on average 9 weeks preterm and

having experienced 3 weeks of intensive care, weighing 2 lbs on average, and having experienced 3 weeks of intensive care, weighing 2 lbs on average, and free of congenital heart malformations, CNS disturbances, and other anomaliesfree of congenital heart malformations, CNS disturbances, and other anomalies

• Performed through portholes of incubatorPerformed through portholes of incubator• Procedure: 45 minutes for 10 days at 3 x 15 minute treatmentsProcedure: 45 minutes for 10 days at 3 x 15 minute treatments

– 5 minutes tactile stimulation5 minutes tactile stimulation– 5 minutes kinesthetic stimulation5 minutes kinesthetic stimulation– 5 minutes tactile stimulation5 minutes tactile stimulation

• Tactile stimulation: ProneTactile stimulation: Prone– From top of head to neck and back x 12From top of head to neck and back x 12– From neck across shoulders and back x 12From neck across shoulders and back x 12– From upper back to waist and back x 12From upper back to waist and back x 12– From hips to feet and back on both legs x 12From hips to feet and back on both legs x 12– From shoulders to the hands and back on both arms x 12From shoulders to the hands and back on both arms x 12

• Kinesthetic treatment: SupineKinesthetic treatment: Supine– Flexion / extension (bicycling) to individual arms and legs and then bothFlexion / extension (bicycling) to individual arms and legs and then both

• Results consistent with benefits listed on previous slideResults consistent with benefits listed on previous slide• Infants released from hospital on average 6 days earlier than control Infants released from hospital on average 6 days earlier than control

group!group!• Field T, Schanberg SM, ScafidiF et al 1986 Tactile / kinesthetic stimulation effects on preterm infants. Field T, Schanberg SM, ScafidiF et al 1986 Tactile / kinesthetic stimulation effects on preterm infants.

Originally published in Pediatrics 77: 654-658, Reproduced in Field T 2000 Touch Therapy. Edinburgh: Originally published in Pediatrics 77: 654-658, Reproduced in Field T 2000 Touch Therapy. Edinburgh: Churchill Livingston.Churchill Livingston.

ResourcesResources::• Bear MF, Connors BW & Paradiso MA 2007 Neuroscience: Bear MF, Connors BW & Paradiso MA 2007 Neuroscience:

Exploring the Brain. 3Exploring the Brain. 3rdrd edition. Philadelphia: Lippincott edition. Philadelphia: Lippincott Wilkins and Williams.Wilkins and Williams.

• Briggs GG, Freeman RK & Yaffe SJ 1998 Drugs in Pregnancy Briggs GG, Freeman RK & Yaffe SJ 1998 Drugs in Pregnancy and Lactation. 5and Lactation. 5thth edition. Baltimore: Williams and Wilkins. edition. Baltimore: Williams and Wilkins.

• Brush FR & Levine S 1989 Psychoendocrinology. San Diego: Brush FR & Levine S 1989 Psychoendocrinology. San Diego: Academic Press Inc. Academic Press Inc.

• Field T 2000 Touch Therapy. Edinburgh: Churchill Livingston.Field T 2000 Touch Therapy. Edinburgh: Churchill Livingston.• Field T 2003 Stimulation of Preterm Infants. Pediatrics in Field T 2003 Stimulation of Preterm Infants. Pediatrics in

Review. 2003;24:4-11. Hadley ME 2000 Endocrinology. 5Review. 2003;24:4-11. Hadley ME 2000 Endocrinology. 5thth edition. New Jersey: Prentice Halledition. New Jersey: Prentice Hall

• Gilbert ES 2007 Manual of High Risk Pregnancy and Delivery. Gilbert ES 2007 Manual of High Risk Pregnancy and Delivery. 44thth edition. St. Louis: Mosby Elsevier. edition. St. Louis: Mosby Elsevier.

• Karch AM 2006 Focus on Nursing Pharmacology. 3Karch AM 2006 Focus on Nursing Pharmacology. 3rdrd edition. edition. Philadelphia: Lippincott Wilkins and Williams.Philadelphia: Lippincott Wilkins and Williams.

• McMahon SB & Koltzenburg M 2006 Wall and Melzack’s McMahon SB & Koltzenburg M 2006 Wall and Melzack’s Textbook of Pain. 5Textbook of Pain. 5thth edition. Elsevier Churchill Livingston. edition. Elsevier Churchill Livingston.

• Tulchinsky D & Little AB 1994 Maternal – Fetal Endocrinology. Tulchinsky D & Little AB 1994 Maternal – Fetal Endocrinology. 22ndnd edition. Philadelphia: W.B. Saunders Company edition. Philadelphia: W.B. Saunders Company

• Van Praag HM, de Kloet R & van Os J 2004 Stress, the Brain Van Praag HM, de Kloet R & van Os J 2004 Stress, the Brain and Depression. Cambridge: Cambridge University Press.and Depression. Cambridge: Cambridge University Press.

How To Give a Good MassageHow To Give a Good MassageWithout Technical TrainingWithout Technical Training

• Tools and EquipmentTools and Equipment– Nutritive vegetable based lubricant (optional)Nutritive vegetable based lubricant (optional)– Table or chairTable or chair– Fingers, thumbs, knuckles, fists, palms, heels of hands, forearmsFingers, thumbs, knuckles, fists, palms, heels of hands, forearms

• CaveatsCaveats– No pressure to axilla, posterior popliteal, femoral triangle, anterior cervical No pressure to axilla, posterior popliteal, femoral triangle, anterior cervical

regionsregions– No pressure over bones, especially the spinous processesNo pressure over bones, especially the spinous processes

• PrinciplesPrinciples– Firm, consistent pressure that is gradually applied and removedFirm, consistent pressure that is gradually applied and removed– Rhythmic strokes and rockingRhythmic strokes and rocking– Circular strokesCircular strokes– Alternate between broad and specific strokesAlternate between broad and specific strokes– Avoid prolonged pressure or over-repetition of one particular strokeAvoid prolonged pressure or over-repetition of one particular stroke– Use muscle anatomy to trace muscles from origin to insertionUse muscle anatomy to trace muscles from origin to insertion– Experiment and have funExperiment and have fun

• Feel and stealFeel and steal– Receive professional massage and appropriate the strokes that you enjoyedReceive professional massage and appropriate the strokes that you enjoyed

Theoretical Sequence For Prenatal Theoretical Sequence For Prenatal TreatmentTreatment

Semi-Reclined: massage to head,neck, arms, legs, feet.

Table is either adjusted flat and client lies on side or client turns to a second table with a pregnancy recess for prone work.

Client hopes that somebody will come and massage them!

Table with recess for abdomen and breasts. Very comfortable during pregnancy.

Side-lying is excellent for work to the lateral aspects of the shoulder girdle and hips and is highly relaxing.

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