TOO FEW COOKS: TOO MANY COOKS A WEEK ago I received a letter from a mother complaining that she was confused by the treatment prescribed f o r her child with cerebral palsy. She had seen three physiotherapists: one did not believe in night splints for her child but favoured an articulated ankle-foot orthosis; another felt that the child required serial casting and did not agree with the orthotic prescription of the first; finally she saw a third physiotherapist who did not agree that serial casting was currently indicated but wondered about therapeutic electrical stimulation and a night splint. One could reasonably argue that therapist-shopping was probably less confusing and hazardous than doctor-shopping and that the treatments would do no lasting harm. The question is, however, that since all three were very experienced therapists, would it have made any difference no matter which regime was chosen, or might it be that one would have been superior to the others? Would gait analysis or detailed neurophysiological examination have solved the problem, seeing that gait equinus does not follow, as cause and effect, obvious clinical abnormalities. There are orthopaedic surgeons who dismiss out of hand ankle-foot orthoses or serial casting, but follow the religion of Newington without the Connecticut facilities for assessment. They do not entertain any doubt, even if subsequently the child is very weak but straight (orthos paedos). There may still be some muscle power, but at a joint angle that the child would have to be a contortionist to use. An old ward-sister used to say to me ‘Mr X’s patients may not walk out of hospital but they lie much straighter in bed’. We criticise Peto, Bobath, Temple Fay, Doman, P.N.F. and Vojta treatments for not having undergone scientific evaluation and not producting statistics with a p value to prove their efficacy. However, paediatrians prescribe baclofen for muscles which are stiff but are not spastic (they may not even know the difference), dope the child with benzodiazepines, and in desperation try high-dose anticholinergics or L-dopa-on what proven basis? The recommendation of one therapist for every 30 children with cerebral palsy is resisted by many Health Boards because we cannot show that therapy makes any long-term difference to the child’s function or social competence, or to mobility in terms not only of miles walked but whether the child will walk at all. Would the child with diplegia walk quicker, further and more efficiently, with less


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energy expenditure, in equinus and mild crouch at 16 years without any surgery, drugs or physiotherapy?. The criticism loaded on rhizotomy in terms of the need for proof of functional . improvement is quite correct. No new procedure should become widespread on the say-so of the media and parent pressure, if in the end it were proved to be harmful and children were actually made worse and sentenced to a life in a chair rather than having independent, even if ungainly, mobility. The media and the parent groups would find no difficulty in looking in opposite directions at the same time and blaming t e medical profession for not properly undertaking scientific trials. The legal rofession could then, yet again, rub their hands and pockets in glee. The need to prove the effectiveness of new treatments is imperative, but we should not let the old treatments rest on their unproven laurels. How often have we heard it said that it would be unethical to complete a proper trial when the initial results were so miraculous that it would be wrong not to give every child a chance to benefit (are you young enough4.e. not too demented-td remember spina bifida and early closure?). University departments like to be first in line tor allanewdevelopments, to prove that they are smart and up to date. Legal pressure may suggest that it is negligent not to perform a particular test or treatment once initial uncorroborated pilot studies are published, making it difficult then t o perform controlled trials. Cerebral palsy is a heterogeneous collection of syndromes with no two children, even with the same topography (e.g. hemiplegia), exactly the same, The age at walking may bear no relation t o the neurology; the deformity (e.g. equinus) may bear no relation to the presumed cause, short' muscle; spastic muscle, muscle imbalance, short leg, etc. Nevertheless, unless we can show that treatments do significantly improve the. quality of the child's life and increase mobility and efficiency, we shall be giving the same conflicting advice in thirty years time. This journal has tried to publicise the need for the propet trial of therapies for cerebral palsy for the last thirty years-no wonder Martin Bax is looking a bit worn at the edges! The famous neurophysiologist John Eccles said that we do not get more forgetful the older we get, we simply have more memories to remember. Is is that we now have more unproven treatments to try? Mea culpa!







Too few cooks: too many cooks.

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