Intended for healthcare professionals

Practice Guidelines

Cerebral palsy in adults: summary of NICE guidance

BMJ 2019; 364 doi: (Published 19 March 2019) Cite this as: BMJ 2019;364:l806

Re: Cerebral palsy in adults: summary of NICE guidance - importance of assistive technology underestimated

The NICE guidance on cerebral palsy (CP) is very welcome and the importance of an annual review by a suitably qualified health professional is vital [1]. For those with severe impairments, the multidisciplinary team is invaluable but what it does is not spelled out in the guidance. This probably reflects the lack of research into assistive technology (AT) and into the problems associated with CP in adults. AT is usually provided after assessment by therapists who may be speech and language therapists, physiotherapists or occupational therapists.

For those with severe CP (e.g. with Gross Motor Function Classification system levels lV and V) AT assists individuals with communication impairments (with communication aids), immobility (with powered mobility) and inability to control simple switches (with environmental control units) which can greatly improve quality of life and independence [2]. The therapeutic qualities of AT are often neglected. Specialised seating [3] can accommodate the subluxed hips, contractures, kyphoscoliosis and other deformities and facilitate the management of spasticity thus reducing the pain and discomfort correctly noted by Bromham [1]. The electric powered indoor outdoor wheelchairs (EPIOCs for those eligible for them [4]) can incorporate tilt-in-space which can itself minimise pain and pressure issues [2]. Indeed standard technology can control communication and the environment from one control system often mounted on a wheelchair tray [2].

The guidance also made no reference to the need to enable those with CP to work. Employment can be greatly assisted with the use of AT. Although neglected by the NHS in recent years [5], government policy now encourages all professionals to facilitate the employment of disadvantaged individuals [6]. The techniques available to support those with CP commence with support during childhood, adolescence and early adult life facilitating the development of confidence and social skills as well as education [7-8]. Placement into work has been transformed by training disadvantaged individuals in the work place rather than training them prior to employment (place then train rather than train then place [9]). For those in work but having problems (which may or may not be associated with changes in their CP), job modifications (accommodations) may be very helpful, whilst those who are out of work can be assisted into work through a variety of ways [7].

Another area not mentioned in the NICE review [1] is the assistance often available from the voluntary sector. AbilityNet offers advice for those with physical impairments using computers. Peer support can be invaluable in supporting disadvantaged individuals during difficult periods [8].

Supporting those with CP transcends the medical model. Rehabilitation professionals recognise the need for all bio-psycho-social methods in providing support for disadvantaged individuals – but need to evaluate their work more effectively so that all can benefit from their holistic approach.

Reference List

(1) Bromham N, Dworzynski K, Eunson P, Fairhurst C. Cerebral palsy in adults: summary of NICE guidance. BMJ (Clinical research ed ) 2019; 364:l806.
(2) Frank AO, De Souza LH. Problematic clinical features of children and adults with cerebral palsy who use electric powered indoor/outdoor wheelchairs: a cross-sectional study. Assistive Technology 2016; 29(2):68-75.
(3) British Society of Rehabilitation Medicine. Specialised wheelchair seating national clinical guidelines. Report of a multidisciplinary expert group (Chair: Marks, LJ). 1-39. 2004. London, British Society of Rehabilitation Medicine.
(4) Frank AO, Ward JH, Orwell NJ, McCullagh C, Belcher M. Introduction of the new NHS Electric Powered Indoor/outdoor Chair (EPIOC) service: benefits, risks and implications for prescribers. Clin Rehabil 2000; 14(December):665-673.
(5) British Society of Rehabilitation Medicine. Vocational Rehabilitation - the way forward: Report of a Working Party (Chair Frank AO). First ed. London: British Society of Rehabilitation Medicine; 2000.
(6) Department for Work and Pensions, Department of Health. Improving Lives: the Future of Work, Health and Disability. 1 ed. London: Department for Work and Pensions; Department of Health; 2017.
(7) Frank AO. Vocational rehabilitation: supporting ill or disabled individuals in(to) work: a UK perspective. Healthcare 2016; 4(46).
(8) Connolly P, Stevens T. Get back to where we do belong. Disability Rights UK, London, 2016.
(9) Grove B. International employment schemes for people with mental health problems. BJPsych International 2016; 12(Research Supplement):97-99.

Competing interests: No competing interests

31 March 2019
Andrew O. Frank
Retired consultant in Rehabilitation Medicine
Northwick Park Hopsital, HA1 3UJ
Northwick Park Hopsital, HA1 3UJ