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Cerebral palsy: more than a definition?

Cerebral palsy: more than a definition?

In this blog post, Mac Keith Press authors, Martin Gough & Adam Shortland examine the definition of cerebral palsy. The emphasis of the piece is on cerebral palsy’s variation from person to person and that its presence is not captured by a single definition or description


What do we mean by the terms ‘disease’ or ‘condition’? Cohen (1953) suggested that there are two main disease concepts.  Disease may be viewed as a distinct entity, so that if a person A has a disease they become ‘A plus B’, where ‘B’ is a disease.  Disease may also be viewed as a deviation from a perceived ‘normality’ due to a number of factors (x1, x2, x3…). The attraction of Cohen’s first concept may be the implicit possibility of a disease-free state or ‘cure’: if a disease is viewed as ‘A plus B’ then removal of ‘B’ with a resulting restoration of ‘A’ is theoretically possible.  This concept may involve an assumed anatomical localisation of ‘B’ which may then become the target of therapeutic intervention.  An ‘A plus B’ concept of person and disease, together with an assumed anatomical localisation of ‘B’, may explain the clinical concept and approach to spasticity in children with cerebral palsy.  Cohen’s second concept, that of disease as a deviation from a perceived ‘normality’, may be represented in the context of children with cerebral palsy by the popular concept of the potential normative power of ‘plasticity’: in this situation however, there is an implicit assumption that rather than true ‘plasticity,’ any changes that occur will be in a positive direction only and will act to restore the expected normative development of the child.

Baron (1981) noted that the medical paradigm may be seen as a functional abstraction with three basic elements: ‘a physician, a patient, and a disease… which each come to be seen as fundamental elements in and of themselves’: ‘physicians then look through their patients to discover the underlying pure disease….what starts out as a heuristic model becomes an ontological fallacy’.  This view was shared by Foucault (2003): ‘Paradoxically, in relation to that which he is suffering from, the patient is only an external fact: the medical reading must take him into account only to place him in parentheses’. 

A definition of cerebral palsy as a condition which is somehow separate from the child, and which focuses on the ‘what it is’ of cerebral palsy, can obscure the child’s experience (or the ‘that it is’) of cerebral palsy which exceeds and is not captured by our definition and is in this way idiotic.  This concept of idiocy (Desmond 2012) is derived from the Greek ‘idios’ which means “one’s own, personal, private”, with the noun “idiotes” indicating a private person.  Cerebral palsy can be seen as idiotic in that it is a unique or singular experience for each child which cannot be fully determined or captured by any definition we use.

Photograph taken by Martin Gough whilst in Yorkshire. Children have imprinted their own faces on the tiles.

This would seem to be an intellectual impasse: we seem to be defining cerebral palsy as something which cannot be defined. This approach would seem to support Cohen’s comment that ‘Philosophical enquiry in medicine is apt to be regarded as an arduous eccentricity’.  And yet, philosophy does have an approach to offer.  Levinas (1979) commented that ‘Western philosophy has most often been an ontology: a reduction of the other to the same’.  By this, he meant that in defining what things are, we change them from being ‘other’, something that we cannot know, and instead make them part of our understanding by objectifying them as ‘same’.   He suggested that our view of what we consider as known (‘the same’) is challenged by experiencing another person: ‘a calling into question of the same – which cannot occur within the egoist spontaneity of the same – is brought about by the other.  We name this calling into question of my spontaneity by the presence of the other ethics’.  This can seem somewhat abstract until we think about an encounter with a child with cerebral palsy: before and beyond any description, diagnosis or classification we can offer is our immediate awareness of the presence of a unique or singular other person.

An ethical approach (to use Levinas’ term) which accepts the singularity of each child with cerebral palsy is intuitively attractive but may make clinical management more of a challenge: if each child is unique, how do we use concepts such as ‘cerebral palsy’?  Derrida (2003), another philosopher, wrote that ‘Ethics start when you don’t know what to do, when there is this gap between knowledge and action, and you have to take responsibility for inventing the new rule which doesn’t exist….An ethics with guarantees is not an ethics….Ethics is dangerous’. We have a choice: we can take an ontological approach where we define cerebral palsy as an independent entity and face the challenge of making each child fit the definition, or an ethical approach where we focus on the child’s experience of the world and on our experience of the child, and work from there.  Ethics may be more dangerous and involve more responsibility, but seems to offer the child and the clinician far more.

Cohen H. The evolution of the concept of disease.  Proc Roy Soc Med 48:155-160, 1953.

Baron RJ. Bridging clinical distance: an empathic rediscovery of the known.  J Med Phil 6:5-23, 1981.

Foucault M. The Birth of the Clinic: p9: translation by AM Sheridan; Routledge, Oxford, 2003. 

Desmond W.  The William Desmond Reader: p47; edited and with an introduction by CB Simpson.  State University of New York Press, Albany, 2012.

Levinas E. Totality and Infinity: an Essay on Exteriority: p43: translated by A Lingis. Martinus Nijhoff Publishers, The Hague, 1979. 

Derrida J. Following Theory, p31-32 (in) life. after. theory. Edited by Payne M, Schad J, Continuum, London 2003.


Martin Gough & Adam Shortland May 2022

Martin Gough and Adam Shortland’s The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to Management is out now. The title challenges conceptions and current practices about the child with cerebral palsy to offer a new perspective and alternative clinical model. Promising to offer a real paradigm-shift in the ways we think about cerebral palsy, this book will be 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.

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.

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How to choose a book cover: Commentary from Martin Gough and Adam Shortland

How to choose a book cover: Commentary from Martin Gough and Adam Shortland

In this blog post, Mac Keith Press authors, Martin Gough and Adam Shortland go into detail about the fascinating and at times difficult decisions around choosing a book cover. Make sure to check out their upcoming publication The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to Management, the subject of discussion in this post.

The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to Management is due for publication in February 2022 and is available for pre-order in both paperback and digital.

Adam Shortland (left) and Martin Gough (right)

Cover images tread a delicate line between expressing the core essence of the content held within the book whilst also necessitating an engaging and inviting cover art. It is often difficult to find an image that can do both well. We debated a series of images before agreeing on the one you see now on the cover. Some were bright but strayed too far from the messages of the book; others reflected our themes well but didn’t ultimately suit the cover format. The image we finally went with was suggested to us by Paul Grossman of Mac Keith Press: we liked it immediately because of the colours and energy of the image but also because we empathised with the figures (one of us goes purple with rage, the other pink with embarrassment!).

The cover image of the book shows a pink figure and a purple figure who appear to be either constructing or dismantling a slightly haphazard pile of coloured plastic blocks. On looking at the image there appears to be some discussion going on between the figures: should the blue block or the yellow block go next on top of the highest pile of blocks? The plan of the structure the figures are building is not very clear: it may be that they were sent to build a basic structure like a wall and got a little carried away in the excitement of playing with the blocks and in discovering new ways of putting them together.  The image conveys a sense of excitement and change although it is hard to know this from the faces of the figures, who are somewhat expressionless. As authors, we were invited to write a book on a specific topic, namely the development of the musculoskeletal system in children with cerebral palsy and the associated implications for clinical management, and we came up with a clear and straightforward plan. Like the figures, when we looked at what was involved in actually writing the book and when we began to see where we could take the discussion forward, we got a little carried away, and after a few attempts ended up with the present book which was not really planned in advance but in some way developed organically and brought in new perspectives through interaction and discussion between the authors.  This is partly because we liked all the topics in the book and wanted to include them all, and also because on looking at the different topics we could see new and exciting ways of putting them together. 

“The book itself is about change and development, and mirrors the change and dynamism implied in the cover image.”

Martin Gough & Adam Shortland
Upcoming title from Mac Keith Press The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to Management by Martin Gough and Adam Shortland

The book represents a snapshot in time for the authors when a range of concepts were brought together and expressed in book form: like the pile of blocks assembled by the figures, the ideas in the book are open to further development and should not be seen as complete or fixed. The book itself is about change and development, and mirrors the change and dynamism implied in the cover image. Rather than discussing a structure, the book discusses a process where, like the coloured blocks in the image, the components of the musculoskeletal system interact to form new arrangements and patterns. This complexity and capacity for self-development in the musculoskeletal system is hinted at by the background of the cover image, which is formed by leaves. The pink figure and the purple figure may be pleased about the outcome of their work and may see it as much more complex and interesting than a basic wall of blocks of a single colour but are probably aware that in comparison to the complexity of a living leaf the complexity of their pile of coloured blocks looks a little underwhelming.  In the same way, we have discussed complex topics in the book but when viewed against the complexity of the developing musculoskeletal system we have at best presented a very simple model.  Like the figures, however, we have to start somewhere: only by appreciating that there are blocks of different colours and that they can be put together in different ways can we implement new ideas. 

The figures in the image are not very expressive but seem to be enjoying themselves as they put the blocks together in new ways. Letting go of the apparent safety and certainty of the standard clinical approach may seem unwise but opens us to the excitement of new perspectives and approaches. Like the pink and purple figures, who would want to build a wall of blocks of the same colour when you could be involved in exploring something new? We hope this book conveys our enthusiasm and excitement in the same way that the image conveys the enthusiasm and excitement of the pink and purple figures working with their blocks.


Martin Gough and Adam Shortland January 2022

Martin Gough and Adam Shortland’s The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to Management is out later this year and available for pre-order now. The title challenges conceptions and current practices about the child with cerebral palsy to offer a new perspective and alternative clinical model. Promising to offer a real paradigm-shift in the ways we think about cerebral palsy, this book will be 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.

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.