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Selective dorsal rhizotomy and energy consumption in children with cerebral palsy: the importance of publishing unpopular results

It is well recognized that individuals with spastic cerebral palsy (CP) have higher energy costs during activities of daily living including walking. Most clinicians assume these changes are due to the increased metabolism of the spastic muscles, especially during gross motor movements such as walking. I commend Zaino et al. for their efforts as well as their boldness in publishing a study that challenges previous publications, commonly held notions, as well as their own study hypothesis. This study demonstrates that spasticity may not be a large contributing factor to the increased energy consumption during walking in children with CP. It was only possible for Zaino et al. to draw this conclusion due to the inclusion of a control group. Previous articles on this topic were mainly case series focused on preand post-selective dorsal rhizotomy (SDR). These lead earlier authors to commit a type 1 error and falsely conclude that SDR reduced energy consumption during gait; however, by including a control group in this study, Zaino et al. were able to demonstrate that the reduction of energy consumption in patients with CP is no different whether or not they have had SDR. These findings contradict previous publications that assumed the observed reduced energy consumption following SDR was due to the SDR and not the natural history of young children with spastic CP. This study highlights the need for control groups in clinical research as well as case series. The inclusion of the control group demonstrated that there is a natural reduction in energy consumption over time and that the reduction in energy observed in this and previous studies after SDR was similar to the natural history. Without the control group, these authors would have likely drawn the same conclusions as previous authors that SDR reduces energy consumption during walking in children with spastic CP and thus committing a type 1 error. Inclusion of the control group makes the findings in the study more accurate and informative for our clinical practices and our clinical decisionmaking. By opposing previous publications and widely held beliefs, this study highlights the potential for errors when drawing conclusions based on case series without matched controls. In a case series looking at procedural interventions, there is no way to control for the natural history changes of the condition over time which is especially important in children during times of rapid development and maturation. Although a major limitation of the Zaino et al. study was its retrospective nature, the addition of a historical control in the retrospective analysis completely changed the conclusion drawn from the analysis of the data collected. It also highlights the need for further investigations into the etiology of the increased energy expenditure during gait in children with CP since it refutes the logical and commonly held belief that spasticity is the primary factor.