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Therapeutic choices in the locomotor management of the child with cerebral palsy—more luck than judgement?
  1. J H Patrick,
  2. A P Roberts,
  3. G F Cole
  1. Orthotic Research & Locomotor Assessment Unit (ORLAU), Robert Jones & Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire SY10 7AG, UK
  1. Dr G F Cole, Shropshire's Community & Mental Health Services NHS Trust, Children's Services Directorate, Cross Houses Site, Shrewsbury SY5 6JN, UKgaynor.cole{at}shropcomm.wmids.nhs.uk

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In the past 15 years or so our understanding of many aspects of cerebral palsy has significantly broadened. Traditional concepts regarding aetiology have been radically challenged, and we now acknowledge that “birth asphyxia”, once felt to be implicated in the majority of cases, has a causative role in approximately 10–15% of cases.1 Antenatal factors are recognised as having a predominant aetiological role; newer techniques in neuroimaging, progress in exploring homeobox genes, and other developments, have supported this view.2 ,3

Therapeutic nihilism, once prevalent in this field, has fortunately receded with the development of an array of new antiepileptic drugs for children with refractory seizures (seen so often in the child with cerebral palsy), and the enthusiastic application of new feeding techniques has done much to improve the nutritional status and well being of these children.4

Newer techniques have also been employed in the management of locomotor impairment and although the benefits conferred by certain treatments are clear, other management options are more controversial. A variety of treatments have been developed in recent years; in addition to conventional orthopaedic surgery and physiotherapy (usually based on Bobath techniques in this country), multilevel surgery,5 ,6 intramuscular botulinum injections,7 selective dorsal rhizotomy (SDR),8 intrathecal baclofen (ITB),9 targeted training,10 and sophisticated orthoses11 all have their advocates. Less orthodox strategies too, such as hyperbaric oxygen, cranial osteopathy, and lycra suits,12 have also been in vogue. In short, confusion abounds.

Cerebral palsy is a heterogeneous condition; one may, therefore, legitimately argue that its management should be highly individualised. For professionals in the field, however, there is a plethora of choice, but a paucity of guidelines. The familiar leitmotif here is: Which child? Which treatment? Although there may be some debate concerning optimum treatment in the …

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