DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY. 1973, 15

I am not trying to proclaim magnificent results from physiotherapy treatment as I simply do not know, and I have the same doubts which lead Drs. Wright and Nicholson to under- take their study. However, I am afraid that their attempt to offer an answer is not sufficient, as their study actually raises more questions than it answers.

Department of Developmental Neurology, University Hospital, Oostersingel 59, Groningen, The Netherlands.

B. C. L. TOUWEN

’The above letter was shown to Dr. Trevor Wright, who has replied as follows: SIR-I would like to thank Dr. Touwen for his critical appraisal of our paper. It was precisely because of our concern about development that we chose development age groups, and we also stated in the text that there was no significant difference between the age ranges of the children allocated to the three treatment groups.

Patients with the same type of cerebral palsy were compared. We are aware that-like any disease-there are differences in severity of clinical findings and pathology. Random selection is probably the best way of taking care of this difficulty, otherwise the evaluation of treatment of any disease process would not be possible. The numbers in sub-groups were small, nevertheless the statistical results all tended to go the same way when considering small sub-groups or larger aggregates. The clinical impressions were in accord with the statistical results. There was nothing in either the clinical findings or the statistical results to lead us to the belief that a study of larger numbers would produce a different conclusion. When starting the study, we did not feel that withholding ‘treatment’ for more than one year would be ethically acceptable. We are, however, going to review the patients who had no treatment for the first 12 months and compare their subsequent progress with those who had, because it has repeatedly been said that early physiotherapy prevents contractures and hastens the development of locomotion. Dr. Touwen says that developing children may not act as their own control. If not, then I presume he would expect the children who were in the study for one year to score better at the end of that year, not only because they had treatment for the last 6 months but also because they were older. The results in table IV do not support this. Of course I agree that there are immense difficulties in comparing one child with another,

either normal or with cerebral palsy, because of the neurological considerations. However, we must not get lost amongst the dendrites when considering some plain facts. They are that when a child with cerebral palsy is presented for treatment an assessment such as we have out-lined is made (in most Paediatric Departments) and on this assessment a plan of therapy is based. That is what our paper is all about.

A final comment. It has been a great disappointment to me that in such an important and basic a subject as physiotherapy for the spastic child constructive criticism has been conspicuous by its absence. I would very much like to improve my own model for evaluation in this and other forms of treatment in this field. Perhaps one of the distinguished con- tributors to this correspondence will do this in detail. This would be a fitting conclusion to our discussions.

The Ryegate Centre, (The Children’s Hospital), Tapton Crescent Road, Sheffield, S10 5DD.

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TREVOR WRIGHT