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Rehab Angel

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Karen Knightly, Nov 8, 2010.

  1. Karen Knightly

    Karen Knightly Active Member

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    I have recently been made aware of the Rehab Angel invented by Podiatrist Neil Frame

    Are any of you using this in your clinics yet? What are your thoughts? I'm thinking of getting one as I think it's a great invention, although, having shown a patient how to correctly use it, if they didn't actually have one themselves in their home, benefits would be limited I would assume.

    Last edited by a moderator: Sep 22, 2016
  2. Griff

    Griff Moderator

    Hi Karen,

    I'm not sure what value having one of these in my clinics would bring, for exactly the reason you mention. Whether it be calf stretching or eccentric loading of the patella tendon, these are things that the patient would need to be repeating at least once daily, and therefore they'd need one themselves. Is the intended market for the sales of these gizmos the patients? Or us as clinicians?

    How much are these Rehab Angels?

    Seems to me to be a bit like a solution for a problem I wasn't aware we had...
  3. Griff

    Griff Moderator

    A bit of searching online and I found the answer: £294.40

    And they boast it is cost effective. How can they say that when it appears to be at least 3 times more expensive than most other similar devices??

    Think I'll stick to recommending a bit of plywood...
  4. Karen Knightly

    Karen Knightly Active Member

    It seems from the video that it's being marketed for clinicians doesn't it, when perhaps really it should be marketed towards the patients.

    At £294 I don't think many patients would want to spend that kind of money either

    I've changed my mind, decided I don't want one after all!
  5. Seen it before back when Karen was a student. It was called the ADEAS board if memory serves- pretty much identical without the spring loading- at the time it was £80, oh how we laughed, oh how we didn't buy it.

    Can I suggest making a ramp, as I did for one of my lectures at biomechanics summer school 2010 out of a slab of plywood and some coach bolts, total cost less than £10
  6. Griff

    Griff Moderator

    Perhaps if someone knows Neil they could direct him here and he could go through the rationale of inventing such a device. He is a member already but has not been on here since 2008 so probably won't see this thread unless nudged.
  7. Griff

    Griff Moderator

    Facile est inventis addere.
  8. Yeah, the real trick is in demonstrating what the perceived improvement actually does. This may well be the result of several thousand pounds of grant money, wich the University now wishes to make some money from. Or it could, just be a case of the "inventor" selling enough units to make their development money back. I'm guessing this won't make it's inventor a millionaire, but stranger things have happened.

    I've got a couple of dozen of things like this sat under my desk, but I haven't got a Denzil Dexter selling them for me on t'interweb (I don't now how things are done in Jim's time warp, but in mine... it's like this: show me the evidence):

  9. neilframe

    neilframe Welcome New Poster

    Simon and thread contributers;

    1. Are clinicians prepared to risk their professional standard in a clinical setting by advocating the use of items that have not been regulated and meet the standards required to maintain patient’s safety?

    2. Is it likely patient’s will feel comfortable with clinicians’ competency when requested to engage with apparatus that seemed to be thrown together or would patient’s feel that clinicians are more professional when providing them with apparatus that meet all clinical validation and evidence?

    3. Has the reader really understood what exactly the device does and why it is more of a clinical piece of equipment rather than for home use?

    4. What evidence do they have that their current practice is providing ‘best health’ to their patient and are they undertaking best practice in their clinical delivery?

    5. Would you the clinician be prepared to stand legal liable for advocating unsound practice and more importantly prepared to put patients at risk?

    6. Should the NHS put it self at risk in allowing clinicians to maintain the use of unsafe pieces of apparatus considering it is about putting the patient first and improving patient’s experience. Does the commentator consider that the patient is not an important element to their practice and advice giving?

    7. What value would the commentator place on keeping the patient safe?

    Neil Frame
  10. Neil, Lets just take a quick look at those exercise ramps offered for sale at the e-store I linked to here: http://www.shapeupshop.com/fitness/flexibility/slant_board.htm there are other kinds I know which I'm sure we could link to also.

    Now are any of these unsafe and thrown together in your opinion, if so, why? I've seen similar ramps and boards used in NHS and private practice for many years, so I'm assuming that someone somewhere within the NHS doesn't perceive them to be inappropriate and a high risk apparatus. How many exercise ramp related injuries are recorded per annum?

    With regard to "best evidence" perhaps you could point us to the peer reviewed articles which demonstrate best evidence for the use of exercise ramps and why the device which you are now marketing has superior evidence to support its use?

  11. I've had a look at the usual sources but couldn't find much published on inclined plane, slant board/ ramp stretches etc.

    I did find this in a peer reviewed journal, I draw your attention to figures 3, 4 and 5.
  12. I guess why the 5 degrees varus post not 6 or 10 or 12 etc or why is this not adjustable as well ?

    Might be a add on for you Neil.
  13. I got these and some others on eccentric loading:




    But I can't seem to find much on the physical characteristics of the ramps themselves.

    This study looked at biomechanics at different angles:

    N.B. they constructed their own slopes for their study:
    "Our experiments demonstrate that performing single-leg squats
    at decline angles >15°all result in a significant increase in the
    maximum patellar tendon force. Any decline board between 15°
    and 30°can thus be used, whichever feels most comfortable to
    the patient. To prevent patellofemoral pain syndrome, we
    recommend avoiding knee flexions >60°. In case a higher
    tendon load is required, we recommend the use of a backpack
    with extra weight."

    And this one: a randomised controlled trial, seems to show that heavy slow resistance training may be more favourable than eccentric work on a ramp for patella tendinopathy:
  14. Foot position (inverted versus everted versus RCSP) doesn't appear to alter quadriceps recruitment in eccentric squat:
  15. What about gastroc/sol complex I was going to start a thread on this but stopped myself 2nd guess my idea.

    a quick basic rundown - medial deviation of the axis will usually put the gastroc/sol complex under load ( STJ axis position dependent I know but I generalize ) and the muscle will eccentric stretch a little - right ?

    now if we then us a varus wedge of 5 degrees and all things being equal laterally deviate the STJ axis- the gastroc/sol complex will be under reduced load and be shorter - right ?

    and then we stretch the muscles ????

    so in reality the medial deviated stj we should use a valgus wedge to maximally pronate the STJ put the gastroc/sol complex under more load - slightly longer then stretch to have the most effective result in muscle stretching - ??

    the reason I stopped myself is the talus position will change and often result in reduced ankle dorsiflexion at the ankle due to increased compression forces between the tibia and talus .

    But I was thinking about it to day. Hope that makes sense.

    ps are you being super secret squirrel guy and hiding when your online these days - posts keep coming up but a red cross against your name.
  16. Full text of this one free here:

    And Jim Richards paper here:

    After my reading and research today, I still don't see why the "rehab angel" should be superior in terms of outcomes than any one of the much cheaper devices already on the market, but I'm sure Neil can tell us why the NHS should be spending the tax payers money on a device which is at least twice, probably thrice as expensive as a similar device, that will likely achieve the same outcomes as the cheaper device, but unlike the cheaper device does not have published evidence to support its use.... right, Neil?

    P.S. This from Jim Richards paper: "Investigators have documented only the use of 25° decline angles10–,12,14,15 and 30° decline angles.13 To begin to understand the biomechanics of single-limb squat exercises, researchers must investigate the biomechanical demands associated with several decline angles."

    Reference 13 from which Jim suggests that the researchers only looked at 30 degree angles, is in fact the Zwerver study in which: "Five subjects performed single‐leg eccentric squats at decline angles of 0°, 5°, 10°, 15°, 20° and 25° (with/without a backpack of 10 kg), and 30° on a board that was placed over a forceplate."

    Just goes to show how research gets misquoted.

    p.p.S. if you really want to make these safer for patients to use- put a hand rail on them.
  17. Mike, thinking about the squat exercise for patella tendonitis: the foot is plantarflexed by standing on the board such that the forefoot is declined on the heel, how will this influence tibio-talar coupling? Ankle plantarflexion should offer the narrower, posterior aspect of the trochlear surface to the articulation with the tibia- right? Lets assume that our 5 degree wedge actually inverts the foot by 5 degrees. How will the addition of this 5 degree varus wedge influence the tibial rotation, if at all?

    In some it might increase peroneal recruitment.

    We then get into the realms of supination resistance: in reality the 5 degree inclination may have zero effect on some individuals rearfoot position, depending on the supination resistance. Thus far, I'm not convinced it is necessary to have a varus post on the ramp. If it is, then use some sticky wedge on one of the much cheaper ramps!

    Don't get me wrong, I love invention, but I also love therapeutic solutions which are not prohibitive due to their cost and can be applied by clinicians globally, and do not exclude developing countries. Hence if you can achieve the same thing with a bit of timber for pence that you can for £300.... it's a no brainer to me.
  18. In some we should get negative power flow which all things being equal external rotation of the tibia, which as you say the planatrflexed position may just mean increased internal STJ pronation moments.

    ´tis a tangled web we weave´

    so we may have external tibia rotation , no change in tibia rotation and I guess internal tibia rotation.

    but in reality 5 degrees may just invert the heel a little and have no effect on the tibia position. EDIT or as you suggest in your edit have no effect at all due to supination resistance.

    Need to read Nester et al wedge - bone pin study which must not be far away from being published.
  19. Please note: the inclined plane used in the research paper published by Jim Richards was NOT the rehab angel (see Figure 2). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2547867/

    It would be nice to have a repeat of this kind of study with the rehab angel versus the cheaper boards.
  20. Griff

    Griff Moderator

    Or maybe even just get the patient on a cheaper ramp and have them perform the single leg exercises whilst wearing their orthoses?
  21. Clever - thats why you get payed the big bucks.

    simple and smart.
  22. CraigT

    CraigT Well-Known Member

    Also a very good way of showing the effect of their orthoses...
  23. Griff

    Griff Moderator

    No-one told me that I got paid the big bucks...

    Neil - with regard to the 'bungalow roof' of the device, (i.e. the 5 degree varus tilt); in the video it is suggested that this will help those with foot level instability perform single leg exercises such as calf stretches and declined small single knee bends.

    Ignoring the fact that there seems to be scant research linking frontal plane foot position and quadriceps recruitment/triceps surae stretching for one moment - what made you land on 5 degrees as a value? And is this adjustable (to offer 10 degrees tilt for example)? Finally, will the bungalow roof 'invert' and provide any valgus tilt?


  24. neilframe

    neilframe Welcome New Poster

    Ladies and Gentlemen

    1. We are all in a sceptical world but never the less, it is highly important that we in the NHS utilise the most up-to-date research. There is shortly to be published a peer reviewed paper that answers your questions regarding optimum, incremental angles we as podiatrists would be looking for when engaging our patients in this area of our evidence based practice.

    2. Obviously, it is not all about price. We must relate any price on a product to the duration of it useful life. It is the whole of life cost which we need to take into consideration and factor in the likely cost and timing of any replacement within our decision making profile. So, a product that may cost £500 with a useful life above 5 years would in effect mean an annualise cost of £100. The issue then is, would a comparatively cheaper product, against the annualise price of one more that is more expensive, produce the same ‘whole of life’ in use result and duration? If one needs to replace the cheaper device after one year of use, then in reality there would be no significant advantage to buy cheaper. In fact the single purchase of the more expense product would actually bring improved cost savings when we look to factor in the incremental costs of different timing of purchases on the cheaper product; on freight carriages and also invoice raising process.

    3. Higher levels of utilisation and equipment activity must be considered in order to improve clinical productivity. If the cheaper product will only undertake the function of one form of exercise regime suitably, the acquisition of other pieces of equipment would be necessary, to cater for the other types of exercises. This then could mean that the aggregate cost of all different pieces of equipment far exceeds that of the one singular expensive product. We know this to be the case all too often and can result in clinicians not having the available budget to cater for their patient needs. This may result in make do arrangements that unfortunately opens up the professional to certain legal risks if something does happen to go wrong when utilising such make do equipment. Case in point "Can I suggest making a ramp, as I did for one of my lectures at biomechanics summer school 2010 out of a slab of plywood and some coach bolts, total cost less than £10" as posted by a professional on this forum.

    4. It is the paramount duty and responsibility of the NHS to ensure that it’s patients are dealt with in a safe environment. This extends to any apparatus that patients encounter whilst in NHS care that also enhances our professional standing, reputation as clinicians and thereby reduces the risk of litigation. These are some of the many considerations that are taken into account when looking at value for money procurement. It is therefore vital that to lessen the risk to both patients and clinicians that evidence be provided to support the use of equipment, along with effective clinical reasoning. It is of prime importance to the NHS that every penny of taxpayers money is spent appropriately and wisely and done so in a transparent manner. It is important to state at this time that procurement of RehabAngel® brings back inward investment into the NHS on every item acquired rather than just cash releasing value. This is also a very important element for procurement consideration.

    5. The NHS is all about raising standards and as a twenty first century healthcare organisation it is about providing world class healthcare utilising best in breed products in order to deliver best care. Moderate care is not an option and as such we should all applaud this initiative and innovation striving to improve healthcare delivery.

    Neil Frame
  25. Neil you should go into politics, while it all great that a peer review paper is coming out, maybe you can answer the questions. Would be nice to hear about it.

    and for the record I don´t care how much it costs or how much money you spent making it or why you think it´s safer than other devices.
  26. Parochial comments about the NHS aside, surely practitioners globally should be striving to improve health-care delivery and implementing the best evidence into their practice. This is an international forum and the majority of members here do not work within the NHS. Best evidence may not be the same thing as the most up-to-date evidence, by the way. I went to the trouble of seeking out some of the published research on the use of exercise boards and posted links to them on this forum, both for my own professional development and for those others who may read this thread. In reviewing this literature, I could find no rationale to add a 5 degree varus wedging to the interface surface of the exercise board. And it appears from the published research that: "Any decline board between 15° and 30°can thus be used, whichever feels most comfortable to the patient." This, is my interpretation of what the best available evidence tells us. 16 degrees seems to optimise knee and ankle effects. None of the published studies employed the rehab angel. Moreover, slow heavy resistance training may provide better outcomes than eccentric training on a ramp, anyway! Yet perhaps I have missed some vital piece of published research which explains the rationale for a 5 degree varus wedge. If so, I'm sure both my colleagues and I should benefit from reading it. Can you cite such a study?

    The point regarding longevity of the the product versus cost is well made. What is the "life-expectancy" of the various models of exercise ramp available in the market place? How frequently do NHS departments currently replace their exercise ramps? How many units of the rehab angel have been field tested within clinical environments and for what duration? It strikes me, although I cannot provide evidence for it, that the lack of moving parts in the cheap, widely available exercise ramps within the market place should mean that there is pretty little that can actually break, so their life-span is limited by what? What is the life-expectancy of the springs in the rehab angel?

    Multi-functional/ role? It can be used to do what precisely? How many wobble cushion / blocks of foam could I buy for £300 to carry-out the exercise demonstrated by the vascular specialist in the video?

    Ultimately treatment outcomes are what should be important. I wouldn't mind paying 3-5 times as much for a similar piece of kit, if the more expensive piece of kit is 3-5 times more efficacious. Do you have any evidence that the rehab angel is more efficacious than other much cheaper products?

    You haven't addressed the early comment made by my colleague in this thread that to be efficacious these kind of exercises need to be carried out daily and therefore a device designed for home use is really what is required. Do we have any evidence which has compared the outcomes of those engaging in eccentric programmes on a daily basis versus weekly, monthly etc.?

    Neil, you still haven't told us why you believe the product you are selling is safer than any of the similar, yet considerably cheaper products already within the market, nor for that matter why it should be safer than a well constructed device built by a professional. Or for that matter, a piece of 2"x4" timber as advocated by some other of our professional colleagues in their peer reviewed article which I cited previously. For the record, I have at my disposal a 3-dimensional CAD/ CAM system to design things like exercise boards upon. I also use finite element analysis software and can run simulations to explore the effects of cyclic loading and unloading and figure out the factors of safety of components in my projects. I also a have access to a CNC router capable of cutting the required components. So can you tell me why any exercise ramp I might choose to build should be "less safe" and moreover, "less professional" as you intimate it would be? Indeed, I assume you also consider the ramps constructed and employed within some of the studies I posted links to earlier as being unsafe and unprofessional since these too were "home-made" out of plywood and bolts? What are the commercially available exercise ramps constructed from if not plywood and bolts?

    I could find no studies of injuries occurring as a result of exercise boards. Do you have any references regarding factors influencing their safe use?

    Neil, this is an opportunity to sell your product to the global market, what makes your product safer, more cost effective and above all, more efficacious than those similar products already in the market?

    One final question, Neil: Can I ask how much funding this project has received to date and the sources of that funding?
  27. Not happy with that statement I made earlier. What the paper actually said was "16° decline angle provided the maximum benefit for the knee extensors with the minimum effect for the ankle." And:
    "The 24° decline angle provided a greater challenge to the ankle and targeted the knee extensors."
  28. I wonder if Neil will come back and discuss the 5 degree varus foot position ??

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