The Tyranny of Evidence…
Beverly Cusick, PT, MS, NDT, COF/BOC pushes back on the current culture of dependence on single-focus, short-term clinical studies that ignore the complex morbidities of cerebral palsy – and the sciences that address them.
The Cusick Center for Learning (CCL) has opened its doors!
The first program in the series The Golden Rule of Managing Pediatric Orthopedic and Motor Development is now available for your professional development – at your convenience, in a pre-recorded webinar!
In this hour-long webinar, Beverly (Billi) Cusick reviews key biomechanical and sensory-motor aspects of early postural control acquisition – the essential foundation for building competent limb use and movement skills. She then demonstrates her “golden rule” concept with two clinical cases, and provides a detailed Q&A segment based on the discussions from the original live webinar.
In conclusion, Ms. Cusick traces the timeline, mentors, and influences that led her to the development of the Golden Rule – a valuable review that ‘connects the dots’ between the contributions of numerous well-known pioneers in physical rehabilitation.
Kudos for Program 1:
I took a course from Billi over 20 years ago (Biomechanics) and it transformed my practice. Love how she integrated all the approaches (NDT, Sahrmann, Tschnarter etc..). Excellent information with clear application, and the science behind the art of postural control facilitation. It was concise, easy to follow, and packed full of golden nuggets. I actually bought Kathleen Porters book and will be sharing it with coworkers at the clinic including office staff!
Enjoyed the historical approach with references to the scientific basis behind the techniques. Good reminder of finding the balance between stability and mobility in order to enhance function.
In Program 2, Ms. Cusick discusses the biomechanical and somatosensory aspects of the developing infant’s progress after stabilizing the body center of mass in prone and supine positions. In this next phase of early movement acquisition, lying leads to rolling and body weight is displaced in the frontal plane and elevated off the surface into quadruped position. The instructor’s golden rule is applied in suggested biomechanical and somatosensory strategies for remediating deficits.
Attendees gave Program 2 a ‘thumbs up’:
It’s very difficult to get clear, concise information regarding infant motor development and I really appreciate the quality of information as well as the convenience of the presentation type.
Billi is a wealth of knowledge which she shares in a clear, concise and clinically applicable way… The webinar allows learning in 1 hours chunks of time, with the opportunity to watch again for the week that follows. The handout follows the slides exactly and can be downloaded ahead of time to maximize learning.
An Open Letter to Caretakers and Therapists for Children with Diplegic CP
Progressive GaitWays president and founder Beverly (Billi) Cusick writes:
“I’ve seen hundreds of families of children with diplegia, in consultation sessions in which I routinely undertake an orthopedic assessment and evaluate postural control, movement strategies, and existing orthoses. Common denominators have emerged that appear to operate to contribute to common problems of contracture development and recurrence, and to diminishing movement skills so often seen with advancing age in children with diplegia.
“I’ve composed the attached letter for caretakers and therapists of children with diplegia to bring them together in their understanding of the sources of many common musculoskeletal problems, and of the fundamental skills and strategies that are needed for effective remediation.”
Clinicians are welcome to download and share this letter with their colleagues, clients, and prescribing physicians.
¡Ahora disponible en español! (Translated by Ursula Ivancic, Kinesióloga Fisiatra Neurorehabilitación Pediátrica Buenos Aires, Argentina
Calendar of Events
Developmental Orthopedics of the Trunk & Lower Extremity:
A Review of Operating Processes with Implications for Management
Saturday, April 11, 2015
Registration: 7:30 am
Time: 8:00 am – 5:30 pm
Cost: $195.00 (Price includes an assessment kit valued at $65)
Contact Hours: 7.25
IL EI: Pending Approval
Beverly Cusick, PT, MS, NDT, COF
Hampton Inn & Suites
8936 Calumet Ave
Munster, IN 46321
Clinicians who are likely to work together to maximize physical function as a rehabilitation team, including PT, OT, Orthotists, Rehabilitation Physicians, and Orthopedists.
Intermediate- pre-course readings are assigned
This introductory program features an overview of the processes that contribute to pediatric orthopedic development, including the following:
Skeletal modeling mechanisms and influences.
Therapeutic limits on influencing the skeletal modeling process.
The influences of the biomechanics of ideal neonatal alignment on modeling the spine and lower extremity joints and on postural control acquisition.
The roles of postural control and massed practice on the orthopedic and functional development.
Developmental changes in muscle and connective-tissue extensibility.
Common errors of lower-extremity skeletal modeling in children with CNS dysfunction.
Strategies for optimizing somatosensory input, postural alignment, and postural control.
Using musculoskeletal assessment findings to gauge effectiveness of therapeutic management.
These principles are applied to pathomechanics commonly observed in children with hypotonia, cerebral palsy, excessive foot pronation, and intoed gait. The content presented in this program is considered fundamental to any (future) discussion of the specific features of orthopedic trunk and lower extremity development.
Distinguish between skeletal maturation and skeletal modeling.
Distinguish between mechanisms of strain and load, and apply this distinction to the “Golden Age.”
Describe the modeling effects of compression, tension, and loaded torque strains.
Describe the typical developmental changes that occur in spinal and lower-extremity alignment.
Describe the normal sequential acquisition of antigravity muscle function in the torso.
Relate normal neonatal soft-tissue constraints to the development of spine curves.
Discuss the role of somatosensory input in postural control and movement skills acquisition.
Describe the ideal features of weight distribution on the foot segments in standing position in infants, preschoolers, and adults.
Relate standing foot, spinal, and pelvic alignment to body weight distribution onto the feet and to muscle recruitment strategies needed to maintain postural control.
Discuss the normal emergence of R1 (first catch) end range of motion in the lower-extremity muscles.
Differentiate between spasticity and soft-tissue adaptation to chronic, tonic muscle recruitment.
Describe the evidence of a history of routine muscle recruitment strategies in range of motion findings.
Given the presence of excessive femoral torsion in a 9-year-old boy, explain the decision to defer corrective efforts to an orthopedic surgeon.
Explain the rationale for lifting under the heel and allowing the ankle to align in plantarflexion in the presence of equinus deformity.
Suggest strategies for delivering massed practice in improved postural alignment.
8:00 Register / Continental breakfast
8:30 Overview of Developmental Changes in the Spine and Lower Extremities
8:45 Skeletal Modeling Mechanisms
9:15 The Somatosensory System in Postural Control Acquisition (or, Where’s the Weight?
10:15 Biomechanics of Ideal Neonatal Alignment in Postural Control Acquisition
10:45 Walking as an Influence on Orthopedic Development
11:30 Developmental Changes in Lower-Extremity Muscle Extensibility
1:00 Common Problems of Postural Control in Children with Diplegic Cerebral Palsy
2:00 Videotaped case – Emilia
2:15 Short Break
2:30 Common Lower-Extremity Modeling Errors
3:30 Short Break
3:45 Using Musculoskeletal Assessment Procedures as Evidence of Skeletal Modeling, Muscle Balance, History of Use, and Success of Neuromotor Re-Education
4:45 Videotaped Case: Setting Management Priorities
5:15 Questions and Discussion
5:30 Turn In Course Evals and Adjourn
About the Speaker:
1972 – BS in PT from Bouve College at Northeastern University (Boston) in 1972, summa cum laude.
1988 – MS in Clinical and College Teaching for Allied Health Professionals – University of Kentucky in Lexington.
1 year – PT staff at (now) Spaulding Rehabilitation Center, Boston, MA
3 years – PT staff and Director for UCP Center, Lawrence, MA
9 years – PT staff at Children’s Rehab. Center (now, Kluge Center), Charlottesville, VA.
3 years – PT Education faculty, College of Health Related Professions at MUSC, Charleston, SC, and Director of PT Services for the Div. Of Developmental Disabilities at MUSC.
1 year, consultant, Cardinal Hill Hospital’s Head Trauma & Pediatrics teams – Lexington, KY.
4 years, assisting in the PT Department at Children’s Hospital at Stanford, Palo Alto, CA.
23 years in private practice.
Part 1: New Paradigms in Pediatric Foot & Ankle Deformity Management – A 2.5-Day Program
Part 2: LABS: Foot & Ankle Assessments, Posting Trials – A 2.5-Day Program
Target audience: This course is designed for the practitioner who has experience in working with children with CNS neuromotor dysfunction, including physical therapists, orthotists, pediatric orthopedists, and physical medicine and rehabilitation physicians. We believe that team education fosters more effective teamwork.
Level: Intermediate – Pre-course readings and review materials are assigned – Enrollees are expected to arrive prepared.
The content covered in this program includes the following topics:
- The emerging sciences of postural control acquisition and maintenance, including the role of the somatosensory system as it is currently understood in relation to load-bearing alignment of the torso, lower limbs, and feet.
- Foot and ankle functional anatomy, biomechanics, development, and pathomechanics in relation to body weight orientation over the base of support and to designing orthotic modifications to optimize foot development and function.
- Body weight distribution on the foot and through load-bearing joints as a causative factor in contracture formation, early onset of pain, and degenerative joint disease.
- Muscle physiology and pathophysiology in the presence of chronic use of compensatory postural control mechanisms while distinguishing spasticity from connective–tissue contractility and muscle transformation.
- Skeletal modeling mechanisms underlying the process of use-related ankle and foot development.
- Characteristics of and factors contributing to healthy foot development.
- Elements of gait development that relate to and support foot development.
- The kinesiology and pathokinesiology related to – and in support of – the safe and effective use of below-knee casts and orthotic interventions designed to improve postural alignment and control and to reduce developmental, flexible foot and ankle deformities that commonly develop in the presence of central nervous system dysfunction, hypotonia, and ligament laxity in childhood. Discussion of orthotic options includes Elaine Owen’s Tuned AFO/Footwear Combinations, heel lifting and weight-line training, orthotic posting and foot packaging principles and strategies.
- Hypoextensibility management is distinguished from the alteration of movement strategies, and includes discussions of interventions such as positioning, resting splints, manual stretching, neurolytics, and serial casting.
- Labs feature closely-supervised trials of several ankle and foot assessment procedures, with findings applied to orthotic posting and design. Assessment tools and materials will be provided for undertaking posting trials to preview effects of proposed orthotic modifications.
- Common developmental foot deformities are identified and described in terms of plane-based anatomical components. Musculoskeletal assessment procedures are reviewed as the findings lead the clinician to a systematic clinical decision-making process regarding orthotic design in terms of desired load-bearing foot and limb joint alignment, magnitude of segment enclosure, degrees of freedom provided or restrained, and posting options. Soft-tissue extensibility findings are also used in the documentation of the effects of assorted orthotic intervention strategies.
Participants completing the seminar portion of this course are expected to be able to:
- Describe, in plane-based terminology, the motions of the joints and various bones of the foot in the open and closed kinetic/kinematic chains.
- Discuss the relationship between joint alignment and related muscle function in terms of joint axis inclination, muscle and loading force vectors, lever arms, and resultant moments.
- Describe the role of the foot and ankle sensory receptors and weight distribution on the foot in the achievement and maintenance of postural control in standing and gait.
- Explain the clinical rationale for using specific assessment techniques to identify features of soft tissue extensibility, joint mobility, and structural alignment in the ankle and foot.
- Discuss the reported reliability and validity of common clinical tests for spasticity.
- Distinguish between spasticity, connective-tissue contractility, and soft-tissue transformation, and discuss management implications.
- Discuss the physiology and functional significance of R1 (first-catch) end range of motion.
- Explain the physiologic and structural changes that are known to occur in chronically over-recruited muscle and surrounding tissues following a history of recruitment for maintenance of verticality.
- Distinguish between dominance and strength within a muscle force couple.
- Upon discovering a dominant muscle, name 3 related areas of concern.
- Describe orthotic posting in sagittal and frontal planes, and discuss posting objectives.
- Discuss the purposes of weight line training in foot and ankle deformity management re proprioception and muscle recruitment strategies used for postural control.
- Name 5 features that identify a sound developing foot.
- Identify the deformities of the foot and ankle that occur most commonly in children or adults with CNS upper neuromotor dysfunction, and describe the components of illustrated deformities at each joint in plane-based terms.
- Determine whether a deformity meets the criteria for intervention with heel-posting in ankle plantarflexion, serial casting, an R-wrap© orthosis, stretch splinting, and/or positioning.
- Explain the rationale for instituting strengthening and range-maintenance measures after restoring soft tissue extensibility.
- Discuss the limitations of stretching exercise as a deformity management tool.
Participants completing the lab sessions of this course are expected to be able to:
- Demonstrate novice skill level in musculoskeletal assessment procedures of the ankle and foot in the open and closed chains.
- Bring the principles of orthotic posting to the findings obtained in assessment lab, and formulate an orthotic design plan.
- Demonstrate novice skill in undertaking an informed, targeted, temporary and exploratory posting trial.
- Participate in a workshop designed to generate ideas for promoting optimum body COM distribution over the feet in standing and walking.
Wearable Therapy: TheraTogs™ Systems, Uses, & Scientific Foundations
A 3.5-Day Didactic Program
Facilitator: Beverly Cusick, PT, MS, NDT, COF/BOC
Day 1 of this program features an overview of sciences of neuromotor and orthopedic development including established principles of kinesiology and biomechanics, physiologic adaptation of body tissues to routine use, new developments in motor learning, and the role of the somatosensory system in this process. The instructor demonstrates the implementation of the sciences in an introduction to TheraTogs Orthotic Garment and Strapping Systems as a modality for expanding successes in therapy sessions into daily life to optimize functioning alignment and stability, and reviews published research.
Day 2 of this program expands upon the introductory content presented on Day 1 with a discussion of skeletal modeling mechanisms and the achievement of postural control as a foundation for movement acquisition. She explores the nature of muscle tone and the relationship of muscle tone to routine use, both typical and pathologic. The program ends with suggestions for using TheraTogs in early intervention to optimize resting postures and the acquisition of essential ingredients for postural control.
Day 3 of this program applies the content from Days 1 and 2 and delves into functioning alignment issues related to the spine, the ankles, and unequal limb length. After demonstrating the Dragonfly TLSO and the molding and fitting process, the instructor reviews the assessment of ankle dorsiflexion range of motion as an important component of optimizing the support base with orthotics. She brings ankle ROM to discussions of postural control deficits and functioning malalignment as they occur in children with idiopathic toe walking, equinus deformity, hemiplegic cerebral palsy, and scissor gait. The program ends with a discussion of the typical development of the hip joint and femur in the transverse plane with a lab session devoted to distinguishing between femoral anteversion and antetorsion.
Day 4 is a half-day program that applies the content from Days 1-3 and is devoted to the biomechanical and developmental factors inherent in intoed and out-toed gait. Instructor reviews the related – and refined – musculoskeletal assessment procedures of hip rotation ROM, modified Ryder’s Test for femoral torsion, and the Thigh-Foot Angle and applies the findings to the safe use of TheraTogs strapping applications. The didactic program ends with suggestions for further research.