On the treatment of cerebral palsy. The outcome of 177 patients, 74 totally untreated.

A review was made of 177 cerebral palsied patients previously included in a follow-up study, concerning whom reasonably detailed information was available as to type, intensity and duration of physical therapy and similar treatment. These patients had all been followed until at least the age of 14 years. Seventy-four had been accidentally or intentionally untreated, and the status of this group at the time of follow-up examination was compared with 103 subjected to intensive physical therapy, with or without bracing and orthopedic surgery. Comparison could be made with original or serial motion pictures, which were available of 132 of the patients. The original composition of the treated and untreated groups was comparable as to type and severity of involvement, mild and severe cases being considered separately. The groups were also comparable as to intelligence, except that the untreated group contained a much higher percentage of mentally defective persons, who would have been expected to do proportionately less well according to published reports. Patients with spastic hemiparesis appeared to develop at least a good quality of locomotion with or without treatment, if the original involvement was mild. Among those with originally moderate or severe hemiparesis, the treated group had relatively better gait and also had fewer contractures. The alleged danger of inducing stuttering or epileptic fits by treatment of a hemiparetic arm appears not to be genuine. The treated group had no greater frequency of stuttering and a much lower frequency of epilepsy (this latter finding is probably based on the high correlation between mental defect and epilepsy, the untreated group including more defectives). Forced preferential use of the hemiparetic hand for uni-manual activities, however, is another matter and is obviously a source of frustration and possibly a factor in stuttering. The ultimate status of the patients with spastic tetraparesis was generally poorer than that of those with hemiparesis. Nevertheless, it appears that quality of gait can be improved and contractures lessened by physical therapy and functional training, for both unilateral and bilateral spastics. The percentage of patients eventually subjected to orthopedic surgery was not much lower in the group receiving intensive physical therapy from infancy. The ultimate gait and hand function of the intensively treated patients with extrapyramidal types of unwanted movement were not essentially different from those untreated. Contractures occurred only infrequently in patients with pure choreoathetosis but were proportionately more common if there was hyperreflexia, an extensor plantar response, ankle clonus, or frank spasticity as in a mixed type of palsy. The methods of physical therapy were mostly stretching exercises and functional training; no claim is made that the patients might not have done better with other methods of therapy. Many of these methods depend on unproven physiologic hypotheses, however, and should be evaluated by comparison with similar untreated patients and not merely with the prior status of the same patient. The tendency of children to improve in co-ordination and function with increasing age must be distinguished from the effect of treatment. The data presented are somewhat discouraging, at least for patients with athetosis and dystonia, but are also a challenge for the development of more effective methods of treatment. At present they suggest that if the number of physical therapists and the number of hours of physical therapy available are limited, they are best applied to the prevention of contracture and the improvement of gait in patients with unilateral or bilateral spasticity. The results in patients with hyperkinetic disorders of movement such as athetosis and dystonia appear less rewarding for the number of hours devoted to them than is the case in the treatment of spasticity. It is nevertheless obvious, and freely acknowledged, that a trial of intensive physical therapy for a reasonable period is usually advisable in the interest of the future peace of mind of the patient and of his parents, and perhaps most particularly if the physician in charge believes the end-result is likely to be poor. Such trials are necessary, but in the interest of honesty and economy of effort should be undertaken with the frank recognition that they are, in fact, experimental trials and should be subject to periodic reappraisal.