Kote on (he Charnley-Muller arthroplasty Like the Charnley arthroplasty, this is also a metal _ lastic articulation but has a larger femoral head ° n j is available in three different neck lengths. It does not necessitate the transfer of the greater trochanter. T h e aim of the design was to provide 110° of motion ( s opposed to about 90° in the Charnley arthroplasty) without subluxation because this range of m otion in excess of 90° is very im portant in many activities of daily living- Post-Operative Management: This is much the same as the Charnley arthroplasty but the periods are much shorter. The patient may be walking as soon as 48 hours post-operatively, and re­ habilitation is generally m uch more rapid. SEPTEMBER 1974 Summary / The striking feature of this operation is that the patient is subjected to very little or no post-operative stress, in contrast to the rigorous rehabilitation de­ manded after partial hip replacement such as cup arthroplasty. Provided there is no mechanical mishap 9 or infection, pain vanishes, and because there is no reflex inhibition, movement of the new jo in t is easily regained. It is also unquestionable that the procedure of total hip replacement demands a high standard of team ­ work am ong the members o f the 'Unit, and successful outcome is dependent on this, factor. Opsoming D ie opvallende kenmerk van hierdie operasie is dat die pasient na die operasie aan m in of geen kommer blootgestel is nie. D it is in teenstelling met die drastiese rehabilitasie wat verwag word na gedeeltelike heup vervanging soos ‘cup arthroplasty’. Mits daar geen meganiese terugslag of infeksie is nie, sal die pyn ver- dwyn en aangesien daar geen refleksbeperking is nie sal die beweging van die nuwe gewrig m aklik herstel. D it is ongetwyfeld dat algehele heup vervanging ’n hoe samewerking onder die lede van die Eenheid vereis en die sukses van die operasie hang af van hierdie span- werk. Acknowledgements Professor L. Solom on and his U nit at Workmen's R ehabilitation Hospital. F I S I O T E R A P I E LETTERS TO THE EDITOR Forest Town School for Cerebral Palsied Children. 15th July, 1974. The Editor, Journal, South African Society of Physiotherapy, P.O. Box 11151, Johannesburg. Dear M adam , A comment on the article “ A short reappraisal of »he Principles o f treatment in Cerebral Palsy” by Miss •S. lrwin-Carruthers in Physiotherapy M ay 1974, seems called for to elucidate certain points that may possibly be misleading. Firstly, may I acknowledge the article as a valuable summary of the neurodevelopmental approach, which should be useful to all students and therapists who are working in this field. T hat this approach is basic in the treatment of cerebral palsy is now generally ac­ cepted. (That is why acquisition of knowledge of this approach is a prerequisite in this D epartm ent and eight of the eleven therapists are fully Bobath trained). U n ­ fortunately, the approach falls into disrepute when its disciples fail to keep up with its originators, who declare that they take the ideas of Peto, V oijta, P N F , absorb them, make them their own and use them, also claiming eclecticism (Personal com m unication 1972). This is why the originator o f the approach remains the greatest therapist in the world in the treatment of cerebral palsy. It cannot, however, be stressed enough that an .eclectic approach can only be successfully employed by therapists with a thorough understanding of norm al development (Peiper 1936) and the disturbances o f motor function in cerebral palsy (as far as present knowledge allows) (Bobath 1972) as well as of the different treatment methods. It is therefore safer for undergraduates or. inexperienced therapists to stick to one approach, even though the end result of treatment may not be as good as it would have been had different methods been used to deal with the multifarious problems which arise in cerebral palsy. It is also necessary to recognise that different methods of treatment have evolved, using the same sound neurophysiological principles on which the neuro­ developmental approach is based. One cannot ignore the work o f K a b a t and Knott, R ood, Brunnstrom and Voijta. In addition, as a caution, the oft quoted thought “neurophysiclogic” doctrine is a most perishable com m odity and it is a mistake to pin one’s hopes on a current interpretation” (M ead 68). As far as planning treatment is concerned, do we really w ant to retain prim itive patterns by utilising them early in treatment (as does Brunnstrom) or do we want to inhibit theiir effect and facilitate secondary re­ sponses? I think that here misunderstanding may be merely a matter of semantics. The argument against surgery and bracing adm irably describes the difficulties which may arise and be perpetuated when conditions for using surgery in cerebral palsy are not favourable. It is absolutely necessary to have a unit where the surgeon is not only conversant with the neurological condition of the child who has secondary orthopaedic problems (Samilson 66) but who is also prepared to work w ith the therapists (H o lt 66), thereby ensuring that the patient is w holly controlled and all treatment integrated. M ost o f the unfavourable changes should be avoided or overcome, but it should be pointed out that certain others, e.g. circulatory problems, are a prim ary symptom in cerebral palsy (Ingram 73) as are sensory disturb­ ances. These may in fact be improved by the increased m obility produced by surgery. As far as the shunting of spasticity is concerned, more recent studies have shown that even simple tendon release often results in unexpected improvement in a tone in a whole extremity as well as the homologous lim b. (N athan and D m itrijevic 1967). This has been one empirical observation also. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 10 P H Y S I O T H E R A P Y SEPTEM BER 1974 M A RE TOUR DAY A LITTLE E A SIE R ! You physios are a hard-worked group, we know. In the day’s work, environment and c o m f o r t b e c o m e m o r e a n d m o r e important — and while there’s not much we can do to help fix the background in which you work, you’ll find a comfy, practical working rig in the new special- purpose uniform we’ve designed with you in mind. It’s a continental style dress, with Bermuda-type shorts to match. A side vent in the skirt and the generous cut, mean that you’ll work more easily, and feel comfortable right through the hard day. Your option o f short or long sleeves, in drip-dry, hard-wearing fabric . . . white or saxe blue. Sizes 3 2 to 42. Elegance and efficiency . . . what more could you ask ? 4 th Floor, Pritchard House, 8 3 Pritchard Street, JOHANNESBURG. Telephone 2 3 -4 4 0 5 '. 8 7 M a rio n Avenue, Glenashley, DURBAN. Telephone 8 3 -7 2 2 6 . Fully illustrated catalogues and price lists o f our full range are available free to you. Just drop us a postcard (P.O. Box 7 5 2 , Johannesburg) or telephone 23-4405- any time, including nights, weekends and holidays. W e’re also happy to execute phone orders, o f course. O X 44 M R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Appliances, when used with discretion, are what they deally should be, a therapeutic aid, not a substitute for treatment. The argument against surgery and bracing may have been valid ten years ago, and still be so where the o r t h o p a e d ic approach t o this problem is ill considered and indiscriminate, and where there is no experience in post-operative treatment. But it does not apply if one uses the principles of treatment so well described jn the article under discussion, and combines them with ju dicio us use of braces and surgery, as is being done in c re a sin g ly in recognised overseas treatment centres CJVfilani Comparetti, Prof. Matthias). Dr. and Mrs. B o b a t h also recognise the need for surgery, although they are still very critical generally (Personal co m m uni­ cation, 1968, 1973). Certainly surgery and bracing should be avoided where facilities are not adequate to cope with the difficulties which may arise. The use of surgery has ifeen a hotly debated issue for many years, but the Controversy may not be a meaningful one as one cannot evaluate a method from a totally different conceptional framework. Possibly our approach has been rather narrowly inter­ preted. It is also unfortunate that surgery is often evaluated in respect of severely involved children, who present for surgery, after years with or w ithout treat­ ment, with severe deformities and very little potential. In some instances it may take many years of skilled therapy to establish the benefit from surgery. It is a fallacy to think that only untreated children develop deformities. Indeed, the answer is to avoid unnecessary surgery. That is why the two primary indications for surgery are firstly for the correction of deformities and secondly to prevent the form ation o f deformities where con­ certed physiotherapy is failing to do so. (Craig, 1973). I wholeheartedly agree that one would not plan to eliminate a Moro-reflex by hamstring transfer, but should the M oro disappear after a child has undergone surgery to prevent dislocation of the hips and to correct hamstring deformity, then I am indeed grateful for the fringe-benefit. 9 It has also to be borne in mind that' the habilitation of a child should be viewed in relation to his daily func­ tional requirements. One often has to compromise be­ tween the excellence of movement patterns obtained in limited therapy sessions and the imperfect carry-over of these movements into the activities o f daily living. Concerned as we are with the development o f the child as a whole, especially as regards his personality and independence of m ind and body (Erikson) we can­ not afford to sacrifice function to prove superiority of any particular treatment per se. Finally, let us remember that we are not considering any rigid or dogmatic technique of treatment, but 'that it is the neurodevelopment approach to the treatment of the cerebral palsied. T houghtful application coupled with procedures which have been empirically proved beneficial in no way detracts but certainly enhances the results of treatment. As summarised by Gillette (1969) “The complexities of the child with cerebral palsy present problems which can be approached by way of m any treatment philoso­ phies. Assumptions as to cause and effect relationships may be disturbing as a new system is brought into SEPTEMBER 1974 11 focus, but as its techniques become fam iliar, they are incorporated into the arm anentarium of the therapist, and the child’s disabilities may be further minimised. Systems of therapy which are yet to be developed will add further knowledge of the mechanisms o f the central nervous system. The therapist of the future will have an ever-broadening choice o f stimuli, and more effective means of com pounding reflexes to produce a co-ordinated m otion.” In this field, where m uch more is to be learnt than is already known, above all is needed an open and enquiring mind to possibly share in the excitement of discovery. I am,. Yours faithfully, A . M A T H IA S , Senior Physiotherapist. REFERENCES 1. Bobath, Dr. K . and Mrs: B: Personal C om m unica­ tion 1968, 1972. 2. Peiber, A. Cerebral Function in Infancy and C h ild ­ hood. Pitm an Medical, 1963. 3. Bobath, K . and B. (1972) “Cerebral Palsy” Physical Therapy Services in the. Developmental Disabilities.” Edited by Pearson, P. H. and W illiam s, C. E. 4. Gilette, H . E. Proprioceptive N euromuscular F acili­ tation” . 5. V oijta, Prof. Personal' Com m unication, 1972. 6 . . Brumstrom, S. Movement in therapy in Hemiplegia, Harper & R ow Publishers, 1972. 7. Mead, S. (1968). “The treatment of Cerebral Palsy” (Presidential address to the American Academy of Cerebral Palsy, 1967). 8. Samilson, R. L. Principles o f Assessment of the U pper Lim b in Cerebral Palsy. C linical O rtho­ paedics N o. 47 July/August, 1966. 9. H o lt, K . S; “ Assessment of Cerebral Palsy Vol. I, Lloyd — Luke (M edical Books) Ltd., London. 1 O'. Ingram , T. S. 1973. “Cerebral Palsy” Textbook of Paediatrics. Eds. J. O. Farfal, G . C. Arneil, Churchill Livingstone. 11. N athan, P. W . and Dmitrijevic, M . R., 1967. “Studies o f Spasticity in M a n ”, Brain. Vol. 90, part 1 . 12. Prof. M ilan i Camparetti. Personal Com m unication 1968, 1972. 13. Prof. H . M atthias Muuster C.P. 'C lin ic.'U n iv ersity Orthopaedic Clinic. Personal Com m unication, 1972. 14. Bobath, D r. K . and Mrs. B. Personal C om m unica­ tion 1968, 1972. 15. Craig, J. J. (1973). “The Orthopaedic approach to the treatment of Cerebral Palsy” , South A frican M edical Journal 47, 1904-8. 16. Erikson, E. H . “C hildhood and Society” . Penguin Books, Hogarth. F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )