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Editors: Brian Neville, Robert Goodman
216 pp Price £40; US$59.95 ISBN 1-898-68319-0 (h/b)
London: Mac Keith Press, 2000 .
The typical child with congenital hemiplegia is born at term after an apparently uneventful pregnancy. All seems fine until late infancy, when the usually right-sided motor weakness becomes apparent. The diagnosis tends to come as a complete surprise, and his (two-thirds are boys) carers will have lots of questions. Why did it happen? What treatment is needed? Might he recover completely? What other problems might he have? What about school? Professor Neville and Professor Goodman have enlisted experts from several disciplines in five countries to contribute to Congenital Hemiplegia. Although over half the book deals with the physical aspects, the often more disabling emotional, behavioural, cognitive, and educational aspects are not neglected.
The first chapter deals with aetiology—still usually a mystery, and Goodman states that ‘It is possible that congenital hemiplegia is determined by some powerful environmental factor that has yet to be identified, and that is not shared by... monozygotic twins. Hemiplegia could be the result of the placenta being located in just the wrong part of the uterus... it is at least as plausible, though, that chance may even be the main factor in congenital hemiplegia’. Various combinations of minor variations (each within the normal range) could lead to it.
After discussion of antecedents and epidemiology, there are well-illustrated chapters on the neuropathology and neuroradiology of congenital hemiplegia, and a new MRI-based classification is proposed. Those with grey-matter lesions (such as migration defect or cortical infarctions) are much more likely than those with just white-matter lesions (such as peri-ventricular leukomalacia) to have epilepsy, learning difficulties, and severe behaviour problems.
The next chapters cover the presentation, neurology, and physical assessment (including assessment of hand function and formal gait analysis). The role of orthopaedic surgery is discussed, and Scrutton's chapter on physiotherapy bristles with good advice. He recommends early referral and intensive physiotherapy in infancy, but so far as ‘regular physio’ for the school age child is concerned, he warns us that ‘many children are treated because they have hemiplegia, not because the treatment will be to their overall benefit... childhood is finite—the time used up for treatment cannot be replaced, and there are so many other things to do which could be much more important for the person than to be undergoing treatment’. I would recommend this chapter to all paediatricians and therapists (including alternative practitioners), and to any adolescents with hemiplegia who are fed up with being bullied into doing their exercises.
Two chapters are devoted to epilepsy, which affects one-fifth of children with congenital hemiplegia. Certain forms of epilepsy (such as status epilepticus of slow sleep) may be missed, and can cause developmental arrest and severe behaviour problems. Most seizures respond well to anticonvulsants, but a substantial proportion of children have intractable seizures, for which Neville recommends early referral for consideration of epilepsy surgery (particularly if there is already a dense hemiplegia and hemianopia).
Half of all children with hemiplegia have psychological troubles. Some of these, such as autism and attention deficit hyperactivity disorder, may be caused by the brain abnormality. Others, such as anxiety and depression (much commoner), are likely to be caused by the child's motor difficulty and the feeling of being different. Goodman and Yude emphasize that the psychological disturbances in children with hemiplegia tend to respond better to treatment than do similar disorders in other children, who commonly have a background of social deprivation and a chaotic family life.
Most children with congenital hemiplegia have a normal IQ and will attend mainstream school. Although language is usually well preserved (irrespective of which hemisphere is involved), specific learning difficulties are found in one-third and must be recognized early. As adults, people with congenital hemiplegia will be more suited to desk jobs than to manual work, so academic qualifications are particularly important. Vargha-Khadem and Muter review the published work (to which they have contributed much) and recommend a battery of cognitive and educational tests to identify each child's strengths and weaknesses. Yude and her co-workers set up the London Hemiplegia Registry in the late 1980s. She discovered that many families felt ill-served by the support groups available at the time, and were hungry for information. She felt that ‘a responsibility is placed on the researchers to both support and inform the families’; so, with a handful of parents with children on the register she started Hemi-Help, which now has over two thousand members. Her chapter might encourage other researchers to follow her example, and offers sound advice for anyone wanting to set up an effective support group.
In the final chapter, Neville makes suggestions as to how the various services needed for children with hemiplegia might be coordinated. My main criticism of this otherwise excellent book is that the subeditors should have ironed out the minor variations in terminology between the Swedish, British, German, and North American authors.
I have just lent my copy to the parents of a child with hemiplegia. They had read about the book in one of Hemi-Help's newsletters and were thinking of buying it. So should you.