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The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to Management
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£80.00
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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.
Readership
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 publication: 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
- 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
- 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
- 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
- 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
- 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
- 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
Clinicians involved in the management of musculoskeletal problems of children with cerebral palsy (CP) would (or ought to) acknowledge the limitations of our armamentarium. Our treatments are crude ‘solutions’ based on a simplistic and incomplete understanding of the underlying pathophysiology. An honest appraisal of our patients' outcomes should instil some uncertainty about the predictability, magnitude, longevity, and ultimately, the utility of these outcomes. In their thought-provoking book, Gough and Shortland eloquently justify the imperative for introspection. Using thoughtful clinical vignettes, the authors make a bold argument for questioning, if not abandoning, our current model of CP in favour of embracing uncertainty in the face of our evolving understanding of the complex processes linking the neurological and musculoskeletal systems and how these are affected in CP.
The authors present a veritable intellectual treat(ise), drawing from the classics, the arts, philosophy, clinical epidemiology, biology, and even physics, to challenge conventional wisdom. The book begins with a philosophical exposition about how we know what we know, how knowledge or beliefs are created, interpreted, and shared until they become received wisdom. The authors apply this lens to the concept of spasticity and how it is treated; a concept they are at pains to point out does not have an agreed definition, is difficult to quantify, and yet is widely accepted within the clinical society, explained perhaps by some collective cognitive dissonance.
Chapter 2 is an object lesson on critical appraisal. Using simple, made-up, but relatable examples, the authors illustrate the fallacies in our interpretation of research findings too often derived from studies hamstrung by small sample sizes, high risks of bias, short follow-up, and reliance on p-values to define differences that might have little clinical significance. They propose that researchers report results as probabilities of success and failure to better inform decision-making. Their critique continues in Chapter 5, where the limitations of the current evidence base are highlighted. They recommend longer-term prospective observational studies as an alternative to randomized trials, and the use of directed acyclic graphs to inform study design and analyses.
Chapters 3 and 4 get to the meat of the matter with a comprehensive review of the cellular structural and developmental biology of the skeletal muscle, skeleton, and nervous systems. Using the analogy of an orchestra, the authors present the musculoskeletal and the central nervous systems as complex non-linear systems or interdependent processes. They describe the growth and development of these systems and their components as trajectories of increasing levels of organization, using causal loop diagrams to illustrate the interactive pathways that culminate in movement and motor control. They provide plausible hypotheses on how these trajectories in CP might be altered by changes in genetic regulation, epigenetic mechanisms, and other factors.
Finally, Chapter 6 returns to an exploration of suitable frameworks for decision-making under conditions of uncertainty. The authors invoke Sartre and Merleau-Ponty in urging us to eschew a normative approach in favour of the child's lived experience to guide our interventions and suggest how such an approach might be applied to the clinical vignettes.
Gough and Shortland are at the vanguard of those questioning the current paradigm. Readers might discover the authors' own biases implicit in some of the presumptions they make in service of their message, but the message is sound. The book raises more questions than provides answers, but what good questions they are. The authors ask – does this need to be so complicated? Perhaps not but that would have left us a book not nearly as interesting. This stimulating book was clearly a labour of love. I recommend it highly for an enriching experience.
Unni Narayanan for DMCN: https://onlinelibrary.wiley.com/doi/10.1111/dmcn.15227
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Improving Quality of Life for Individuals with Cerebral Palsy through Treatment of Gait Impairment
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