FAQs for
Physicians

What is AposTherapy® and what are its components?

AposTherapy® is an innovative medical treatment for people suffering from lower limb or low back pain and loss of function. The treatment is mainly relevant for conditions that are attributable to musculoskeletal disorders. AposTherapy® is non-surgical and non-pharmaceutical, FDA-cleared and CE registered. It combines pain reduction with improved function and muscular control of the joints, both of which lead to an improvement in quality of life.

AposTherapy® is comprised of three integrated components: the AposTherapy® device, treatment that is performed during normal daily activities and the AposTherapy® clinical pathway. These are discussed in the next three Q&A’s.

Pain reduction occurs, in most cases, immediately upon wearing the bespoke AposTherapy® device. The treatment is based on performing simple daily activities with the AposTherapy® device which is individually calibrated for each patient based on a thorough initial clinical evaluation conducted by an AposTherapy® Trained Clinician (ATC). The treatment can take place anytime, at home or in the office, as part of one’s daily activities, according to patient preferences and subject to a detailed treatment plan provided by the ATC. The treatment therefore does not interrupt the patients’ daily routine. After a few weeks of using the device at home, patients report reduced pain in daily activities while in regular shoes as well. Patients are then regularly seen for follow-up appointments, where they are re-assessed and monitored. The device’s calibration and the treatment plan may change based on the patient’s progress. This ensures a maximized therapeutic effect.

The AposTherapy® device is personally calibrated for each patient. It consists of two Pertupods, which are convex perturbation units. The Pertupods are mounted on a special shoe-like platform and located below the main weight-bearing areas of the forefoot and heel on each foot. Pertupods are available in two diameters, a variety of convexities and in two levels of hardness for each level of convexity. The Pertupod height can be changed by adding spacers and its weight can be increased by adding a weighted disc. Based on the integration of clinical findings, the results of the computerized gait lab and questionnaires, the gait pattern and the AposTherapy® methodology, the ATC can calibrate the location, weight and convexity of each Pertupod.

The location of the Pertupods changes the load distribution along the kinematic chain by changing the location of the center of pressure (COP). This changes the location of the ground reaction force in relation to the various joints, resulting in an altered load distribution within the joints and a subsequent pain reduction.

Simultaneously, the convexity of the Pertupods challenges the muscular control to create an improved muscular pattern within various daily tasks.

According to the individual treatment plan, patients use the device during daily indoor activities allowing the improved muscular control to be instilled.

What stems from the above is that the device is a powerful driver of motor learning because it allows patients to perform thousands of repetitions of the improved pattern of neuromuscular control, within the patient’s environment and during daily activities which patients find difficult and painful.

Examples of the long-lasting long-term effects of the device can be seen in this video.

This video explains how the treatment works for knee pathologies.

Patients are monitored through clinical, quantifiable, valid and reliable outcome measures. Each patient goes through a computerized gait lab and fills out computerized standard questionnaires (WOMAC and SF-36 in most cases). The gait lab provides spatiotemporal parameters of gait (step lengths, velocity and single limb support) that form objective, functional outcome measures. The questionnaires provide quantifiable measurements of the patients’ levels of pain, function and quality of life. Patients are treated in annual treatment packages that include the initial consultation, the AposTherapy® device and its subsequent calibrations and parts, as well as 5 or 6 follow-up appointments within the first year. Gait lab and questionnaires are repeated in each follow-up appointment giving the AposTherapy® trained clinician a thorough objective and subjective view of the patient’s progress. The gait lab and questionnaire results are integrated with the findings collected during the patients’ interview and physical assessment. Combined, these provide an important decision-supporting tool to determine whether or not to change the device’s calibration or adjust the treatment plan. The outcome measures from the gait lab and various questionnaires are fed into the AposTherapy® clinical tracking system which processes them into an easy-to-understand format. This can be graphically presented to the patient, presented to the referring health care provider, used for assessment of effectiveness of treatment by policy makers and insurers and so on. This makes the AposTherapy® clinical pathway a leader in data collection and clinical decision making for a host of musculoskeletal conditions.

There are a number of advantages to an active treatment that is performed during daily activities.

First, patients suffering from musculoskeletal conditions have altered motor patterns in various tasks. It is widely believed that this altered muscular control contributes to continued symptoms and may hasten the deterioration of degenerative conditions9-13. The concept of task specificity states that each learned motor task is learned and controlled individually14,15. It is therefore necessary to specifically train in each task. It is clearly beneficial to introduce a perturbation into all the activities which have an altered muscular control to enhance the muscular control.

In addition, thousands of repetitions are needed to create motor learning so that the improved motor pattern is instilled. As patients wear the AposTherapy® device, each step or activity performed becomes a repetition. Since patients typically wear the device for 1-2 hours a day, they can easily accumulate the number of repetitions needed to create an instilled and improved motor pattern.

Last and not least, performing the treatment within their daily activities reduces the demand on patients’ schedules and boosts compliance and adherence.

Each patient goes through a comprehensive evaluation in the initial consultation, which is their first assessment with the AposTherapy® Trained Clinician (ATC). The evaluation process includes going through a computerized analysis of the patient’s gait, computerized standardized questionnaires that quantify the extent of their physical problem and the effects it has on the patient’s quality of life (WOMAC,SF-36) an interview and a physical examination by the treating ATC.

Based on all the above information the ATC then discusses the expected benefits of the treatment with the patient. If the patient’s goals and the expected benefits from the treatment can be aligned, the ATC will proceed to calibrate the AposTherapy® device specifically for the patient’s symptoms and gait deviations. The patient then takes the device home and uses it according to a tailored treatment plan provided by the ATC. The gradually progressive treatment plan ensures that using the device is seamlessly integrated with the patient’s daily activities.

Patients are asked to attend regular follow-up appointments in the first year of treatment in order to assess their progress and maximize the results of AposTherapy®. Follow-up appointments include the gait lab, questionnaires, and a reassessment by the AposTherapy Trained Clinician (ATC). Based on the improvements seen in the gait lab and reassessment, the ATC may decide to change the device calibration, the treatment plan or both. This ensures patients improve as much as possible.

Over the course of treatment, the follow-up appointments need to become less frequent.  To maintain the benefits, patients are expected to continue using the device for an hour or two each day while performing their daily activities. Patients are monitored through follow-up appointments as long as they are in treatment approximately 3-4 times a year.

The shoe part of the AposTherapy® device is merely the platform onto which the Pertupods are attached. The clinical effects of the AposTherapy® device are a result of the location, height, weight and convexity of the Pertupod attached to the ‘shoes.’ The comprehensive improvements in pain, function and quality of life that most patients feel within a few weeks are a result of the combined capabilities of the ATC, the treatment plan, patient adherence and the AposTherapy® device.

The AposTherapy® device has a unique dual-action: it reduces pain by re-distributing the loads away from the damaged, painful anatomical structures and simultaneously improves the muscles’ control over the joints by subliminally training neuromuscular control in a variety of activities. Orthotics can help re-distribute the loads on the joint, but, possibly because of their limited effects of muscular activity, they do not seem to have long-term effects on the joint’s function 16,17.

The AposTherapy® device is re-calibrated over time according to the patient’s progress or changing needs. The challenge to the patient’s neuromuscular control is increased either through a gradual increase of the convexity of the Pertupods, an increase in the time the device is used daily or both. In addition, if, over time, the patient has new complaints for any reason, the device can be re-calibrated to address them as well.

A central part of AposTherapy® is the fact that it is a long-term treatment, carried out over months and years. This is especially of value in chronic or degenerative pathologies.

Patients are regularly re-assessed every few weeks or months at follow-up appointments, carried out by specially trained clinicians. Included in the follow-up appointments are a computerized assessment of the patients’ gait, a clinical evaluation and an assessment of their walking with the device. Based on an integration of the above information, the ATC can decide to change aspects of the treatment. In most cases of orthotics, however, past the first few weeks of use, patients who have orthotics are seldom re-assessed for refitting the orthoses.

AposTherapy®, being a conservative treatment, is very low-risk. There are no documented adverse events of the treatment. It is important to stress that patients are thoroughly assessed by the AposTherapy® trained clinician for risk of falling and the application of treatment is only for those patients who are deemed suitable for it.

Following damage to the joint structures, such as osteoarthritis, meniscus tears, ligament tears, etc. the knee may hurt for a prolonged period of time. Studies show that damage to joint structures and pain can alter the muscular control of the joint and are a precursor to knee osteoarthritis. This change in control leads to an increased load on the already damaged, painful area in the knee. In turn, the continued symptoms lead to a maintenance of the altered muscular control in an attempt to decrease movement in and around the knee. The patient may be locked in a vicious cycle because of this, potentially for months and years.

AposTherapy® simultaneously reduces the loads going through the damaged parts of the joint and retrains the muscles to improve the neuromuscular control. Within a few weeks, this control pattern is learned and performed without the device in a variety of activities, thus breaking the above vicious cycle.

AposTherapy® has been widely researched, and to date there are close to 53 studies published, 23 of these specifically demonstrate the positive effects of AposTherapy® in a variety of conditions such as knee osteoarthritis, meniscus tears, patellofemoral pain, hip osteoarthritis, low back pain and more. The other studies deal in basic gait biomechanics, the mechanism of action of the device, etc.

Read peer-reviewed research about AposTherapy®

Which patients are suitable for AposTherapy®?

Generally speaking, AposTherapy® is suitable for musculoskeletal conditions of patients of all adult ages, including most elderly patients. Based on the AposTherapy® Trained Clinician’s (ATC) assessment and clinical reasoning, patients who are either deemed at risk of falling, and those who may have negligible benefits from the treatment, do not start AposTherapy®.

AposTherapy® is customized individually for each patient based on a thorough clinical assessment, computerized gait lab and computerized questionnaires. If, based on these results, patients are deemed suitable for treatment, i.e. they are likely to benefit from it and are not at an increased risk of falling, they can start treatment. Patients perform the treatment according to the specific, easy-to-follow treatment plan provided by the ATC. The treatment itself merely requires that patients perform their daily indoor activities while wearing the AposTherapy® device. The individually tailored treatment plan progresses from week to week increasing patient exposure and benefit from the device. It is an extremely easy to follow and adhere to treatment modality.

AposTherapy® is suitable for patients suffering from musculoskeletal conditions and diabetes provided that they do not have open sores in their feet (diabetic foot) and do not have severe sensory loss in their feet.

Generally speaking, AposTherapy® is suitable for patients with conditions affecting the joints, bones, muscles, ligaments or other tissues of the low back or legs.

AposTherapy® is generally not usually suitable for:

  • People over the age of 80 who use walking aids (a stick, walker, etc.) devices on a regular basis due to balance difficulties
  • People who have had two or more falls in the past 12 months in mundane circumstances, such as tripping for no apparent reason.
AposTherapy® helps prepare for surgery by training the muscles, reducing ineffective movement compensations and reducing pain. It is therefore ideal as part of the pre-habilitation. The more active the patients are prior to undergoing surgery, the more likely they will be to have sufficient muscle strength and intact general health, therefore, the more likely they will be to fare well after the surgery.

What can patients expect?

During the Initial Consultation, patients go through a thorough clinical assessment by an AposTherapy® Trained Clinician (ATC), as well as a computerized gait analysis and computerized questionnaires. Discussing the expected benefits for the individual patient, based on the above conclusive assessment, is one of the core principles of the AposTherapy® treatment approach. Short-term and long-term goals are set with the patient at the initial consultation and are re-assessed at each follow-up appointment. Goals are always aligned with patient values and physical condition. We adhere to a policy of not starting treatment in cases where the patient is considered to have a significant balance deficit or in cases where the expected benefits are not significant. In our experience, the rate of success of AposTherapy® is very high and over 80% of the patients experience a reduction in symptoms and improved function within the first three months of treatment. However, there is no such thing as 100% success in medicine.
AposTherapy® reduces pain and improves function and quality of life. The decision regarding surgery is made by the patient and their orthopedic consultant and it is part of the AposTherapy® credo not to interfere in this decision. Having stated that, many AposTherapy® patients have experienced pain reduction and improved function that were so significant as to allow patients and providers to defer surgery. The accumulated clinical global experience at Apos Medical Assets and some published and yet unpublished data strongly suggests that AposTherapy® can (i) reduce the need for surgery significantly; and (ii) improve the outcome of surgery when AposTherapy® is used as part of post-operative rehabilitation.
Usually, patients feel an amount of pain relief even during the initial calibration of the AposTherapy® device, due to the re-distribution of loads away from the symptomatic joints and the improved muscle recruitment. After a few months of AposTherapy® (in most cases around three months), as motor learning takes place, the pain relief and improvement in function is evident outside of the time patients spend wearing the AposTherapy® device. However, sometimes with more severe symptoms and other conditions this can take a little longer.
Most of our research is based around knee osteoarthritis although we have supportive evidence for other conditions. Due to the nature of how the treatment works, it can be beneficial in many other pathologies including lower back, hip, knee and ankle pain. It can also be used as a rehabilitation tool following common surgeries to optimize outcomes, which is discussed in the following headings.
Patients can start AposTherapy® at any stage after an arthroscopy starting from the moment they are allowed to bear full weight on the operated leg.

One of the challenges in rehabilitation after joint replacement surgery is to improve the patient’s movement patterns and, more specifically, to normalize gait and weight bearing. If these goals are not achieved relatively quickly, their achievement becomes more and more difficult as time since surgery lengthens. This is due to soft tissue changes, such as contractures and also because pre-operative faulty movement patterns will likely continue if new improved motor control is not learned and instilled. In addition, patient adherence to rehabilitation tends to decrease over time.

AposTherapy® can be started as early as four weeks after a joint replacement. The device is calibrated with two aims: to decrease pain thereby encouraging weight bearing on the operated leg and to improve the neuromuscular control over the leg in a variety of situations.

Physical Therapy and AposTherapy® complement each other after major surgery such as knee or hip replacement. There are important aspects of rehabilitation that can be dealt with through traditional Physical Therapy, such as range of motion, strength of specific muscles, etc. The use of AposTherapy® will instill the benefits of these treatments in a subconscious manner into all weight-bearing activities in a form of rehabilitation that patients easily adhere to.

As the patient improves, the calibration of the device is changed, and the challenge provided through it is increased. This ensures maximal results of the rehabilitation process.

There have been three studies published to date demonstrating excellent results for the integration of AposTherapy® and traditional Physical Therapy post knee replacement18,19 and post hip replacement20.

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