Develop. Med. Child Neurol. 1973, 15, 401-402

Letter to the Editor

‘Are We Handicapping the Handicapped?’ SIR-I was surprised a t the letters to the Editor that interpreted my editorial ‘Are We Handicapping the Handicapped ?’ as a condemnation ‘of all treatment for cerebral palsied conditions’ and as an ‘attack on physiotherapy’ (D.M. & C.N., February 1972). These polemical remarks (and others of a similar vein) cannot go unanswered.

The editorial intended to raise the issue of treatment ‘side-effects’. ‘Iatrogenic’ disease in possible in any therapeutic endeavour, whether it be medical, surgical, psychological or physiotherapeutical. One must weigh the benefit of the therapeutic regime against the risk of complications. I do not believe this has been critically appraised by those who have recommended specific treatment regimes for motor-handicapped individuals.

I wish I had had more space available than is customary for an editorial or for a letter to the editor. If so, I would have had a better opportunity to defend myself against those who interpreted the editorial to mean that I am a therapeutic nihilist when it comes to treatment intervention for cerebral palsied patients and their parents. This is far from the truth. I make good use (at least I hope so!) of the traditional approaches such as bracing, surgery, and measures to prevent contractures. Even with these techniques, I fully realize that controversy exists and, unfortunately, often their use is recommended semi-empirically without hard data to support (a priori) their efficacy. Nonetheless, I carefully evaluate any possible ‘iatrogenic’ effects; for example, will the cosmetic ‘handicap’ of a brace prove more disabling than the benefits obtained with a functionally improved gait? If so, I may have second thoughts about using the brace.

As regards physiotherapy, I tend to favor an individualized treatment program which emphasizes facilitation of those intentional movements which will be of practical use to the child. A good example is that of the therapist recommending to the mother of a baby with symmetrical tonic neck reflexes that she place the infant in a position of slight neck and trunk flexion so that the arms may assume a flexor position. The hope is that this will ease the ‘voluntary’ attempts at hand-to-mouth movement needed for self-feeding and thumb sucking.

There are many other practical techniques, based on knowledge of neuro-physiological principles, which will permit the baby to assume a better functional position in order to succeed on his own. In a sense, these programs utilize bits and parts of the well-known eponymic treatment regimes, but without the expectation that the dyskinetic movements will diminish or disappear; the primary interest is to assist the child to function optimally and with less frustration, even though there may not be basic improvement in the dyskinesis.

As I indicated in the editorial, I am not convinced that we can alter the natural course of the neuromotor disability with the treatment techniques now in common use. In addition, I have fears that subtle complications may be the result of indiscriminate application of the present day treatment ‘vogues’.

I would like to quote from Dr. I. B. Pless’ letter (D.M. & C.N., April 1973). I may be accused of specifically mentioning this one letter because it was rather complimentary, in

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DEVELOPMENTAL MEDICINE AND CHlLD NEUROLOGY. 1973, 15

contrast to the majority. This may be true; nonetheless, I still believe that the following quotation epitomizes my feelings: ‘There is no alternative but to assess all such treatments by means of randomized clinical trials. The end-points must, however, include an evaluation of the consequences of therapy in terms of the child’s total functioning on a day-to-day basis, as well as a particular neurological or locomotor outcome. Such trials may well prove that an extra ten degrees of movement in a joint is not worth the amount of school absence required, or that a few more seizures are preferable to diminished ability to concentrate.’

Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New York 10461.

LAWRENCE T. TAFT

To help you with your study of child development

The Physical Management of Developmental Disorders Errington Ellis Clinic No. 26. pp. lo. sop. Developmental Screening 0-5 Years D. F. Egan, R. S. Illingworth, R. C. Mac Keith Clinic No. j o . pp. 64, E I . J O . A Neuropsychiatric Study in Childhood Michael Rutter, Phil$ Graham, William Yule Clinic Nos. 3 ~ 1 ~ 6 . pp. 272. E j . 7 ~ .

The Neurological Examination of the Child with Minor Nervous Dysfunction Bert C. L. Tounvn, Hein? F. R. Prechtl Clinic No. 38. pp. IOJ. Ez.2,.

The Child with Delayed Speech Edited by Michael Rutter and J . A. hi. Martin Clinic No. 43. pp. 268. k j . ~ o .

All the above titles are from the series Clinics in Developmental Medicine and are available through most booksellers.

Distributed by William Heinemann Medical Books Ltd., Kingswood, Tadworth, Surrey.

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