Shining a Light on the Role of Spasticity in Children with Diplegic CP

TARGET AUDIENCE: Rehabilitation team members, including orthotists, physical therapists, occupational therapists, physical medicine and rehabilitation physicians, and pediatric orthopedists.

LEVEL: INTERMEDIATE – Pre‐course readings are assigned.

Course Description

In children born premature and those with diplegic cerebral palsy (CP), findings obtained with diffusion tensor imaging (DTI) have brought significant challenges to the common definition of CP as “a motor disorder caused by a static lesion to the upper motor neurons resulting in spasticity”. The presenter discusses findings by researchers that question the definition and challenge the common notion that spasticity is present, that it causes contracture formation and gait pathology in children with diplegia, and that it is a suitable target for “spasticity reducing” interventions.

She discusses the confusion over the difference between increased tone and hyperreflexia; challenges to the validity of the Modified Ashworth Scale and the Modified Tardieu Scale as spasticity tests; and presents abundant reported evidence of shortfalls of effectiveness of, and complications associated with commonly-administered spasticity treatments including intrathecal baclofen, botulinum toxin-A injections, and selective dorsal rhizotomy. She concludes the program with a presentation of several science-based management strategies for children with diplegic cerebral palsy and suggestions for clinical research involving clinicians in orthotics and associated rehabilitation team members.

2019 Schedule

April 6, 2019 – Warsaw, Poland

April 8, 2019 – Warsaw, Poland


Course Description (PDF)

Course Objectives

Participants in this course are expected to be able to:

  • Define tone, hypertonus, and hypotonus.
  • Describe ideal human resting muscle tone and the contribution of adjacent tissues.
  • Discuss the relevance of physiologic adaptation to use history in terms of muscle tone.
  • Describe R1 (L1, Lo) end range on the typical passive length-tension curve.
  • Define an antigravity righting reaction and discuss its significance in daily life.
  • Relate the stimulation of somatosensory load receptors to antigravity righting reactions.
  • Discuss the role of the tactile and somatosensory systems in movement acquisition and brain mapping.
  • Discuss the proof of validity of JW Lance’s definition of spasticity (1980).
  • Differentiate between hyperreflexia and muscle tone.
  • Describe the status of the sensory system in children with CP.
  • Define a body center of mass (COM) and describe the ideal projection of the human body COM over the base of support in static standing in typically developing children of age 4 years and in adults.
  • Compare the body COM projection onto the support base in typically developing toddlers to that of children with diplegia.
  • Describe the muscle recruitment strategy needed to remain upright in the presence of a chronically anterior displacement of the body COM in standing and in walking. Relate this strategy to development of common soft tissue contractures in children with diplegic CP.
  • Explain the validity of EMG during stretch as evidence of “spasticity”.
  • Discuss the evidence of long-term effectiveness of treating “spasticity” in children with diplegic CP using intrathecal baclofen, selective dorsal rhizotomy, and Botulinum toxin-A.
  • Discuss the principle of managing degrees of freedom as a postural control and motor learning strategy, and relate this principle to serial casting and orthotic design for children with diplegic CP.
  • Explain the rationale for building trunk and hip control of postural alignment and the body COM as a contracture prevention and gait management strategy.
  • Suggest 2 strategies for optimizing functioning sensory input
  • Suggest 2 strategies for managing degrees of freedom.


Beverly (Billi) Cusick, PT, MS, COF is an internationally-known pediatric physical therapist whose specialty is the management of lower extremity deformity, particularly in children with cerebral palsy and other CNS deficits.

Ms. Cusick received her BS in PT from Bouve College at Northeastern University (Boston), and her MS in Clinical and College Teaching for Allied Health Professionals from the University of Kentucky in Lexington. She is an Associate Professor for the Rocky Mountain University of Health Professions – Pediatrics Program – Provo, Utah (2006-present) and is NDT basic- and baby-trained.

Since 1978 she has written or co-authored over a dozen publications. She has guest-lectured at annual conferences of the APTA, the NDTA, and the American Academy of CP and Developmental Medicine; at the ISPO Consensus Conference for Orthotics in CP; for the British Association of Prosthetists and Orthotists; and most recently at the International Conference on Cerebral Palsy in Sydney, Australia.

Ms. Cusick is the founder of Progressive GaitWays, LLC and the inventor, President, and Chief Medical Officer of TheraTogs, Inc.

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