In/ . Rohnhil. Mcd. 1984: 6 : 25-30 0 Eular Publishers -

Symposium

Functional electrical stimulation in external control of motor activity and movements of paralysed extremities

Research and clinical practice and applied technology in Yugoslavia

FKANJO GRACANIN

Summary Functional electrical stimulation (FES) has been described as electrical stimulation of muscle deprived of nervous control with a view to providing muscular contraction and producing a functionally useful niovcment. I t is used in the rehabilitation of neurological and locomotor disorders. Its effects can be explained in a number of ways: (a) a s a functional reorganization of the interneuron system, (b) the formation of alternative pathways. and (c) changes in the morphology of cells of the central nervous system. The results of research and development are presented.

Resume La stimulation electrique fonctionnelle (FES) est une technique basee sur I'electro-stimulation d u muscle depourvu d'innervation volontaire: elk a pour hut d'entrainer sa contraction et un mouvemeni dirige. La methode s'npplique dans le cadre de la reeducation fonctionnelle de diversesaffections neurologiques et atteintes de I'appareil locomoteur. Ses ellets benefiques peuvent etre expliquesde plusieurs faqons: (a) reorganisation fonctionnelle d u systeme des interneurones: (b) formation de voies de transmission de rechange: (c) modifications histo-morphologiques des cellules du systeme nerveux central. L'auteur fait le point de la recherche actuelle dans ce domaine.

Zusammenfassung Die funktionelle elektrische Stimulation (FES) ist definiert als Elektrostimulation von Muskeln, welche der nervosen Kontrolle berdubt sind, wobei man der .4nsicht ist. eine muskulare Kontraktion und eiiie funktionell nutzliche Bewegung zu erzieien. FES wird in der Rehabilitation von Patienten mit neurologischen Krankheiten und Funktionsstorungen des Bewegungsapparates angewendet. Die Wirkungen konnen auf verschiedene Weise erklart werden: a) funktionelle Reorganisation des interneuralen Systems. b) Ausbildung alter- nativer Leitungsbahnen, c ) Veranderungen der Morphologie der Zellen des zentralen Nervensystems. Die Ergebnisse von Forschung und Entwicklung werden beschrieben.

Resumen El estimulo electrico funcional (EEF) se ha descrito como el estimulo electrico del musculo carente de regulacion nerviosa, con vistas a aportar contracciones niusculares y producir un movimiento funcionalmente util . Se emplea para la rchabilitacion de trastornos neurolbgicos 4 Iocomotores. Sus efectos pueden explicarse de distintas maneras: (a) como una reorganizacion funcional del sistema de interneuronas, (b) la formacion de vias alternativas, y (c) cambios de la morfologia de las celulas del sistema nervioso central. Se presentan 10s resultados de la investigacion y desarrollo.

Key words injury patients - Idiopathic scoliosis - FES systems.

('orrc,.\/"jti~/[~n[,[, to:

Rehabilitation - Functional electrical stimulation - Hemiplegia - Cerebral palsy children - Multiple sclerosis - Spinal cord

Franjo Gratanin. MD. DSc.. Professor. Department for Physical Medicine and Rehabilitation. University Hospital "Dr. M. Stojadinovic". Vinogradska 29. 41000 Zagreb. Yugoslavia.

In the last 20 years the use oflow-frequency currents has been constantly acquiring popularity. not only in the treatment of pain but also in the conrol of movements, both motor func- tions in general and motor reflex mechanisms. It has proved most effective in patients with impaired upper motoneurons with siniple defects of motor activity such as drop-foot.'-3 In addition to the control of striated muscle contraction of the extremities, the use of currents has been found advantageous in controlling the function of the urinary bladder, sphincter and diaphragm. Preserved electrical excitability of periph- eral nerves and contractility of muscles represented a pre- requisite for long-lasting and chronic use of electric pulses applied through the skin surface to control movements and motor functions.

The development of electronics and miniaturization of electric pulse generator5 led to portable systems which a dis- abled person can easily use in everyday life. In 1954 and 1956. independently of the use of low-frequency currents in the treatment of spasticity. faradic currents were first used in Yugoslavia in the control of dorsal foot flexion and eversion during the swing phase o f a hemiplegic's gait. The beginning and the duration ofstimulation were controlled by a physical

therapist and the method itself was primarily therapeutic in nature, as evident from the improved gait and posture after the stimulation had been stopped. Soon after that, research directed to this specific question was started. This promoted the study of the organization ofmotor activity in man and the changes involved in i t . together with the development of technology and the biocybernetic principles of external movement control.

The first result ofsuch an interdisciplinary approach was a clinical application of the Electronic Walking Aid4 system which, due to the large size of the stimulator and the batteries, was applicable exclusively in the course of the therapeutic programme at the institution. It was followed by miniatur- ized FES systems5-' intended primarily for the control of dorsal flexion and eversion of the foot in hemiplegic patients during gait. Of these systems the clinically most widely used are those of Ljubljana Functional Electronic Peroneal Brace type PO 8, evaluated in the USA and admitted to use by the Board for Food and Medicines in WashingtonX (Figure I). Another system in extensive clinical use, intended to be used by patients independently a t home, is FEPA lo9 (Figure 2). Similar technically improved systems have been developed.

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~ _ _ _ __ Int Rchahrl . I f i d . 1984; vo1.6. no. I

flastic Knee suppwt with electrodes

Stimulator

i = I

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Figure I Functional Electronic Peroneal Brace type PO 8.

The first clinically applicable FES system: Ljubljana Figure 2 Patient with an applied FES skstem type FEPA 10

Figure 3 Ljubljana Functional Electronic Brace type FEPA I I . Its characteristic feature is a wireless connection between the switch in the insole of the \hoe and the pulse generator. For this reason a transmitter is built into the insole.

Figure 4 Microles system primarily intended for the stimulation of n. peroneus. Due to its small size i t can be adjusted onto a knee support close to stimulation sites.

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GRAi'4NlN: F t S in external control of motor act ib i tb

For example. FEPA 11 with wireless connection between the generator ofelectric pulses and the switch built into the insole (Figure 3)." Younger hemiplegic patients with less seriously impaired motor functions benefit by a Microfes system 'I (Figure4)fixed onto theextremityat the knee height,close to n. peroneus to be stimulated.

Simultaneous clinical and neurophysiological studies have shown that by this method it is possible not only to improve the kinematics ofgait and posture, but to facilitate externally motor activity in agonistic muscles and inhibit antagonistic muscles.l?.l3 Mechanisms of reciprocal innervation which are absent in this type ofpatient, and which are a prerequisite for performing selective muscle contraction and functional movement^'^ (Figure 5) . can be restored. T h e knowledge of these ficts, as well as selective movements of fingers and wrists provoked in laboratory conditions with a hemiplegic patient. encouraged the development of electronic systems such as the Ljubljana Functional Electronic Radial Brace'' (Figure 6) and Hemifes." In both cases a controlled contrac- tion of linger and wrist extensors is involved; however, it should be noted that with the second system the duration and the intensity of stimulation are proportional to the effort under voluntary control of the patient. They are applicable to heniiplegic patients capable ofvoluntary control offlexion who, however. cannot perform extension due to the paralysis of extensors and an excessive tonus in flexors.

The experiences acquired with patients suffering from hemiplegia and parapareses have made it possible to transfer the method first to the rehabilitation of patients with mul- tiple sclerosis and subsequently also to the rehabilitation of cerebral palsy children.

Reside the existing FES systems using surface electrodes. systems using implanted electrodes adjusted close to the nerve1'-'' have been developed. With certain patients these produce a more functional aid than the systems usingsurface elcctrodes.

For the purposes ofcontrolling the mechanisms ofgait and posture there has been development of multichannel sys- terns.?"-" These were first applied to hemiplegics and later on to patients having paraparesis at various levels. The devel- opment of two-channel stimulation and stimulation se- quences made possible the use of FES with cerebral palsy

In these cases the sequences differ somewhat from those selected for adults but improved kinematics of gait could be achieved together with reduced equinovarus.

internal rotation. walking with overlapping feet and exces- sive hip and knee flexion (Figure 7). Table 1 shows different modes ofstimulation control and their application in clinical practice.

Indications for FES

In applying FES systems two approaches are at our dis- posal.

1 . From a medical point of view the first approach is repre- sented by the applicability of FES as a therapeutic method during rehabilitation. o r else the application of an FES system which the patient applies independently at home for different periods of time as an orthotic aid with a therapeutic efrect. In this approach it is only a temporary application of the system (from some weeks to some years).

2. The second approach is more cybernetically oriented and implies the use of an FES system as a substitute for a lost motor function which the patient can apply for an indefi- nite period of time irrespective of the therapeutic effect.

At present. the use of FES systems for an infinite period of time is not acceptable for different reasons, the most impor- tant of which are as follows: (a) as yet imperfect interface technology, (b) unreliable functioning of the system due to defects of the peripheral parts of the system such as connec- tion wires and switches, (c) impossibility o f a n optimal posi- tioning of electrodes, together with difficulties with patient acceptance and application of the system (often as a result of psychological, social. geographic as well as climatic factors). Therefore. in addition to medical indications, other factors should also be considered when prescribing FES systems. They are factors conditioning or restricting their use in com- parison with classical orthotic or electronically more sensi- tive and more exacting slstems.

For these reasons the application of FES systems with hemiplegic patients in order to control dorsal flexion and eversion of the foot duringgait is indicated in only 25-30'%) of hetniplegic cases treated at rehabilitation institutions. With patients suffering from multiple sclerosis there exists an indi- cation for the application ofsimilar systems when the patient is still capable ofwalking. though with difficulty and by using

Figure 5 FES for a longer period of timc. There can be observed restoration of reciprocal inhibition with rcspect 10 single phases ofgait.

EM(; record ofmuwlcactivity during the gait ofa healthy subject (1eft)and a heniiparcticalier the recover) from CVI. who has used

NORMAL, PERSON HEM IPLEG IC PATIENT

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Table 1 Modes of controlling the stimulation of nerves and leg muscles

~~ ~~ ~~ ~~~

I . Unilateral one-channel stimulation Electrical stimulation starts with Heel-off in the phase of support and lasts during the whole swinging phase t i l l Heel-strike. The variant are so-called Preset. when the stimula- tion time is defined in advance. and “walking rate”,when the stimulation time is regu- lated by the walking speed. These time intervals are usuall) shorter than. for example. in the Heel-off-Heel-strike,

(a) lpsilateral control

(b) Contralateral control

2. Bilateral one-channel stimulation (a) lpsilateral control (h) Contralateral control

Electrical stimulation begins with the stance phase and lasts t i l l the beginning of swing phase ofthe non-stimulated leg. Variants Preset and walking rate are possible.

Stimulation sequences are partly covering themselves Characteristics are the same as in I.(a) and l.(b).

(c) CCA FES (contralaterally controlled Stimulation of left and of right leg i s reciprocally dependent. and the stimulation alternating functional electrical stimulation) sequences do not cover themselves.

3. Two-channel stimulation

4. Multi-channel stimulation

Represents stirnulation of two nerves or stimulation of the corresponding antagonistic muscles of one joint, or the stimulation of synergistic muscles of two or more joints.

Stimulation of many muscles or muscle groups and nerves with application of stimula- tion sequences with which we wish to simulate the muscle activation pattern during the gait of normal person.

aids such as a walking stick, crutches or with the help o f another person, and with whom electrical excitability of peripheral nerves has been preserved. Apart from other insti- tutions in the word, about 2000 patients ofthis type are being treated in our institutions. Many of them still apply stimu- lation systems at home, whereas others have stopped using the aid due to improved motor activity. The FES methods developed for children, namely contralaterally controlled stimulation and contralaterally controlled alternating FES, have also rendered possible the application of FES in serious cases of children incapable of motion. To date we have had 400 cases (unilateral o r bilateral) irrespective of the clinical picture such as hemiplegia, diplegia. monoplegia, etc.

A particular application oIFES systems concerns children with idiopathic scoliosis.25-2’ with whom the stimulation of paravertebral muscles above the convexity of the curve is indicated as a result of electrophysiological analyses and clinical manifestations. A theoretical basis thereto is implied in the changes of postural motor mechanisms2x which has

Figure 7 Child with spasticdiplegia using bilateral FES ofperoneal nerves. The improvement i s evident from the absence of equino- varus. internal rotation and walking with overlapping feef.

Figure 6 Ljubljana Functional Electronic Radial Brace. The switch is positioned on the forearm, in the vicinity of the elbow: on its contact with a surface i t activates a generator or electrical impuke which i s located above the finger and wrist extensors.

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GRACANIN: FES in external control of motor activity -

been confirmed by drastic changes in the pattern of the EMG activity of paravertebral muscles following electrical stimu- lation of several weeks’ duration.’M In addition to this ap- proach, t he possibi I it y of segmen tal insu fficiency ?9 has been considered, and on this basis the explanation of the effect of FES is much more difficult.

In addition to the aforementioned systems and methods as used in clinical practice with predetermined indications, contraindications and application procedures, patients suf- fering from multiple sclerosis have, in the last few years, been given epidural stimulation. This requires surgical interven- tion and for the time being is intended to improve certain motor functions as well as the function of the urinary blad- der.”.” Due to its most exacting character, as well as the size of the system itself, the aforementioned multichannel stim- ulation is applicable a t institutions specializing in rehabili- tation and research. and has no wider application. In certain cases of spinal cord injury the present investigations have pointed to the possibility of maintaining the patient in an upright posture and achieving marching in parallel bars, or with the help of suitable stilts. This has been done by posi- tioning the electrodes in a certain way and applying pro- grammed stimulation sequences. In such cases the practical application of FES, being still sporadic, continues to be an object of investigations and is clinically applied only on indi- vidual patients.’?,’?

References 1 . GRACANIN. F.. PREVLC, F. and TKONTELJ, I. Evaluation of use of

functional electronic peroneal brace in hemiparetic patients. Proc Intrrnutionul Symposirtm on E.t.ierna1 Control of Human E.\-tremitrr.c. Dubrovnik. 1966. Belgrade: Yugoslav Committee for Electronics and Automation. 1967; 198-205.

?. GHACANIN, F. The role of functional electrical stimulation in rehabilitation. Eiiropu . b f d Ph jx 1972; 8: 48-55.

3. GRACANIN, F. Functional electrical stimulation in control of motor output and movements. E l ~ ~ c ~ t r o ~ ~ n c i ~ p h a l o ~ r . Clin. Ncuro- phi:siol. 1978; 34: 355-368.

Electronic walking aids for patients with peroneal palsy, World .Wed E k ~ c m J n . . 1966; 4 (2): 58-61.

5 . GRACANIN, F. Electrical stimulation as orthotic aid: experiences and prospects. In: Murdoch. G. (ed.). Pro.\thrlrc und Orthotic Practicv. London: Edward Arnold, 1969; 503-511.

6 . G K A ~ A N I N , F., KHAI.J, A. and REHEKSEK, S. Advanced version of the Ljubljana functional electronic peroneal brace with walking rate controlled tetanisation. In Proc.. Int~~rnutionul Sj,mpo.srum on E.t.tcsrna/ Control of’Hlrman E.\-trrmirrc% Dubrovnik. Yugo- slavia. 1970; 487-493.

7 MAI.Eilc, M.. TRNKOCZY. A,, REBERSEK, S., ACIMOVIC, R., GHOS. N.. STROJNIK. P. and STANIC, U. Advanced cutaneous electrical stimulators for paretic patients’ personal use. In Proc. Intc~rnutional Symnposium on E.xtcwiul Control O / Hurnun Ex- trcwrtic.s. Dubrovnik, Yugoslavia. I978 : 233.

8. CHAPANIN. F. In.striiciion .2lunitul,/iir I . s a j i r yf Lphl jana Func- tioriul E/wlrunic Bruw 7:lpcp PO8. Houston: TIRR, 1971 ; 24.

9. GRACANIN. F. and VHABIC. M. In\truction .bfaniiul/i)r Ljirhljanu I . ‘ i ~ t i c ~ t i o n a I Elt,ctronic, Peronoal Bruce i’:rpc’ F-EP.4 10. Ljubljana: ZRI. 1974.

10. Jt.cii.iC, A,. SMOLNIK. R.. URSIC. I . and G R A C A N I N . F. Radio- frequency peroneal brace with surface electrodes RPB 2. F i n d R q w I ufPrujtW 19-P-58391-FOl. Ljubljana, 1971 ; 20-23.

1 1 . VOIWVNIK, L.. S T A N I ~ . U.. KKAIJ. A,. ACIMOVIC. R., G R A ~ A N I N .

tional electrical stimulation in Ljubljana. Projects, problems, perspectivcs. In: Hambrecht, F. J. and Beswick. J . B. (eds). Firnc- iionu/ k,.kWricd Stiinulatron. App/ic.uiron.c in Neural Prosthese.s. New York-Basel: Marcel Dekker Inc., 1977; 39-54.

12. G R A C A N I N . F. Possibili meccanismi neurofisiologici implicati durante la stimularione electrica funzionale. Lo Riahihlazionc.

4. VOIIOVNIK, L., DIMITRIJtVl~. M. R., PRWW. T. and LOGAR, M.

F., GHOBEI.NIK. S., SUHEL., P., G(K‘t.C. D. and PIXVNIK. S. Func-

1973; 3: 101-107.

Both for one-channel and multichannel stimulation a number of biomechanical models have been constructed, based on various mathematical representations. Considered therein is the modelling of musculoskeletal and neuromus- cular systems.34

Further investigations are under way to determine the effects ofelectrical stimulation ofperipheral nerves upon the more complex organization of motor activity, the effects of which have already been established clinically. In addition, neurocybernetic investigations are in progress and they should contribute to a better understanding of the underlying mechanisms and to the development of more sophisticated devices for external control of movement. Account should be taken of the possibilities of both afferent and efferent FES in relation to their effect upon the change in the organization of motor activity. Parallel to the already developed FES meth- ods and FES systems, and investigation programme has been promoted into methods and techniques of objective evalua- tion of therapeutic effects upon the mechanisms of gait and posture as well as hand movements. These make possible qualitative and quantitative evaluation of the changes in the kinematics and kinetics of gait and posture, as well as in reflex motor mechanisms and patterns of both voluntary motor activity and those movements provoked by means of FES.

13. D I M I T R I J E V I ~ , M. R.. GRACANIN. F., PRF:VEC, T. and THONTFLJ, J . Electronic control ofparalyzed extremities. Bio-Mrd. Eng. 1968;

14. GRACANIN. F. Use ofelectrical stimulation in external control of motor activity and movements of human extremities. M P ~ . Prog Techno/. 1977; 4: 149-156.

15. G R A ~ A N I N . F. and DIMITRIJEVIt, M. R. An electronic brace for externally controlled movement in wrist and fingers of the hemi- paretic patient, In Proc Symposium on E/ectronic5 in Medicine. Ljubljana, Yugoslavia. 1968: 9.

16. GRACANIN, F. Study of physiological and electronic problems of functional electrical stimulation in central paresis of upper extremities. Report to Research Community of Slovenia. Lju- bljana, Yugoslavia, 1967.

7. V A V K ~ N . E. Implantable functional electrical stimulation and surgical problems. Proc. 4th International Sjwqwsi i tm on Euicr- nal C’ontrol oflluman E.x-ircJmicies, Dubrovnik, 1972. Advances in External Control of Human Extremities, Yugoslav Committee for Electronics and Automation, Belgrade, 1973; 554-560.

8. JEGLI?. A. Two-channel implant approach to an orthotic device. Proc. 4th lnternutional SjImpo5ium on E.rternal CiJnirol y f Hit- man E.t.trc~mrtrc.s. Dubrovnik, 1972; 647-656.

9. STROJNIK, P.. GRACANIN, F. and VAVKEN, E. The present state of the Ljubljana implant. Advances in External Control of Human Extremities. Proc. 6th International Svmposium on E,uicvnal Control ($‘Human E.utremitics. 28 August-I September. Du- brovnik, Belgrade, ETAN, 1978; 269 -275.

20. K R A I J . A. and GROBELNIK, S. Functional electrical stimulation - a new hope for paraplegic patients? Bull. Prosth. Rex. 1973;

2 I . STANI?, U.. ACIMOVIS, R., BAJI), T., GKOS, N. and K L J A J I ~ . , M. The use ofoptimal multichannel stimulation in the correction of hemiplegic gait. Advances 1 1 1 E.t.trrnu1 Conirol (?/‘Human Ex- tretnitics. Belgrade: Yugoslav Committee for Electronics and Automation, 1975: 269-278.

22. ACIMOVIC, R., STANiC. U., GROS, N. and BAJI), T. Correction of hemiplegic gait pattern by multichannel surface stimulation dur- ing swing phase and stance phase. In: Komi, P.V. (ed.), Bionie- chanic.5, V-4, Inter. Ser. on Biochem. VoL-la, 1976; 444-451.

23. GRACANIN, F.. V R A B I ~ , M. and VRABIE, G. Six yearsexperiences with FES method applied to children. Eur. Med. P h w 1976; 12: 61.

24. GRACANIN, F. Evaluation of “CCA” FES system in habilitation

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of CMP children. Final Report to Research Council of SR Slovenia. M-309/87600. Ljubljana, 1980.

STWANPIC. M. FES in external control of some mechanisms in idiopathic scoliosis. Proc. 5th Intcwiutrotiul .Sj~mposiurn ow E.vtornul Control of’ Ifitmuti E.vtremitii,.s. ETAN. Yugoslavia. Dubrovnik, 1975: 45-58.

26. G R A ~ A N I N , F. and B I ~ J A K . F. The role of postural reflex mech- anisms in etiopathogenesis of vertebral column deformities. Proc. .Y~,rnpo.\iirrn oti .Yudio.\i.\ atid KIpho t i .~ . Zagreb, 1977; 201-266.

27. G K A ~ A N I N . F. and BIY-JAK, F.. PreSeren-Strukelj. M.: Importance ofelectrophysiological analyses for determining an optimal ther- apeutic program for patients with idiopathic scoliosis. Proc. 6th LSjwpo.~iitm ot? Scoliosis and K!pho.rr.s. Zbornik na Trudovi. Skopje, 1979; 79-86.

28. GRA~ANIN. F. Functional electrical stimulation in the treatment of idiopathic scoliosis. Rchuhrli/aciju. 1982: 3: 141-147.

~ ~ . G K A ~ A N I N . F.. V R A U I ~ . M.. BILJAK. F.. U<;KONOV%i. S. and

29. T~oh’ I t i .~ . J.. PtCAh. F. and DIMIIRIJFVIC., M . R. Segmental neu- rophysiological mechanisms. Pro(, Sj,mpo.\irofi o t i Sco/io\i.\ otid Ktphosis. Zagreb, 1977: 273-278.

30. D I M I T R I J E V I ~ . M. R.. SH~.RWM)II. A.M. and F A ~ ~ A N I L . J. Mech- anisms of motor control augmentation using continuous epidural spinal cord stimulation. In Proc /n/Prnu/iotia/ . y jwpos iurn oti E.wrna1 (’ontrol ol’Hitmun E.v/rcmitio.s. Dubrovni k. Yugoslav- ia, 1978; 657.

3 I. G R A ~ A N I N , F. Functional electrical stimulation. In: Kottke, J . F.. Stillwell, G. K. and Lehmann. F. J. (eds.), Krii.swi.\ Hutidhook o/ Physical h-lrdicirrc utid Rchahrli/a/rori. Philadelphia: W. H. Saunders, 1982; 372-385.

32. VOUOVNIK. L., BAJI). T.. KRAI-J, A,. G R A ~ A N I N , F. and S I R O J N I K .

P. Functional electrical stimulation for control of locomotor systems. (‘RC‘ Crri. R w B i t w r y . 1981: 6: 63-131.

Book reviews

The literature of back pain

A Buck Puin Bihliogruphi.. Barry Wyke. Lloyd-Luke. London. f 17.50, 463 pages. ISBN 0-85234-193-7.

The literature on back pain is dispersed among innumerable medical and scientific publications. I t encompasses anatomy. physiology, neurology, histology. biochemistry. mechanics and pathology within the basic sciences and numerous clinical aspects such as diagnosis. pathogenesis. epidemiology. sociology, psychological and legal as- pects as well as various treatment methods.

Professor Wyke has accomplished a monumental task by extract- ing from the literature those papers which have research relevance, historical significance or which contain contrasting or controversial contributions from different countries. The papers are mainly in the English language and include publications up to the end of1979. It is intended to publish 3-yearly supplements. Professor Wyke has devised his own classification into categories, most of which are mentioned above. In the section on Diagnostic Features. papers on thermography. skin elasticity and electrical resistance are listed under “Dermography”. I would have preferred “Dermometry”. If. as I suspect, the volume was compiled without the aid ofa computer or word processor, it is the more impressive ifperhaps somewhat less than perfect in its cross-referencing.

Within each section, references are listed alphabetically by author and papers which deal with several aspects ofback pain are listed in more than one section. I t is possible to get an impression of the formidable amount of work which has been published about the spine and about back pain. Therefore it is unfortunate that we are still so far away from the definitive answers in this field. In fact, less than 6 per cent of the text is devoted to references on treatment. References on analgesic drugs are justifiably excluded and there are very few references on acupuncture or TENS. References to more recently developed diagnostic methods are lacking. mainly because ofthe restriction ofthe bibliography to work published before 1980. Such methods as ultrasound scanning. computerized axial tomogra- phy. radioactive scanning and nuclear magnetic resonance will hopefully appear in the supplements.

The bibliography provides a reliable review of scientific work on the variousaspects ofback pain published in the English language. It might have been easier to keep i t up to date i f i t had been published as a paperback. I note that although the Back Pain Association. who sponsored the book, aim to promote research into the causes. treat- ment and prevention of back pain. they have seen lit to place full copyright restrictions on this volume.

W A L T ~ K LOFHI.

A practical approach to cerebral palsy

Ear!,* DiaRnosis and Therup? in (‘(whrul Pulsj,. Alfred L. Scherzer and Ingrid Tscharnuter. Marcel Dekker. Inc.. New York, 1982. 289pp.. with 70 illustrations. SFr. 105.-. ISBN 0-8247-1 828-3.

Children with cerebral palsy still constitute a large part ofthe work of the clinicians and therapists ofthe district child handicap centre for whom this will be a welcome vude mecum. Subtitled “A Primer on Infant Development Problems” i t is the third ofa series on pediatric habilitation, the first two volumescovenng the prevention ofmental retardation and the management of developmental disabilities through diet and medication. This book starts by defining the prob- lem of cerebral palsy and its aetiology and an interesting spot of history. The eight subsequent chapters cover neuro-developmental assessment and diagnosis, management in clinic and at home. and assessment of treatment. Although there is plenty of theoretical dis- cussion the flavour ofthe book is essentially practical. reflecting the wide experience of the authors. a paediatrician and a physical ther- apist. I t is particularly welcome to read of their comprehensive approach to the child and its Family. thus avoiding an over-narrow pursuit of abstract neurology. However, neurology must be served and it is disappointing to find that intraventricular haemorrhage and other discoveries of the physician caring for the newborn and his

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ultrasound equipment go unmentioned. There is a realistic assess- ment of the various eponymous treatment regimes and a crisp dis- cussion of the limited place of drug therapy. The descriptions of normal and abnormal motor development and the early and subtle signs of cerebral palsy are especiallb good. There are many useful photographs of the physical and developmental signs and several examples of checklists for recording assessment and progress. I t is particularly important to be objective about treatment. and the final chapter is a balanced assessment of research in this field, with a helpful section on the difficulties in conducting controlled studies.

The index lacks detail; the references often cite a single (and pre- sumably the first) initial of authors - effectively disguising the authorship of two British professors of paediatrics - and citing unpublished lecture notes really will not do. Despite these unfortu- nate lapses in polish the book is recommended as a practical and compact introduction to a subject whose management has pro- gressed spectacularly from the mechanistic and orthopaedic train- ing of individual muscles to the comprehensive and co-ordinated appraisal and management of the disabled child and his family.

TIMOIIIY CIIAMB~M

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