Danger of limiting interventions for children with cerebral palsy to level one evidence Gregory B Firth Department of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa Correspondence to: [email protected] doi: 10.1111/dmcn.12392

SIR–There are concerns over the recent article by Novak et al.1 Although the paper is extensive and exhaustive in covering the management of children with cerebral palsy, I do have the following misgivings. 1 The authors allude to the difficulty in studying children with cerebral palsy, especially regarding the different disability types and the fact that each child and intervention are so extensive and varied. Each child has a complicated management plan individualized to that child. The red, yellow, and green traffic light model tries to simplify an extremely complex combination of factors that need to be synthesized on a case-by-case basis before management can be planned. This method oversimplifies an extremely complex issue. 2 There is also a danger that giving botulinum toxin a green light for specific indications may lead to its overuse when it is not indicated, with potential unknown long-term complications.

3 It is difficult to know how to interpret the result that hip surveillance received a green light. What do we do with these children if orthopaedic surgery only achieved a yellow light? Does this mean that we should diagnose the inevitable dislocation and then observe the child because surgery only has a yellow light? That does not seem the correct thing to do. 4 These guidelines could become dangerous if used by parents who decide that all yellow light interventions should be avoided. This could occur in the setting of multiple published studies supporting the good medium and longterm outcome of orthopaedic surgery in terms of single event multi-level surgery,2,3 knee contracture surgery correction,4 and hip surgery for hip displacement.5 Admittedly these all have lower levels of evidence, but should we stop operating until we have level one evidence when we can see in the available literature that these children can be helped using current techniques? I agree that more rigorous designs and methodology are needed to improve the levels of evidence, but surely in the meantime lower levels of evidence can still be used as a basis of management?

REFERENCES 1. Novak I, McIntyre S, Morgan C, et al. A systematic

3. Firth GB, Passmore E, Sangeux M, et al. Multilevel sur-

5. Dhawale AA, Karatas AF, Holmes L, Rogers KJ, Dab-

review of interventions for children with cerebral palsy:

gery for equinus gait in children with spastic diplegic

ney KW, Miller F. Long-term outcome of reconstruc-

state of the evidence. Dev Med Child Neurol 2013; 55:

cerebral palsy: medium-term follow-up with gait analy-

tion of the hip in young children with cerebral palsy.

855–910.

sis. J Bone Joint Surg Am 2013; 95: 931–8.

Bone Joint J 2013; 95: 259–65.

2. Thomason P, Selber P, Graham HK. Single Event Mul-

4. Al-Aubaidi Z, Lundgaard B, Pedersen NW. Anterior

tilevel Surgery in children with bilateral spastic cerebral

distal femoral hemiepiphysiodesis in the treatment of

palsy: a 5 year prospective cohort study. Gait Posture

fixed knee flexion contracture in neuromuscular patients.

2013; 37: 23–8.

J Child Orthop 2012; 6: 313–8.

Comments on a systematic review of interventions for children with cerebral palsy Tim Theologis Nuffield Orthopaedic Centre, Oxford, UK. Correspondence to: [email protected] doi: 10.1111/dmcn.12401

SIR–I have read with interest the article by Novak et al.1 I applaud the effort made by the authors to establish which interventions are evidence-based in this field of clinical practice. However, I believe that, in its present form, the article is confusing, misleading, and potentially dangerous Letters to the Editor

393

Danger of limiting interventions for children with cerebral palsy to level one evidence.

Danger of limiting interventions for children with cerebral palsy to level one evidence. - PDF Download Free
41KB Sizes 2 Downloads 3 Views