The Musculoskeletal System in Children with Cerebral Palsy: A Philosophical Approach to ManagementMartinGoughAdamShortlandClinics in Developmental Medicine. London: Mac Keith Press, 2022 £75.00 (Hardback) pp. 192 ISBN: 9781911612537.

Abstract

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. Not required.