A randomised controlled trial on clinical effectiveness of massage therapy in multisensory environment for residents with severe and profound intellectual disabilities (SPID)

Abstract

Background: Institutional care is the major service provision for people with severe and profound intellectual disabilities due to their high dependence on activities of daily living and physical illness. The daily schedule is usually non-stimulating and monotonous, which can be the contributing factors of their challenging behaviour. The adverse consequences of challenging behaviour can induce physical injury to self, as well as others. As a result, physical isolation and social exclusion are inevitable. Eventually, quality of life of these intellectually disabled persons could be compromised due to markedly reduce access to the community and recreational facilities. Recent literature has suggested that relaxation activities could reduce their challenging behaviour contributed by the counteractive effect of muscle relaxation on psychological distress. Despite having inconclusive evidence, multisensory environment and massage therapy have been increasingly used to manage challenging behaviour. Aim: The aim of this study was to evaluate the clinical effectiveness of multisensory environment and massage therapy for residents with severe and profound intellectual disabilities in improving positive behaviour, and reducing the challenging behaviour through observations and non-invasive instrument as measuring tools. Methods: A randomised controlled trial with mixed methods design was conducted in a long-term care facility in Hong Kong to evaluate the effects of three intervention groups, i.e., multisensory environment, massage therapy and their combined use with a control group of usual care on reducing the challenging behaviour of residents with severe and profound intellectual disabilities. All eligible residents were recruited and then randomly assigned into one of the three treatment groups, or usual care only (n=31-34/group) for 10-week intervention after a one-month washout period. Outcome measures, including frequency and severity of challenging behaviour, adaptive and maladaptive behaviour, alertness level, and physiological data (heart and respiration rates), were assessed at recruitment, and immediately after the 10-week intervention. Carryover effects were also assessed two weeks after the completion of all intervention in the usual care environment. After completion of the quantitative study, a semi-structured interview was conducted for the primary nurses of the participants in the qualitative study. Their perceptions on the benefits and limitations of the interventions were explored to supplement the quantitative data as all participants were unable to express themselves. Results: A total of 129 participants (63 male and 66 female) completed the study. There were significant improvements in frequency and severity of challenging behaviour, respiration rate, amount and duration of adaptive behaviour, passive alert and sleepiness in the study groups. The primary outcomes, frequency and severity of challenging behaviour, showed significant change between groups, but unable to identify which group was more remarkable in pairwise comparison, probably due to insufficient sample size and homogeneous of the sample. Participants in the three intervention groups showed persistent reduction of respiration rate than the control group, especially in the multisensory environment and the combined treatment. Participants in massage therapy had significantly greater increases in their amount and duration of adaptive behaviour over 2-week follow-up than those in multisensory environment, and those in combined treatment; and they also showed greater reduction in sleepiness during and after the intervention. The massage therapy in multisensory environment demonstrated the most relaxed level in passive alert during the intervention, and massage therapy maintained its passive alert level after two week follow up. Overall, the within-group effects on most study outcomes were significant in the study. The perceptions of the nursing interviewees were very positive to the massage therapy and multisensory environment but commented the insufficient dose and duration of the interventions, especially the massage therapy. Nevertheless, they did not notice the gradual improvement of the participants in the frequency and severity of challenging behaviour. Conclusion: Generally, the therapeutic effect of massage therapy was more significant than multisensory environment and combined treatment, and able to sustain for 2 weeks. Though massage therapy had greatest magnitude of change in frequency and severity of challenging behaviour than other study groups, the significance level of pairwise contrast test was not substantiated. Hence, there is a need for additional strategies to enhance longer-term effects of massage therapy and multisensory environment in reducing challenging behaviour in the usual care environment. Brief mental exhaustion could be resulted due to overwhelming of sensory inputs in the multisensory environment; hence, there is a need for manipulation of dose and frequency of the treatment. The findings also indicated that the adaptive behaviour appeared to be associated with the alertness state. More research work is necessary to identify the potential predictive factors in order to improve the primary and secondary outcomes of these treatments for the residents.