In recent years, there has been a paradigm shift—both in our expectations for recovery of physical function after stroke or other neurological injury, and in how we view the inevitability of physical decline with aging. Neuroscience research has produced positive evidence of the plasticity of the human brain and nervous system, and physiologists continue to debunk the myths that significant muscle atrophy and the concomitant decline in motor ability are unavoidable with aging.^1-6 This has resulted in a general move away from teaching compensatory strategies and a shift toward an increased emphasis on active movement, strength training, and more intensive practice. For therapists to effectively incorporate these new, evidence-based physical therapy recommendations into their current practices, however, they will have to have a means to safely get their clients moving.

The NeuroGym® Technologies line of enabling equipment was developed specifically for this purpose over the course of many years of physical therapy practice with neurologic patients. The equipment also is proving to be extremely useful in mobilizing seniors and improving their level of functional independence. Created to overcome obstacles to active training, NeuroGym equipment includes devices to effectively train the "building blocks" of mobility, such as strength and range of motion at key joints (NeuroGym Ankle Trainer, Tilted Stepper, and Portable Pulley), equipment to aid in mobility (Sit-to-Stand machine and Bungee Walker), as well as tools to allow specific training of balance and motor control through motivating biofeedback (NeuroGym Trainer).⁷ By allowing for the enrichment of the motor retraining environment, NeuroGym Technologies equipment helps to create and enable situations in which clients can actively attempt movement, get feedback, and practice intensively—all in a safe and highly motivating environment. These features are crucial to a successful, evidence-based motor relearning program. In today's health care environment, physical therapy equipment also must help therapists provide practical, cost-efficient treatment and not be unreasonably demanding on staff time and facility budgets.

ESSENTIAL BUILDING BLOCKS TO MOVEMENT

Strength and control at key joints such as the ankles is an important building block to balance. Often, ankle strength training is done with ankle weights or devices that do not isolate the ankle and foot from associated lower limb movement. For individuals recovering from neurological injury, this type of exercise may be difficult because of limited strength and reduced ability to target and control the required muscles. What is needed is a device that can train ankle mobility and strength in each of ankle eversion, inversion, plantar, and dorsiflexion, even in individuals with extremely limited ankle strength and motor control.

The NeuroGym Ankle Trainer was developed to meet this challenge. The foot is secured in position, and the device may be locked such that movement in only one plane at a time is allowed. The portability of the device and ease of connection to either elastic tubing or a pulley improves the ease of training. Often, targeting and control of ankle muscles is an important therapeutic goal. With the addition of a position sensor, the Ankle Trainer can be used along with the NeuroGym Trainer system to allow for intensive motor learning through speed-sensitive biofeedback training.

THE SIT-TO-STAND TRANSITION

Figure 1. The Sit-To-Stand machine uses an adjustable counterweight system so that the standing motion can be actively initiated and assistance can be gradually reduced as strength and motor control improve.

When mobility is extremely limited, as, for example, in patients making the transition from bed or wheelchair to independent standing, initiating sit-to-standing training is part of the early treatment plan. Such training, however, is often limited by patient weakness, reduced range of hip and lower-extremity joint range of motion, and difficulties in motor control and coordination. To help overcome these obstacles and assist the therapist in optimizing this aspect of rehabilitation, NeuroGym Technologies developed the Sit-to-Stand machine. Its design enables patients to attempt standing from a sitting position by applying as much counterweight as is necessary to assist with a smooth standing motion. Unlike other equipment that actually pulls the patient to standing, this device allows the therapist to adjust the counterweight to apply the minimum amount of assistance necessary, thus promoting active, client-initiated movement (Figure 1).

MOBILITY AND GAIT TRAINING

The relearning of basic static balance as well as more complex dynamic balance control is a primary goal of neurological rehabilitation. In a recent research report reviewing PT interventions for patients with stroke, Jette et al⁸ found that gait training consumed the largest percentage of therapy time compared to other treatment activities. The emphasis on balance and gait training highlights the importance of this aspect of rehabilitation; and underscores the importance of providing to therapists the most effective and efficient means of achieving successful therapeutic outcomes.

Figure 2. The Bungee Walker provides graduated support from below, rather than support from above as in most body-weight support machines. This allows more natural and realistic practice, particularly of the protective reactions necessary to prevent falls.

The relearning of a motor skill like gait cannot occur if an individual is not able to experience the opportunity to actively try (and fail) repeatedly. This is typically difficult to safely achieve without the assistance of multiple therapists or without the aid of extensive body-weight support equipment. The NeuroGym Bungee Walker was designed to overcome these obstacles and achieve optimal training requirements. Unlike other walking assists that support the client in a harness mechanism from above, this machine provides graduated support from a mobile seat underneath the client, allowing maximum mobility as well as the comfort of sitting to rest when necessary. In the Bungee Walker, clients can practice a full range of static and dynamic balance tasks safely and with an ease of movement that closely approximates mobility without an assistive device (Figure 2). As a result, patients can experience dynamic destabilizing motions and safely relearn protective backward and sideways stepping.

Patient motivation is not a problem when the therapist has tools such as the Bungee Walker. Any number of dynamic balance skills can be practiced in the Bungee Walker. Kicking a soccer ball or playing balloon volleyball—while secured in the Bungee Walker—allows enjoyable, intensive practice of dynamic balance skills without the fear of falling. With practicality in mind, it was designed to fit through a standard doorway, so that it may be used in patients' rooms or in hallways, thus increasing the "virtual" gym space.

KEEPING THERAPY MOTIVATIONAL

Retraining motor skills such as balance or gait requires intensive practice. This may lead to boredom and a reduced likelihood of patient compliance. Whether training basic weight shifting or higher-level mobility skills, intensive balance practice while in the Bungee Walker also can be combined with the motivating interactive biofeedback provided by the NeuroGym Trainer.⁹

The NeuroGym Trainer is a comprehensive biofeedback system that enables intensive, speed-sensitive balance training. Information from pressure sensors placed under the feet is interfaced with computer games in which real-time weight shifting in all directions, on one or both legs, or even in dynamic tasks such as jumping, is used to control the game. The NeuroGym Trainer has the capacity to monitor weight shift (pressure sensors), postural control (position sensors), and muscular activity (emg sensors), either in combination or alone. The therapist can easily design a balance-training session to target one or a number of treatment goals by adjusting the parameters that will control an interactive biofeedback game. For the patient, then, balance training becomes an enjoyable and rewarding experience as they play a computer game, such as steering a race car down a track or playing paddleball, by successfully performing weight shifting with pressure sensors underfoot and position sensors on the trunk to encourage the desired posture.

The NeuroGym line of enabling equipment has removed many of the limitations previously faced by PTs wanting to provide safe, intensive, and enjoyable mobility training. From initial attempts at standing to the practice of complex dynamic mobility and agility, this line of rehabilitation equipment provides therapists the means of translating the scientific evidence of neuroplasticity into effective clinical practice.

The evidence base for new approaches to rehabilitation in neurologic and geriatric populations continues to expand the expectations for physical therapy treatment outcomes. Many modifiable factors such as muscle strength, joint range of motion, and mobility can be positively influenced with appropriate treatment methods and training intensity. The NeuroGym line of enabling equipment helps clinicians fulfill the type of therapy and exercise programs that laboratory studies in the movement and basic sciences are suggesting would be most effective. The onus is on rehabilitation professionals and facilities to revisit their current programs and ensure that restorative care is truly that—measurably improving the functional mobility and independence of all patients.

Avinoam Nativ, PhD, PT, has been involved in the research and development of physical therapy equipment for more than 20 years, and maintains an active physical therapy practice dedicated to the treatment of movement disorders. Nativ can be reached at.

REFERENCES

1. Nelles G. Cortical reorganization—effects of intensive therapy. Restor Neurol and Neurosci. 2004;22:239–244.
2. Behrman AL, Bowden MG, Nair PM. Neuroplasticity after spinal cord injury and training: An emerging paradigm shift in rehabilitation and walking recovery. Phys Ther. 2006;86:1406–1425.
3. Wolpaw JR, Tennissen AM. Activity-dependent spinal cord plasticity in health and disease. Ann Rev Neurosci. 2001;24:807–843.
4. Chen R, Cohen LG, Hallett M. Nervous system reorganization following injury. Neurosci. 2002;111:761–773.
5. Morris SL, Dodd KJ, Morris ME. Outcomes of progressive resistance strength training following stroke: a systematic review. Clin Rehab. 2004;18:27–39.
6. Brandon L, Boyette LW, Gaasch DA, Lloyd A. Effects of lower extremity strength training on functional mobility in older adults. J Aging and Phys Activ. 2000;8:214–227.
7. NeuroGym Technologies Inc. Available at: www.neurogymtech.com/products/. Accessed April 17, 2007.
8. Jette DU, Latham NK, Smout RJ, Gassaway J, Slavin MD, Horn SD. Physical therapy interventions for patients with stroke in inpatient rehabilitation facilities. Phys Ther. 2005;85:238–48.
9. NeuroGym Trainer. Available at: www.neurogymtech.com/products/neurogym_trainer.php. Accessed April 17, 2007.