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• W2166362244 abstract "SIR–I have read with interest the article by Novak et al.1 I applaud the effort made by the authors to establish which interventions are evidence-based in this field of clinical practice. However, I believe that, in its present form, the article is confusing, misleading, and potentially dangerous if its recommendations are perceived as prescriptive by clinicians and/or families. Cerebral palsy (CP) is not a single clinical entity: it encompasses a wide variety of clinical syndromes which are often very different. The clinical management needs of an ambulant child with athetoid CP, for example, are very different from those of a non-ambulant child with spasticity affecting the whole body. Therefore, a wide variety of treatment modalities are necessary to cover the wide variety of clinical needs. Some of these treatment modalities may be effective for only a small subgroup of children with CP. Attempting to establish the evidence of treatment efficacy for the whole population of children with CP without recognizing the heterogeneity of the condition is misleading. Establishing the efficacy of single-event multilevel surgery in children with diplegic spastic CP is extremely challenging. This is because of the small number of children treated (circa 100 per year in the UK), the variety of surgical interventions necessary, and the heterogeneity present, even within this small subgroup. Attempts to produce good quality randomized controlled trials in this population are affected by recruitment problems, ethical and funding issues, and the difficulty of these trials reaching sufficient statistical power because of the small sample.2 The small number of good quality trials in this field reflects the inherent difficulty of organizing them and not necessarily the lack of treatment efficacy. In this situation, clinical practice should be led by the best available evidence. Unfortunately, the Novak et al. article excluded this option by introducing the traffic light system criteria. Contrary to the example used above, pharmacological trials are easier to organize and the abundant literature on those is evident. It is not surprising that the evidence for the use of botulinum toxin (BoNT-A) for the management of spasticity is readily available. However, clinicians are aware that the indications for the use of BoNT-A are different to those for orthopaedic surgery. Muscle contractures and secondary bone and joint deformities cannot be corrected with BoNT-A. Orthopaedic surgery does not treat spasticity. Comparing the evidence on the efficacy of those two treatment modalities, which aim at treating different problems, in the management of the whole population with CP is confusing and misleading. Whether or not there is evidence on the efficacy of a treatment modality depends on whether or not trials have been conducted to test this particular treatment. This, in turn, depends on feasibility, funding, availability of appropriate and validated outcome measures, and ethical issues. As the present article shows, evidence is available when a simple question can be asked through a straightforward trial design. The evidence is scarce when study designs are more complex for the reasons discussed above. This suggests that assessing the evidence on the efficacy of a large number of treatment modalities aimed to address a wide variety of clinical problems in a heterogeneous condition is flawed. Going a step further and using the traffic light system incorrectly to guide treatment decisions is dangerous: clinicians and families are often attracted by over-simplified management algorithms, particularly if they are said to be based on evidence. This over-simplification does not take into account the individual condition and needs of the patients, and is likely to lead to clinical decisions that are not in their best interest. Further to that, it may rule out treatment options necessary for the individual patient. An example of a misleading and confusing message included in this paper is that on the management of hip displacement. Surveillance is given a green light whilst orthopaedic surgery is given a yellow light. Surveillance in itself does not maintain a displaced hip in joint as it does not represent a form of treatment. The Swedish paradigm3 provides excellent evidence that combining surveillance with preventative surgical intervention and, in some children, the addition of bony surgery, can maintain hip integrity. Orthopaedic surgery is often indicated in the management of children with CP to treat or prevent painful musculoskeletal deformity.4 Hip displacement is one example but there are many others: painful foot deformities in both ambulant and non-ambulant children, patella-femoral pain, skin breakdown, and infection in the hand caused by finger contracture, to name a few. Severe scoliosis can cause cardio-pulmonary compromise and pain. However, these issues have not been addressed in the article. Producing good quality research to demonstrate the efficacy of orthopaedic surgery in alleviating pain and in treating potentially life-threatening conditions is not straightforward for the reasons discussed above. The advice from the present article is to approach yellow lights, in this case orthopaedic surgery, with caution. On clinical grounds it is self-evident that painful and potentially life-threatening conditions should continue to be treated despite the scarce evidence. The traffic light system suggested in this article can easily mislead clinicians and patients/families and deprive children from beneficial treatment." @default.
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• W2166362244 date "2014-03-14" @default.
• W2166362244 modified "2023-10-02" @default.
• W2166362244 title "Comments on a systematic review of interventions for children with cerebral palsy" @default.
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• W2166362244 doi "https://doi.org/10.1111/dmcn.12401" @default.
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