Why don't we know more about what we are doing?

There have been huge changes in science and technology in the past 30 years. We now understand the genetic basis of many diseases, and with the complete mapping of the genome, our knowledge will expand tremendously. We have CT, MRI, computer-guided surgery, gait analysis, and a host of other advances which have made medical care for our patients more effective. While these changes have profoundly altered the way patients are cared for, it seems that orthopaedic decision making for treatment of children with cerebral palsy (CP), remains more of an art than a science, and there are few objective criteria for intervention which clinicians agree upon. Then why is it that we seem to be lagging behind in the area of orthopaedic treatment of CP? CP is a very heterogeneous condition: although we can classify patients with CP into diplegic, hemiplegic, and quadri-plegic types there is, within these groups, a wide variation in involvement. Not only is it difficult to measure precisely the severity of involvement, it is even more difficult to assess the patient qualitatively in terms of all aspects of their motor deficit, including spasticity, extrapyramidal involvement, weakness, deficits in coordination, and motor planning, etc. There is a multitude of other factors that will influence outcome of our patients such as motivation, the amount and type of therapy, and exposure to activities which may enhance physical development. Our patients rarely have a single intervention which further confuses attempts to assess impact of a chosen intervention on function. There are equally complex issues in the area of outcome measurement. We have seen the introduction of a variety of standardized outcome measures in the past two decades, however, only one of these, the Gross Motor Function Measure, is referenced to the child with CP. Although many of these measures are able to detect major changes in function, their sensitivity is limited. There are many significant obstacles in establishing long-term scientifically sound clinical trials to assess interventions for patients with CP. In the current medical environment, remunerative clinical care is valued to a much higher degree than clinical research unless this research is well funded with generous indirect costs, such as drug studies supported by pharmaceutical companies. Not only does this limit research but results in few clinicians being well trained in clinical research in the area of CP. If one is able to obtain funding for long-term clinical research there …