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Management of the motor disorders of children with cerebral palsy, 2nd edition
  1. S M Wallis

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    Edited by David Scrutton, Dianne Damiano, Margaret Mayston. Cambridge: Cambridge University Press, 2004, £50.00 (hardback), pp 191. ISBN 1-898-68332-8

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    There has been an interval of 20 years since publication of the first edition of this book, and this second edition reflects the progress in this field. David Scrutton has invited two colleagues, Dianne Damiano from the USA, and Margaret Mayston, originally from Australia to join him as editors, and together they have commissioned contributions from an international group of experts who reflect the current approach to care. The book is written primarily for therapists but there is much of value for paediatricians.

    The introduction describes current treatment dilemmas. In the past, physiotherapy programmes were based on philosophies of care. Modern management is based on clinical principles with a scientific rationale for their use. Evidence for their efficacy is emerging but remains sparse.

    The first chapter defines cerebral palsy and describes the various cerebral palsy syndromes, their correlation with MRI scan findings, and the concept of causal pathways. A wide range of descriptive terminology for cerebral palsy still exists which results in confusion, and more emphasis on areas of agreement would have been useful, such as that reached by collaboration between cerebral palsy registers.

    The broad principles of care are well covered. Peter Rosenbaum has written an excellent chapter on the benefits of family centred care, involving the extended family such as grandparents. The evidence shows that this is associated with greater satisfaction with care and adherence to therapies, and is most important for children with complex disability and multiple problems, where the risk of fragmentation of care is high. He then persuasively argues that developmental interventions should focus on promoting participation and achievement of functional goals, rather than fixing impairments. Eva Bower and Roslyn Boyd follow with helpful practical guidance to therapists on goal setting, models of assessment, and reliable tools to measure change or outcome. It is made clear that goals differ from aims, they should be specific and measurable, and relate to problems experienced by the child.

    The second half of the book is devoted to therapeutic possibilities. At the cerebral level, some exciting possibilities are emerging based on neural plasticity in the damaged nervous system, such as constraint induced therapy. The reader is reminded that abnormal muscle tone is only one feature of the motor syndrome in cerebral palsy, and other aspects, such as muscle weakness, may be successfully treated with strengthening exercises. There has been an explosion of interest in new treatments for spasticity, such as intrathecal baclofen and focal injections with botulinum toxin. In controlled trials to date, functional gains have been limited and overall muscle tone can be reduced by simple measures, such as relieving pain or ensuring a good night’s sleep.

    The orthopaedic contribution emphasises the progressive nature of the musculoskeletal disorder in cerebral palsy and how this confuses families who learn that cerebral palsy is due to a static cerebral lesion. A biological clock is ticking and unrelieved muscle spasm gradually leads to muscle shortening, bony torsion, joint instability, and ultimately degenerative arthritis. Appropriate management in childhood may influence the natural history. For example, monitoring of the hips in bilateral cerebral palsy with early intervention reduces the risk of dislocation and painful arthritis in adulthood. A chapter is devoted to the conservative management of deformity, using 24 hour postural care in conjunction with strategies to facilitate movement and function.

    The wealth of alternative therapies and approaches to care, combined with a lack of hard evidence to promote one above the other, has been confusing for parents as well as professionals, and Margaret Mayston’s contribution is helpful for both. She describes the various treatment approaches, ranging from the Bobath technique to alternative or complementary therapies such as hyperbaric oxygen, giving a balanced view of the available evidence as to their merits and disadvantages.

    With the increasing lifespan of the most severely impaired young people, the chapter on cerebral palsy in adults is sobering and should be essential reading for the paediatric team. There is evidence of a gradual loss of function and independence, aggravated by increasing weight and loss of physical fitness. Adult care is at best fragmented, and a case is made for a coordinated service for adults similar to that provided for children by the community paediatrician.

    Overall the editors must be congratulated for bringing together a wealth of information from diverse sources. At times fuller descriptions of important new measures, such as the Gross Motor Function Classification System (Palisano et al, 1997) or promising new therapies would have been welcome. Nevertheless the book is essential reading for therapists and paediatricians specialising in neurodisability. A copy should be available for all child disability teams and is a valuable addition to the paediatric department library.