Subject: Cerebral Palsy and Other Motor Disorders

Series: Clinics in Developmental Medicine

Publication date: 09/02/2022

ISBN: 9781911612537

Edition: First

Pages: 192

The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to Management

Martin Gough and Adam Shortland

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Hardback edition (complete book)


The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to Management (ebook) Ebook edition (complete book)


Buy individual chapters

Do we need a paradigm shift in our approach to the assessment and management of the musculoskeletal system in children with cerebral palsy? This book encourages clinicians to reflect on how their thoughts and approaches are shaped by the clinical society. Using new perspectives and expertise, this book will inspire clinicians to rethink conventions about the child with cerebral palsy, consider how they communicate these new concepts to their fellow clinicians, and act to bring about positive changes in the management of children with cerebral palsy.

  • Provides a critical review of the current understanding and management of musculoskeletal deformity in children with cerebral palsy.
  • Transfers current understanding of muscle and bone physiology and function, from the realms of research into mainstream clinical thinking.
  • Advocates for an alternative clinical model of assessment and intervention, focusing on the experience of the child with cerebral palsy and their experience of the world.
  • Proposes the concept of the musculoskeletal system in the child with cerebral palsy as a linked system of interactive processes and subsystems, extending from individual molecules to the child and their environment.


A critical resource for clinicians and researchers involved in the care of children with cerebral palsy including Neurologists, Physical Therapists, Orthopaedic surgeons and Neurosurgeons, as well as researchers and clinicians in the philosophy of medicine.


Author podcast

In this podcast, authors Martin Gough and Adam Shortland discuss their upcoming publication with us, The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to Management.

Martin Gough

Martin Gough trained in orthopaedics in Ireland where he developed an interest in the orthopaedic management of children with cerebral palsy and in gait analysis.  Following fellowship experience in Toronto, he was appointed as consultant in paediatric orthopaedics at the Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, in 1998, where he was able to combine these interests as part of the team in the One Small Step Gait Laboratory.

Adam Shortland

Adam is in receipt of an award from the leading UK children’s charity, SpARKs (Sports Aiding Research for Kids) for his contributions to medical research. Adam is the director of an MSc in Clinical Engineering at King’s College London. It forms part of a unique programme of training to bring people with a background in the physical sciences into clinical practice. He is reader (Associate Professor), King’s College London.

Foreword ix
Preface xi
Acknowledgments xiii

  1. What We Think and Why We Think It: Our Clinical Model of Cerebral Palsy 1
    The Sound of Silence 3
    How Do We Know What We Know? 5
    Imposing a Structure on Sensory Information: Defining Our Own Reality 6
    System 1, Heuristics, and Bias 8
    Is All Knowledge the Same? 9
    Knowledge Within the Clinical Society 11
    The Concept of ‘Spasticity’ 13
    Does It Matter If There Are Differing Concepts of Spasticity? 15
    The Role of Cognitive Dissonance 17
    Clinical Evidence and the Scientific Process: Is This Not an Objective Process? 18
    Thomas Kuhn and the Role of the Paradigm 19
    Factors Influencing Paradigm Change in a Clinical Society 21
    Moving Towards a New Paradigm 23
    The Objective Body and the Lived-in Body 26


  1. A Made-up Story About Data, Knowledge, and Clinical Judgement 28
    The Randomised Controlled Trial 30
    Sample Sizes and Outcome Statistics in Randomised Controlled Trials 30
    Bias in Randomised Controlled Trials 37
    Short-term Follow-up and Long-term Outcomes 39
    Clinical Guidelines 40


  1. The Musculoskeletal System: Not Just a Structure but a Process 46
    What Is a System? 46
    Linear and Nonlinear Systems 47
    Cellos and Muscles 48
    The Orchestra as an Example of a System 49
    Considering the Human Musculoskeletal System as a Process
    Rather Than a Structure 50
    Entropy, Information, and the Cell 51
    The Cell Membrane: The Difference Between Inside and Outside the Cell 56
    Proteins: The Workhorses of the Cell 56
    How Are Proteins Formed in the Cell? 57
    Being a Cell Takes Energy 59
    The Mitochondrion: The Cell’s Power Station 59
    Cellular Energy Balance 61
    Systemic Energy Balance 62
    A Cell Is a Process as Well as a Structure 63
    The Skeleton: More Than Just a Framework 63
    Skeletal Muscle: The Prime Mover 65
    The Myocyte: The Basic Biological Unit of Skeletal Muscle 65
    The Components of Muscle Contraction 66
    The Molecular Basis of Muscle Contraction 67
    Muscle Architecture and Muscle Function 68
    ‘Slow’ and ‘Fast’ Muscles 70
    Skeletal Muscle Is Dynamic and Responsive 70
    Muscle Innervation 72
    Control of Movement: The Nervous System 72
    The Neuron: The Basic Biological Unit of the Nervous System 72
    The Basis of Neuronal Signalling: The Action Potential 73
    Providing the Energy for Neuronal Signalling 74
    The Concept of Upper and Lower Motor Neurons 75
    The Central Nervous System Really Is a System … 75
    … And Is Part of a Larger System Which Includes the Skeleton and Muscles 76
    Interactions Within the Musculoskeletal System: Balancing Energy and Growth 77
    Considering Musculoskeletal Growth as a Process 78


  1. Musculoskeletal System Development: Typical and Altered Trajectories 79
    Concepts in Cell Development: Epigenetics, State Space, and
    the Adaptive Possible 79
    Considering Musculoskeletal Growth as a Trajectory 80
    Contents vii
    Entropy and Developmental Trajectories 83
    This all Sounds a Bit Complicated … 84
    Causal Loop Diagrams 85
    Energy Costs of Growth 87
    Musculoskeletal Development in the Embryo 88
    Muscle Contraction Begins Early 89
    The Role of the Corticospinal Tract 89
    Movement and Motor Control After Birth 90
    Skeletal Muscle Fibre Growth and Development 91
    Factors Influencing Muscle Fibre Growth 92
    Effect of Skeletal Muscle on Skeletal Development 93
    Musculoskeletal Development in Children with Cerebral Palsy 95
    Effect of Early Developmental Changes on Subsequent Musculoskeletal
    Growth and Development 96
    Putting It all Together: Understanding and Exploring the
    Musculoskeletal System 99
    Where Do We Go from Here? 100


  1. Evidence-based Medicine and Cerebral Palsy 102
    Clinical Experience and Evidence-based Medicine 103
    The Problem with Randomized Controlled Trials in Cerebral Palsy 104
    Summary of the Weaknesses of Evidence-based Medicine When
    Applied to Cerebral Palsy 117
    Building the Evidence for Treatment: Enhancing the Power of
    Observational Studies 117
    Summary 124


  1. What Does all This Mean? 125
    Looking Again at How We View Clinical Knowledge 126
    The Cynefin Framework and Knowledge Domains 127
    Clinical Knowledge and the Cynefin Framework 130
    Clinical Knowledge and Uncertainty 131
    A Systems Approach to Clinical Knowledge 133
    The Role of External Factors in System Development 135
    Is This Helpful for Clinical Practice? 136
    Critical Systems Heuristics 137
    Sartre: Existence Comes Before Essence 141
    Merleau-Ponty: We Are Ensembles of Lived Meanings 142
    The Clinical Relevance of the Lived-in Body 143
    The Child with Severe Cognitive Impairment 144
    The Lived-in Body as a Focus for Intervention 145
    Putting Theory into Practice 146
    Does Life Really Need to Be This Complicated? 152

Conclusion: Putting It into Practice 154
References 156
Index 169


From the foreword:
You will not have read a book like this before. Intellectually fearless it is the product of wide reading and deep thought. Any student of biology cannot but be aware that what is known is but a small fraction of what is to be known. Confronted by the suffering of a child and family, Gough and Shortland open a space for us to pause and not rush to judgement. It is to be recommended to anyone involved in the management of children with cerebral palsy. There is also much food for thought here for those involved in decision making in a wider context.

Richard Robinson Emeritus Professor of Paediatric Neurology, Guy's, King's, and St Thomas' Hospitals, London, UK

The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to Management: Foreword by Richard Robinson - £0.00
The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to Management: What We Think and Why We Think It: Our Clinical Model of Cerebral Palsy (free ebook!) - £0.00