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Physiotherapy for cerebral palsy

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Therapies can make people feel better and/or they can have specific measurable effects on the condition treated. The two effects do much to explain the conventional versus complementary or alternative medicine schism. A problem for conventional practitioners is that complementary/alternative practitioners often claim that their methods have the second type of effect when there is little or no evidence to show it and little or no sensible theory to suggest it possible. Nevertheless it can not be denied that making people feel better is a perfectly valid and necessary aim.  Physiotherapy for children with cerebral palsy is conventional and parents want it. Professionals promote it to the extent of describing “certain services or facilities” (including physiotherapy) as a “basic right” without “having to meet a strict test of effectiveness”.1 Now researchers in Southampton (Eva Bower and colleagues. Developmental Medicine and Child Neurology 2001;43:4–15) have tested two common beliefs: that more physiotherapy is better and that in providing it, precise objectives (goals) are better than general aims.  A total of 56 children aged 3–12 years with bilateral cerebral palsy (Gross Motor Function Classification System grade III, IV, or V) each had six months of study treatment from their own physiotherapist (56 physiotherapists: 54 “eclectic” and 2 Bobath). They were randomised to four groups: usual physiotherapy with general aims, usual physiotherapy with specific goals, intensive (1 hour/day Monday to Friday) physiotherapy with general aims, and intensive physiotherapy with specific goals. The main outcome measures were function (Gross Motor Function Measure) and performance (Gross Motor Performance Measure). Neither extra physiotherapy nor goal setting significantly influenced these outcomes although there was a trend towards better function after six months in the intensively treated children, which declined over the six months following the end of trial therapy. Almost all of the physiotherapists, and many of the parents, considered the intensive physiotherapy too tiring for themselves and the children.  It seems that this degree and type of intensive physiotherapy gives no measured advantage over standard provision and may be unacceptable. (The “routine” group received some 2 or 3 hours of physiotherapy a month and the “intensive” group around 15 hours a month; perhaps something in between would be better). A comparison of routine and intensive physiotherapy tells us nothing about the value of routine therapy but the question remains, is it the physiotherapy or the physiotherapist that patients and parents need? Martin Bax in an editorial (Ibid: 3) reasserts that “we must try and see provision of services and facilities as basic rights for children with disabilities”. It is difficult to disagree with that, but we are still free to ask, which services? which facilities?, and the answer must be, those that best provide for the needs of the children and their parents. Present decisions must depend on present knowledge and present circumstances but it ill behoves us to turn our backs on the principle of “strict tests of effectiveness”. That is where we (at least, those of us who haven't yet joined the bandwagon) part company with much of complementary or alternative medicine.


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