Physical therapists today need to be cognizant of using tools that are versatile. With limited space and/or budgets, PTs need to find tools that will work for multiple patient populations and goals.

In the case of lower-extremity resistance training, which is applicable to many different patients and needs, this is especially the case. Often, machines exist that offer PTs excellence and extensive options in one or a few capacities. A tool like this that focuses on one area, such as performance enhancement for athletic clients, can be very effective for PTs who focus on a specific patient population. But for the majority of PTs, who treat athletes and older patients and children, and who need to worry about cost-effectiveness when purchasing equipment, a machine that offers flexibility is the ultimate find.

Today, new tools are gaining interest and users because of their ability to do just that. These progressive machines that offer lower-extremity resistance training for multiple populations, applications, and resistances give PTs the ability to maximize cost and space and to get creative, applying their extensive knowledge to new and challenging regimens.

In this article we will take a look at two of these new tools and will test their flexibility. By examining their lower-extremity resistance training capability at opposite ends of the spectrum—the elite athletes and their goals of performance enhancement, along with injured or debilitated elderly patients and their goals of function restoration—we can determine the true extent of their versatility.

PERFORMANCE ENHANCEMENT

PTs are accustomed to using advanced tools to aid in athletic rehabilitation. For athletes recovering from injury, machines offered by the giants in the industry can contribute to effective restoration of function. Now, new tools are also offering the ability to give highly functional and talented athletes a performance edge yet still offer the flexibility to treat elderly patients with far reduced goals.

Kenji Carp, a PT, athletic trainer, and competency certified vestibular therapist, is clinic director at Physiotherapy Associates in Eugene, Ore. His patient population leans heavily toward athletes with orthopedic conditions. While he assists his Little League to professional athletes with classic rehab after injury, he also offers the ability to improve performance with functional training and tools.

"A wealth of research shows that lower-extremity resistance training is effective for rehabilitation but also for enhancing performance and preventing injury," Carp says. "The biggest challenge then is to offer an effective entry-level resistance, giving these athletes the physiological stress to adapt. I need to give their muscular system a challenge, but not such a challenge that they can't get started and move down the path to greater performance."

As PTs know, a number of tools and techniques currently exist to navigate this tricky road. The classic method is to start with open-chain strength training, with the leg free to move off the floor. While this type of free or cable weight training is useful, especially in early stages, research shows its ultimate effect can be limited, and it doesn't provide an expansive range of challenge. Another option is the classic leg press machines. But again, these machines are limited. They're difficult to get into, and their overall size can be intimidating. Finally, floor exercises like double-leg squats and functional closed-chain exercises can put too much stress too quickly on the lower extremities and place the entire training in peril.

Carp has found his solution through the Shuttle, offered by Contemporary Design Company in Glacier, Wash.

"I've found all the benefits I'm looking for, without the limitations of the classic lower-extremity resistance training exercises, with the Shuttle," Carp says. "It's particularly useful for performance enhancement with athletes because it's easy to get started, dialing the resistance down. But at the same time, you can ramp up the resistance to very challenging levels. It's a machine that's easy to get into and easy to customize."

Carp works with the main Shuttle model, the 2000-1, which offers progressive functional rehab and training for athletes, general orthopedics patients, geriatrics patients, and more. The Shuttle consists of a horizontal stand with an adjustable backrest (for easy access), a kickplate, expansion towers, and elasticord resistance. This type of resistance promotes both concentric and eccentric loading of muscle throughout all phases of motion, strengthening the neuromuscular system to cope with acceleration forces and improving reactive response to ground contact.

For PTs who work exclusively with athletes and want to take advantage of the device's performance-enhancement ability, the Shuttle MVP model offers additional levels of resistance for elite sport-specific training. The PT can use this specialized Shuttle to focus the neuromuscular system and teach it to improve speed, agility, vertical jump, and power.

Overall, the Shuttle aids in athletic power enhancement by transitioning well to plyometric exercises. Moving in the way the athlete naturally moves, but adding resistance to train the muscle to work at a higher level, pushes past the barriers of typical lower-extremity resistance training and moves athletes to a new level.

Kenji Carp, PT, instructs a patient on proper body form and positioning.

Another new device in the field utilizes progressive lower-extremity resistance training for enhanced athletic performance, but focuses on stability rather than plyometrics. The FT-450 from Cybex International, located in Medway, Mass, uses an upright dual adjustable cable column with a support pad that creates different levels of stability and different demands on the muscles.

"By offering the patient and the PT various levels of stability, the patient has an opportunity to return to function or to improve on function," says Paul Juris, executive director of the Cybex Institute, the research arm of Cybex International. "With a device like this, athletes can return to and enhance their performance."

Thinking about the function of legs and stability illustrates why this tool could be an effective addition to the PT toolbox for athletic performance enhancement. To maintain a fixed position in space, and to improve our ability to do this, patients can stand on one leg while performing movement with the other without any support. But this is extremely challenging in many cases. To mitigate that challenge, patients could work against a light workload, but in the process they limit their chance of improving capability. Alternately, patients could maintain the heavy workload while holding on to a fixed object or location. This, however, further limits the ability to improve stabilization.

With a partial degree of stability, using a pad positioned anywhere from the shoulders to the knee, PTs can solve the issue for patients. Athletes can work on lower-extremity resistance training with greater weights without sacrificing functional movement and attain even greater core muscle activation. PTs can gradually decrease the amount of stabilization with positioning, progressively improving performance.

"What the FT-450 does is bridge a gap in the fitness and athletic space," Juris says. "By providing this partially stabilized position, patients can increase workload dramatically but still integrate motion. It's creating a solution that doesn't exist anywhere for PTs. Plus, independent studies are showing that this partially stabilized environment is the best overall way to improve strength and muscle activation—a major potential benefit for athletic performance."

BEYOND ATHLETES

The Shuttle and the Cybex FT-450 are tools that offer a major boost for performance enhancement. But their real power lies in their multifaceted capabilities for PTs with diverse patient populations.

For Carp, the Shuttle is the device that he can feel confident investing in because of its expansive options for his full patient load. Besides athletes, the other major proportion of his patients is those with vestibular conditions deriving from multiple sclerosis, Parkinson's disease, falling, strokes, and other conditions. These patients are typically elderly and have significantly different goals when it comes to physical therapy. But the Shuttle allows Carp ultimate adaptability for all of his patients.

"My patients with balance issues as a result of vestibular conditions really benefit from the progressive lower-extremity resistance training," Carp says. "What's great about the Shuttle is I can dial the resistance way up for my 11 AM appointment, a high school linebacker trying to improve his game. For my 11:45 appointment with an elderly patient, I can use the same device and simply dial the resistance way down. That gives my patient confidence but also gives me flexibility with one machine."

For elderly patients and those with balance problems, the Shuttle offers a safe platform for patients to develop and hone proprioceptive responses while performing specific activities. PTs can provide a progressive level of instability to teach the body to restabilize and to negotiate unpredictable changes in force, direction, and placement in space at the neuromuscular level. For the lower extremities in particular, stabilizers can aim directly at the joints of the hip, ankle, knee, and trunk, and involve various exercises and activities to build strength and balance.

Carp closely watches his patient during a lower-extremity exercise.

For PTs, the ability to use one machine for multiple patients, multiple muscle groups, and multiple applications is liberating and better for the bottom line.

"The Shuttle is not at all limiting," Carp says. "How I apply the device depends on how creative I can get. Knowing research best practices, including what motions recruit specific muscles, means I can apply an entire range of applications for lower extremities but also the core and upper body. The Shuttle gives me the ability to use one machine for all my patients, whether they are early in the rehab process or need to be challenged at the highest end of the spectrum."

Carp has used the Shuttle for 5 years with heavy, daily continuous use and values the "bang for the buck" he gets for the space it takes up. He is planning to upgrade to a newer model to further enhance his ability to treat all his patients and their specific goals.

The Cybex FT-450 is another potential resource for PTs looking for the ability to treat multiple patients with lower-extremity resistance training and serve multiple goals. The introduction of incremental degrees of stability, and the progressive nature of lower-extremity resistance training offered through the FT-450, make it a powerful tool for the geriatric population.

"We want to give PTs the ability to multitask, and the FT-450 does just that," Juris says. "For patients recovering from stroke, for patients needing to improve their balance, or for a number of other conditions affecting elderly patients, the FT-450 is instrumental in getting the patient's system to function at a higher capacity in a progressive way."

Just as the tool offers a range of exercises for athletes looking to improve their performance, with a wide spectrum of degrees of stability to do that, the FT-450 uses the same approach to build strength and balance for elderly patients. The stability pad is a referencing element to remind the body where to stay in space and a challenging element to retrain the body or orient itself.

"Ultimately, regardless of the patient and their condition, the FT-450 is designed to give the PT and the patient better results," Juris says. "Patients of all capabilities can develop strength, balance, coordination, and stability, and more effectively target specific areas of the body in a progressive manner. In that way, the tool is very different from any other."

The Shuttle and the FT-450 hold a unique spot for PTs using lower-extremity resistance training. Other companies, however, do offer lower-extremity resistance training tools with some flexibility for physical therapists and their patients. Med-Fit Systems focuses on exercise for adults and seniors, and offers tools like the Nautilus and Korebalance series for PTs to leverage. SCIFIT focuses on fitness and strength conditioning through bioDensity isometric strength technology and its REAL (Rotary Exercise Accommodates All Levels) Strength series. LifeFitness is a leader in personal and commercial fitness tools, and offer entire programs dedicated to athletes and performance enhancement.

For PTs who have highly varied populations, and who need tools that can offer the best in performance enhancement along with the most expansive resistance options for those with limited function, the Shuttle and FT-450 are ideal options for now and the future.

Amy Lillard is a contributing writer for Physical Therapy Products. For more information, contact .

Body Weight Control

At CATZ, building strong balance is key to successful lower-body rehab

By Alan Ruskin

Our philosophy is first and foremost to control our own body weight." With these words, Kevin Wentz, PT, CSCS, spells out the approach utilized at Competitive Athletic Training Zone (CATZ), Pasadena, Calif, for the rehabilitation of lower-body injuries and infirmities.

By "control our own body weight," Wentz is not referring to weight control in the sense of stepping on the scale, but rather to building strength through controlled balancing of the hips, legs, and ankles.

"Whether for therapeutic or performance-enhancing purposes, our program consists of many exercises designed to improve control of body weight through a range of motion, such as bending, squatting, lunging, balancing on one foot, and so on," Wentz says. "First, the patient must be able to handle his/her own body weight in a controlled manner in order to progress through rehabilitation."

In rehab, according to Wentz, "most patients are initially unable to bear their own weight in controlled positions." To rectify that, CATZ uses a basic two-stage process. The first stage involves three fundamental positions as the basis for various exercises: 1) square stance, in which the weight is distributed evenly on both feet; 2) split stance, in which one leg is forward and the other back; and 3) single limb, standing on one leg. Standing, bending, squatting, and lunging exercises are done in all three positions.

"What we use as the ultimate test in this phase is the single-leg squat, which must be accomplished at an angle of 90 degrees or better," Wentz says. If patients aren't able to progress adequately on their own, "we use parallel bars and crutches to assist them."

Once patients have gained sufficient strength and stability to handle their own body weight, they're ready for stage 2, which involves adding more resistance in the form of weighted vests, such as those manufactured by Hyper Wear® LLC, Austin, Tex. The vests fit comfortably over the upper body and have pockets for adding weights totaling up to 25 pounds. "It's just like adding weight to your own body," Wentz notes.

Wentz also notes that even when therapy is for the lower body, weight is added only to the upper body, and he cautions against using ankle weights. "Adding weight to the ankle can lead to foot and heel problems. The impact of the heel strike, especially when running, will be multiplied exponentially. I would not recommend ankle weights for running."

"We don't use any machines," Wentz adds, "just the vests and sometimes sandbells (also from Hyper Wear). Of course, with athletes, we have to take it to a higher level. The emphasis is still on controlling body weight but at a higher velocity, so we speed up the exercises. And depending on the sport, we add agility and change-of-direction exercises."

Typically, CATZ sees lots of knee injuries and ACL reconstructions, which usually require 2 to 3 weeks of therapy, with 1- to 1½-hour sessions three times per week. Sprained ankles, angle surgeries, hip injuries and replacements, and foot injuries such as torn tendons are also common.

CATZ, co-founded by Jim Liston, MEd, CSCS, and Wentz, has been in operation since 1992. In addition to the Pasadena facility, there are branches in Anaheim, Calif, and Yorba Linda, Calif. There are also a dozen training facilities, minus the rehab, located throughout the United States.

—Alan Ruskin