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The treatment of gait problems in cerebral palsy
  1. R J Jefferson

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    Edited by James R Gage. Cambridge: Cambridge University Press, 2004, £85.00 (hardback with CD-ROM), pp 423. ISBN 1898683379

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    I settled down to read this book, thinking it would be instructive and enjoyable—and I was not disappointed. Basic principles are clearly explained in the text and are well illustrated with appropriate clinical examples and case studies, supplemented by the CD-ROM.

    Jim Gage is a master in the use of automated gait analysis to rationalise surgical decision making for children with walking disorders, and, with his wealth of experience, accumulated over more than 20 years, is a very appropriate editor for this volume. The clarity of his own thought processes is evident in his explanation of biomechanical principles applied to the complex dynamic gait problems encountered in children with cerebral palsy. A particular highlight is his chapter on the biomechanics of normal gait. His fellow contributors are all acknowledged experts in their own fields and complement his contributions well.

    The main focus is the correction of problems with gait and the text illustrates how gait analysis can provide clear insight into the safety and efficacy of potential surgical intervention. The book is divided into five sections. Early chapters cover the neuroanatomical, neurophysiological, and biomechanical background; further sections are devoted to patient assessment, gait pathology in cerebral palsy, treatment options including detailed discussion of orthopaedic surgery, and assessment of outcome. The role of the multi-disciplinary team is emphasised. The kinematics and kinetics of gait together with biomechanical modelling are covered in detail (and here the reader may just start to feel a little insecure in his knowledge of mathematics!).

    The chapters on treatment demonstrate the logical differentiation between the primary, fixed problem—that is, the neurological injury itself; the secondary biomechanical problems, resulting from abnormal growth forces, which are amenable to treatment; and the tertiary compensatory problems which do not require treatment per se. Patterns of gait pathology are discussed with specific attention to hemiplegia, di/quadriplegia, and crouch gait, and the respective surgical solutions. Illustrative case studies are included and the data on the CD-ROM facilitates correlation between the clinical picture and the kinematic plots. The treatment role of selective dorsal rhizotomy is carefully delineated. One chapter is devoted to non-operative treatment modalities including botulinum toxin and intrathecal baclofen. Perhaps the section on botulinum toxin could have been expanded in the light of its increasing popularity as a first line treatment for reduction of dynamic spasticity—I was a little disappointed that it received only a passing mention in the treatment of upper limb deformities in hemiplegia, although there was more discussion of its use in the lower limb.

    Although not all of us have access to a gait laboratory—and indeed it would not be appropriate to subject all our patients with gait disorders to complex gait analysis—clinical gait analysis is readily performed in most centres treating children with spasticity. Basic biomechanical principles are equally valid across the spectrum of gait analysis, whether planning botulinum toxin injections or multi-level orthopaedic surgery. This book ably expounds these principles and illustrates their application to specific case studies, representative of the most frequently encountered patient scenarios in clinical practice. The biomechanical rationale for the proposed treatment is explained, and the results are demonstrated from follow up studies. As such the clinician has a guide to refer to as he follows his own, sometimes uncharted, course. I suspect that I shall be dipping into it many times to refresh myself of the finer details as I manage the children in my own clinical practice.

    I thoroughly recommend it to anyone with even a superficial interest in the field—beware, you may find yourself more involved as a result!

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