What is AposTherapy® and what are its components?
AposTherapy® is non-surgical and non-pharmaceutical, FDA-cleared and CE registered for treatment of knee osteoarthritis. 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, activity that is performed during the patient’s normal daily routine and the AposTherapy® clinical pathway. These are discussed in the next Q&A’s.
AposTherapy® is based on performing simple daily activities with the footworn device, which is individually calibrated for each patient based on a thorough, initial clinical evaluation conducted by an AposTherapy® trained clinician. The activity 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 program plan provided by the clinician. AposTherapy® 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 program plan may change based on the patient’s progress in order to increase the therapeutic effect.
The AposTherapy® footworn 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 a personalized program, patients use the device during daily indoor activities, making it possible for 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.
Examples of the effects of the device can be seen in this video.
Patients are monitored through clinical, quantifiable, valid and reliable outcome measures. Patients go 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.
The first year package includes 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 program specifications.
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 by policy makers and insurers and so on.
There are a number of advantages to the fact that AposTherapy® is performed during daily activities.
First, patients suffering from knee osteoarthritis 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, using the device within patients’ daily activities reduces the demand on their schedules, facilitating adherence.
Each patient goes through a comprehensive evaluation in the initial consultation, which is their first assessment with the AposTherapy® trained clinician. 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 clinician.
Based on all the above information then disc, the clinician discusses the expected benefits of AposTherapy® with the patient. If the patient’s goals and the expectations can be aligned, the clinician will proceed to calibrate the footworn device specifically for the patient’s symptoms and gait deviations. The patient then takes the device home and uses it according to a tailored program specifications provided by the clinician. The gradually progressive program makes it possible for the patient to integrate the wearing of the device into their daily activities.
Patients are asked to attend regular follow-up appointments in the first year of the program in order to assess their progress and enhance the results of AposTherapy®. Follow-up appointments include the gait lab, questionnaires, and a reassessment by the AposTherapy trained clinician. Based on the changes measured in the gait lab and reassessment, the clinician may decide to change the device calibration, the program specifications or both. This enhances patients’ progress and improvement.
Over the course of the program, the follow-up appointments become necessary at less frequent intervals. 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 in the program, approximately 3-4 times a year.
Whether or not the patient continues with the program, the footworn device is their’s to keep.
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.’
In addition to the footworn device, the AposTherapy® program offers the benefits of having a capable clinician overseeing the process along with a personalized program.
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 on muscular activity, they do not seem to have carry-over 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 program, carried out over the course of a year or more.
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 clinician can decide to change aspects of the program. In most cases of orthotics, however, patients with orthotics are seldom re-assessed for refitting beyond the first few weeks.
AposTherapy®, being a conservative solution, is very low-risk; there are no documented adverse events. It is important to stress that patients are thoroughly assessed by the AposTherapy® trained clinician for risk of falling. Only patients who are found suitable are offered AposTherapy®.
AposTherapy® has been widely researched, and studies specifically demonstrate the positive effects of AposTherapy®.
Which patients are suitable for AposTherapy®?
Generally speaking, AposTherapy® is suitable for patients of all adult ages, including most elderly patients. Based on the AposTherapy® trained clinician’s assessment and clinical reasoning, patients who are either deemed at risk of falling, and those who may have negligible benefits, 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, i.e. they are likely to benefit from it and are not at an increased risk of falling, they can begin the program. Patients use the AposTherapy® device according to the specific, easy-to-follow plan provided by the clinician. The program itself merely requires that patients perform their daily indoor activities while wearing the AposTherapy® device. The individually tailored program progresses from week to week increasing patient exposure and benefit from the device.
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.) 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.
What can patients expect?
During the Initial Consultation, patients go through a thorough clinical assessment by an AposTherapy® trained clinician, 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® 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 aligned with patient values and physical condition. We adhere to a policy of not starting patients on the program 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 knee patients experience a reduction in symptoms and improved function within the first three months. However, there is no such thing as 100% success in medicine.
Patients may feel pain relief even during the initial calibration of the AposTherapy® device due to the re-distribution of loads away from the affected areas and the improved muscle recruitment.
After a few months of AposTherapy® (in most cases around three months), as motor learning takes place, the knee pain relief and improvement in knee function becomes evident outside of the time patients spend wearing the AposTherapy® device. However, in cases of more severe symptoms this process can take longer.
Most of our research is based around knee osteoarthritis although it can be used as a wellness device for other reasons. Due to the nature of how the it works, it can enhance wellness for people with other pathologies including lower back, hip, knee and ankle pain.