Book Review

The Cerebral Palsies: Causes, consequences, and management

N Engl J Med 1998; 339:1484November 12, 1998

Article

The Cerebral Palsies: Causes, consequences, and management
By Geoffrey Miller and Gary D. Clark. 368 pp. Boston, Butterworth–Heinemann, 1998. $75. ISBN: 0-7506-9964-7

Sometimes the taxi driver knows the diagnosis. Before the child arrives for his developmental evaluation, the driver is thinking, “This kid has cerebral palsy.” But recognizing cerebral palsy is not always so easy. It is even more difficult to articulate its characteristics, define its boundaries, and understand its causes and consequences. What characterizes the motor impairment we call cerebral palsy? The answer lies in the developing brain.

Cerebral palsy is a chronic, nonprogressive disorder that results from an abnormality of or injury to the developing brain. The Cerebral Palsies: Causes, Consequences, and Management meticulously details the various mechanisms of brain injury and causes of the cerebral palsies. By making cerebral palsy plural, Miller and Clark emphasize its heterogeneity in terms of both cause and pathophysiology. In addition to chapters that provide an overview and descriptions of normal and abnormal brain development, there are excellent chapters about the various perinatal, genetic, traumatic, infectious, and cerebrovascular causes of cerebral palsy. Well-written chapters on ultrasonography, neuroradiography, and electroencephalography are rich with details and pictures. These first 10 chapters support the argument that cerebral palsy is many different entities. However, the distinctions between these entities are often blurred.

This book is an excellent summary of the various mechanisms of brain injury and the causes of cerebral palsy, but clinical correlations and discussions of the consequences and manifestations of cerebral palsy are not as strong. The superficial treatment of diagnosis, functional impairment, and management provides little or no new information to the clinician. The chapters on bladder control and feeding are useful, as is the emphasis throughout the book on family-centered care and interdisciplinary team management. (The feasibility of providing this care in our current era of managed care and cutbacks in government funding is not addressed.) The chapters on neurorehabilitation and therapies are disappointing, with only short sections on recent advances in technology, surgery, and medical management of the cerebral palsies (including assistive technology, orthotics, neuropharmacology, selective dorsal rhizotomy, botulinum toxin injections, and intrathecal baclofen infusions). There is virtually no information on how the cerebral palsies affect adults.

We are ready for a neuroanatomical description of the various causes, mechanisms, and pathophysiologics of brain injury to complement The Natural History of Cerebral Palsy, Crothers and Paine's definitive 1959 description of the clinical entity (Cambridge, Mass.: Harvard University Press). The Cerebral Palsies is not this kind of comprehensive textbook. Its excellent discussions of causes and mechanisms of brain injury are not well complemented by discussions of how these types of brain injury are functionally expressed throughout a person's life, or how specific interventions should be chosen or timed to optimize outcome in patients with various types of brain injury.

Any discussion of the cerebral palsies should confront the great mystery: Why are there children with evidence of severe brain injury who function so normally, while others with normal brains and normal histories have severe multiple disabilities? Now that we have a clearer understanding of mechanisms of brain injury, we need to focus on mechanisms of brain recovery and factors that facilitate it and improve functional outcome.

Marilee C. Allen, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21287-3200