The Musculoskeletal System in Children with Cerebral Palsy

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Martin Gough and Adam Shortland. The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to Management. London: Mac Keith Press; 2022 (174 pages) ISBN 978–1-911612–53–7 (£ 75.00)

It is almost a presumption to judge a book written by a senior Pediatric Orthopaedic surgeon, Martin Gough, who has been operating in the field of cerebral palsy (CP) for over 20 years in the middle of London at Evelina London Children's Hospital and by Adam Shortland, a fine scientist from the same house, who knows the necessary data and background. Their department is the largest unit for Pediatric Orthopaedic surgery in the South of London, specialized on neuromuscular disease, mainly CP, running a gait laboratory and performing 500 operations and 4,500 outpatient treatments per year.

On top of that, the books' preface is written by none other than Richard Robinson – Emeritus Professor of Pediatric Neurology, deceased June 2022. He was the disciple of Ronnie Mac Keith, who is said to be the founder of European Neuropediatrics.

Finally Mac Keith Press is the publishing house, known for its critical and philosophical texts. This is where Pediatric Orthopaedics meshes with Neuropediatrics and Science, the ideal case.

Gough and Shortland write about the musculoskeletal system (Chapters 1, 2, and 4) of CP in children finally in a way that incorporates that there is no unique treatment. They address the various treatment options, incorporate the study base and their experience (Chapters 2 and 5), and make a concise statistical and anatomical functional excursion (Chapter 3).

And yet, this book is like no other medical book.

The description of the cover picture says it all. “The book looks at how we need to form models of complex reality, how these models need to be flexible to change, and why it is important to avoid replacing one certainty with another.”

Chapter 1 serves as an introduction revealing that the paradigm of Goughs' department is “in crisis,” that an established department needs to review and change its concepts. The authors clarify that there are a number of different and competing interpretations of the core concept of spasticity and that there is a lack of evidence to support some of the current intervention options they use. For explanation basic principles of human behavior are set out. International literature covering centuries sends the reader diving into important philosophical basics of which at times is so important to be reminded. At the end it becomes clear that reviewing paradigms are important, that humankind tends to avoid changing paradigms, that we unconsciously rather keep the old. With this basis they make the transition to the actual topic of CP—the term spasticity which needs to be defined; and the big topic of interventions.

Chapter 2 is titled “A made up story about data, knowledge, and clinical judgment.” Here they carefully talk about the design of studies, the studies' bias and remind us to read these studies thoroughly while using new interventions and to verify and question their design and effectiveness. The chapter goes deep into double-blinded randomized controlled trials, Cohens' standardized effect size and odds ratio using the gross motor function measure, the Modified Tardieu scale, and the International Classification of Functioning, Disability and Health for explanation. It defines the aim of every intervention which is to improve the participation and contentment for the patient and parents.

Chapter 3 is called “The musculoskeletal system: not just a structure but a process”. It takes us deep into biochemistry and physiology with very few diagrams, so it is hard to read but good to repeat the facts about muscle and nerve cells, cell organelles, citrate cycles, oxidative phosphorylation, hormonal interaction and neuronal networking.

On top of that Gough and Shortland do not get tired of mentioning Johann Sebastian Bach, explaining the second law of thermodynamics and talking about entropy. They remind us that there is no evidence for the musculoskeletal development and function of children with CP to be altered out of the pre-existing range. Also they state that we have only limited ability with the migration index (MI) on an X-ray of the pelvis to predict hip development in children with CP under the age of 8 years. On top they cite that young adults with immobilization in bed for 6 to 7 days lose oral glucose tolerance and have less insulin effect on glucose uptake concerning the quadriceps muscle.

Where does this take us to considering the interventions on children with CP such as immobilization by orthosis, denervation of a growing muscle, reduction of sensory input from the lower limbs by selective dorsal rhizotomy, and altering the alignment of the lower limbs by surgical intervention?

Chapter 4 then includes the development of musculoskeletal system into discussion and the altered ways of development in patients facing CP. They explain the consequences a reduced input of the developing corticospinal tract has on the developing spinal cord networks and on neuromuscular development. It provides explanations for the symptoms of CP seen from the cellular level such as the pointed foot gait. It is a symptom for the need to provide increased stability in the presence of reduced proprioception. It is a symptom for reduced capacity to develop a low-entropy state in muscle because of impaired energy availability. And it is a symptom for maintaining sarcomere length at an optimal level for force production.

Chapters 5 and 6 finally consider the context of studies to the live experience of a child with CP. The authors address the study of Novak I, Mclntyre S, Morgan C, et al. A systematic review of interventions for children with CP: state of the evidence. (Dev Med Child Neurol 2013;55(10):885–910. doi:10.1111/dmcn.12246), the most downloaded article in the history of publishing journal. It is an analysis of systematic reviews and other sources of evidence in the area of treating CP. Gough and Shortland consider the limited degree to which we can apply data to the clinical management of an individual child and take into account the interindividual experiences a practitioner has undergone facing the uncertainty of a new model.

I was glad to read this philosophical book after 10 years of work on Clinical Neuropediatrics having learned in the Neuropediatric School of Theodor Hellbrügge, Munich, the founder of Social Pediatrics. The reader should be indulged in the treatment of children with CP, even if the book goes far beyond CP and pediatric orthopaedics on essential philosophical questions.

At the end the authors leave a void for the reader in the field of CP management never specifying their paradigm at Evelina Children's Hospital that they find certain requirements to be reconsidered and reevaluated. And it leaves a void in your heart as coming to the end of his career Martin Gough needs to recognize that his system of CP treatment is “in crisis,” not being able to pass on his paradigm to the next generation.

But once again Adam Shortland and Martin Gough point to our interindividual realities – what actually is reality?

Thank you to the authors.

Publication History

Article published online:
23 January 2023

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