J. R. Gage, M. H. Schwartz, S. E. Koop, T. F. Novacheck (eds): The identification and treatment of gait problems in cerebral palsy

This is multi-authored text which covers far more than just the identification and treatment of gait problems in cerebral palsy (CP). It is a comprehensive review of the etiology, manifestations, assessment, and treatment of the ambulatory CP child. However, each individual chapter is relatively short and to the point, and, thus, manageable. These chapters provide sufficient information to inform the reader of the most important issues, but do not overwhelm one with information. It is, therefore, up to the reader to overwhelm themselves by utilizing the comprehensive reference list at the end of each chapter. Although the majority of papers are written by health professionals from the Gillette Children’s Hospital group, there are multiple other authors who are leaders in the field, including Warwick Peacock and Leland Albright from the neurosurgery world, both of who are pioneers in the neurosurgical treatment of CP, Kerr Graham and members of his group from Melbourne, as well as Henry Chambers from San Diego, and John Davids from South Carolina in the orthopedic section. The book includes two CDs, one of which contains dynamic video illustrations to demonstrate a variety of clinical issues which cannot be conveyed with a simple photograph, such as athetosis and other tone abnormalities. The disk also contains multiple case studies which are keyed into the discussion in the book. In addition, there are excellent videos of surgical procedures narrated by Dr. Novacheck himself, which are well videographed, well edited, and demonstrate clearly the technical aspects of many surgical procedures. The second disk is a tutorial on gait which is an update of the previous excellent gait CD produced by the Gillette group and should be studied prior to using this text book. These CDs are excellent adjuncts to the printed work and truly enhance the information provided on the written pages. The book is divided into six sections, each of which have four to eleven individual chapters. Section 1, titled “Typical Musculoskeletal Development,” has background regarding normal musculoskeletal and neurological development, as well as an excellent chapter on normal gait. This gait chapter is augmented by the video, and this section alone is reason enough to purchase the book. Section 2, “Gait Pathology in Individuals with Cerebral Palsy: Introduction and Overview,” contains outstanding chapters by the neurosurgeons Peacock and Albright on tone disorders. These first sections of the book read like a symposium on neurological and orthopedic manifestations of CP. Another outstanding chapter in this section is the chapter authored by Gage and Schwartz on “Consequences of Brain Injury in Musculoskeletal Development,” which contains within it a segment which should perhaps have been separated as an individual chapter between pages 116 and 128 on levers and lever arm problems. This is a concept which Gage has introduced to the clinical world. These principles are critically important for those providing interventions for children with CP. There is also a very interesting chapter on muscle structure and function by Shortland et al. After a discussion of normal muscle morphology and function, the authors discuss the deficits in the muscle in spastic CP which contribute to the clinical manifestations, as well as the role that exercise may play based on this basic knowledge. They also discuss the theoretical detrimental affects of muscle weakening surgery, although others in the field may not agree with this analysis. The next section, “Patient Assessment: Introduction and Overview,” focuses on assessment, including clinical examination, as well as computer-based gait analysis. Following this is a section on non-operative treatment, including excellent chapters on orthoses as well as pharmacologic management. The heart of the book, however, is the large section on operative treatment, which includes chapters on intrathecal baclofen and selective dorsal rhizotomy and other neurosurgical treatments of CP, followed by a section on orthopedic treatment. The orthopedic treatment is, as expected, heavily weighted toward the approach used by the staff at Gillette, much of which is based on the work of Delp and his associates on muscle length. Although this work is theoretically very interesting, I think that there is too much emphasis on this derived data on muscle length. In my own thinking, it is the tension within the musculoskeletal unit which is the critical factor and not the calculated length of the musculotendinous unit. The final section includes excellent chapters on measurement tools and the long-term consequences of interventions using the World Health Organization (WHO) framework for disease and function (ICDF), which examines the multiple domains of function of a person with a chronic handicapping condition. There is also an excellent chapter on the important topic of post operative management. Given that most authors are from the Gillette system, there is a heavy emphasis on the philosophies followed there in the treatment of patients with CP and very little mention of other approaches, and it should be recognized that there are other procedures and approaches which may also be quite valuable, and none of us has the final answer to what is the best treatment for any given patient. Certainly, there are still many people who treat patients with CP who feel that tendon lengthening procedures are quite valuable in the treatment of these patients. In addition, the single-event multilevel surgery (SEMLS) approach is stressed, which may work quite well for the people at Gillette, but has the problem of making others feel that if they don’t correct all of the deformities in one sitting, they have not treated their patients properly. The non-orthopedic staff at Gillette refers to these multilevel bone and soft tissue surgical events as “shark attack.” Certainly, there is room for a sequential approach to treatment and it should be stressed that if one is not certain that a particular operative intervention is indicated as part of the overall package, that this can wait and can be done at a subsequent surgery. The old concept of birthday surgery as articulated by Mercer Rang is certainly not to be resurrected, but this approach began with Achilles tendon lengthening as the first in the sequence of “birthday surgeries” which we now know is probably the last thing one should do in this patient group. In addition, only the authors’ preferred techniques are presented, such as only proximal correction for femoral torsional deformities. I’m sure that their method of correction of tibial rotational deformities works well for them, but it is a bit complicated, and this procedure can be done much more simply if one uses the supine position and places wires for rotational correction. However, these nit-picking comments should not detract from the huge value of this text. It is an excellent book which should be read by all clinicians caring for patients with CP. This book provides an excellent starting point for approaching understanding and treatment to improve the lives of our patients with CP.