'Instead of certainty we have search …’

The title of this commentary is from the introduction by David Scrutton to the latest edition (2004) of Management of the Motor Disorders of Children with Cerebral Palsy. It reflects the change in our approach to the treatment of children with cerebral palsy (CP) that has taken place during the last decades; a change that can be attributed to many factors. The two articles by Mary Law and Johanna Darrah and their co-workers highlight some of these factors. The articles represent an important contribution in the search for optimal treatment strategies for children with CP. What were we so certain of previously and how have our perceptions changed? What are we now searching for? Child characteristics, task demands, and environmental influences are currently common starting points when considering interventions and how the child can best reach a certain goal. Previous approaches often depended on changing child characteristics, where the atypical muscle tone was a hub around which services, to a large extent, revolved. Therapists could observe how the children adopted more normal movements when guided by the therapists’ skilled hands. But outside the treatment rooms the children invented and adopted other, for them more functional, movement solutions. Since then, much water has flowed under the bridge. Today many studies search for how impairments in CP relate to motor capacity and functional performance using the International Classification of Functioning, Disability and Health – Children & Youth as a conceptual framework. Some of the results are not as clear-cut as we previously might have thought, while others form the basis of the child-focused intervention used in the article by Law et al. The new context therapy, however, allows us to radically alter our perspective and reflect on task demands and environmental influences on children’s performance. Uniquely, we are also able to read a full description of one of the treatment arms in the study. Chapeau! to the authors and to the publishers. The article by Darrah et al. points out the importance of thoroughly describing the interventions used in different studies and making those descriptions publicly available for discussion. Most studies within this field of research are effectiveness studies, examining interventions under real-life conditions supposedly resulting in high external validity. Randomized controlled trial studies, however, strive for high internal validity, which is difficult to reach fully with heterogeneous populations and when the study is performed in a naturalistic setting. In the context approach it is difficult to say what is the active ingredient (changing the environment, the collaborative process of goal-setting, or the one-therapist model) or if the results emerged through an interaction between these different factors. Both treatment alternatives were found to be equally efficient, which could offer a choice of treatment approach that best fits the family, the child, and the therapist. Though I do find it puzzling that the parents of more than half of the children assessed for eligibility declined participation. Could this be a group of parents with different needs and preferences? As a theoretical basis, the authors describe the possibilities inherent in the dynamic systems theory (DST) where interactions between many subsystems occur to reach a functional goal. A keyword in DST is self-organization, i.e. no external element of planning is present. This presumably would mean that the child with CP is able to self-organize movements. But isn’t that at variance with the idea that the therapist can discuss with the child and instruct the child on what could be a possible movement solution in a specific situation? What actually would be the role of the therapist in a system that self-organizes? Our search continues. The ongoing randomized controlled trial study by Ketelaar et al. will soon provide us with further knowledge to discuss. The goal is to ensure that the time the child spends in therapy may be worthwhile.