Feature In Praise of Low-Tech Tools In an increasingly technological age, mainstay items of physical therapy such as exercise balls, foam rollers, and elastic resistance bands retain their therapeutic value—and will continue to do so, these PTs say. By Eric Ries | August 2019 Eva Norman, PT, DPT, sustained devastating injuries when she was hit by a car while roller skating at age 13. "I was told that I would never walk again," she says. "They were going to amputate my left leg. I had multiple fractures and wounds. I was in rehab for 4 months." When her outpatient benefit was exhausted, her parents hired a physical therapist (PT) to work with the teenager in her home. "Thinking about those days is painful," she says. "They were the darkest hours of my life. But it's also ultimately a happy story because of the results. "My PT [who asked not to be identified in this article] cared so deeply about my health and well-being, and was such a good listener, that I connected with her in a deep, meaningful way. I committed myself to her intense physical therapy program because I trusted her when she said that I would walk again with no deficits, even though that might have seemed unlikely to others." Indeed, 8 months after the PT's arrival in her home, Norman was walking with only the slightest of deficits. "I'm getting emotional as I say this, but she rehabbed me back to life." Norman credits the PT's ability to be "aggressive yet fun" and lauds the skills of "her wonderful hands." But she gives a major shout-out to something else, as well: "the low-tech tools that played a huge role in my recovery." "My PT used parallel bars to help normalize my gait," Norman recounts. "She challenged my static and dynamic balance by using a balance disc in the parallel bars to help me get over the fear of falling and injuring myself. She progressed my leg and arm strength with ankle weights and resistance bands. She strengthened me by having me do functional movements and simulate tennis strokes using a racket and swimming strokes—all with resistance bands or tubing. She used resistance bands to strengthen my trunk while I was walking and moving in various directions. She advanced my exercises by adding more weight and by using the stability ball and the water, as well as the treadmill." Today, Norman is the president of Live Your Life Physical Therapy in Champlin, Minnesota, a mobile medical wellness practice that meets patients and clients where they live, work, and otherwise congregate—including private homes, health clubs, offices, community centers, and adult day programs. Services include physical therapy; occupational therapy; speech-language pathology; acupuncture; massage; health coaching; and nutrition. But if the practices and practitioners differ from visit to visit, the constant is what Norman calls the "toolkit" that each employee keeps in his or her "office"—otherwise known as the trunk of his or her car. (Or, in most cases, sport utility vehicle. This is the snowy upper Midwest, after all.) "All of the tools that we use must to be practical for our purposes—portable, easy to use, durable, and low-cost for people to purchase for themselves," she says. At the kit's core are what Norman calls the "evergreen" tools of the rehab trade. She recites a list that includes such items as ankle weights, foam pads, transfer and balance discs, stretch and resistance bands, exercise balls, and foam rollers. In fact, Norman also serves as a consultant for OPTP—short for Orthopedic Physical Therapy Products—a major manufacturer of the kinds of low-tech products that are at the core of Norman's practice. The company is conveniently located in Minneapolis, just down the road from her business. "Earlier today, I used balance and stability trainers with a 10-year-old gymnast to help improve her ankle range of motion, strength, and static and dynamic balance," Norman notes. Her company's goal, she says, is "to transform lifestyles by taking an approach of wellness and preventive treatment, using many of the same low-tech tools that were so important to my own recovery." Sara Baker, PT, MS, president of Inspire Health in Atlanta, is another fan and user of low-tech tools—citing their practicality, portability, and cost. She's a certified Pilates instructor for Toronto-based Merrithew, which sells equipment, training, and educational materials. "After managing my symptoms conservatively for 7 years, I had my cervical fusion C3-6 in July 2017 due to a cervical kyphosis, multiple levels of bulging discs, spinal cord compression, and myelopathy," she recounts. "I used a deflated mini-stability ball the first few weeks after surgery—placed under my head and neck for proprioceptive input while I did breathing exercises, gentle upper extremity range of motion, craniovertebral head nods, and some closed-chain lower extremity movements for low-level spinal stability challenge. I have used stability discs, resistance loops, a twist ball, a foam roller, toning balls, and mini-stability balls for subsequent phases of therapy. "Recently," she adds, "if I'm having a day that causes my neck pain to flare up, I use my small prop equipment for an at-home workout—focusing on spinal extensor strengthening, core strengthening, proprioceptive input, and fascial stimulation. This regimen relieves my symptoms—and all of the equipment fits neatly in my closet." "These types of products are never going to go away," Norman says. "They're just as effective today as they were years ago." "There are so many things you can do with them," Baker adds. "You can use them for both therapy and fitness. And they aren't going to break anybody's bank, which encourages people to keep them in their home for self-care beyond rehab." Such is the concept behind the product line sold by Chattanooga, Tennessee-based Magister Corporation. President and chief executive officer David Maley says the premise in starting up the company was "'let's go simple'—let's focus on products that are basic, versatile, have great utility, and are low-cost." So, how does Maley define "simple"? He says, "The joke around here, when we want to add items to the product line, is, it can't be plugged into a wall and has to fit into a briefcase." While it's true that many Magister products stretch those fanciful limits, "We're talking about stuff that's very low-tech," Maley says. "They're not the sexiest things, but PTs use them every day, because they work." Built-In Non-Obsolescence And because they have held up over time. Items that one typically might see in a physical therapy clinic, or perhaps in the home of a physical therapy patient or client, include resistive bands and tubing; exercise, yoga, and Pilates mats and balance pads; resistive hand exercisers to boost grip strength, dexterity, and mobility; molded forms to promote healthy spinal alignment and address slumped posture, head and neck pain, and lumbar dysfunction; and insole and heel cushions. "These are products that don't ever become obsolete," Maley says, "whether they're manufactured or distributed by us or by someone else. Just because they've been around for a long time doesn't mean they're outmoded." He speaks from personal experience. "Both my wife and I used balance pads to add difficulty to lunges and squats when we were rehabbing from knee surgery," Maley notes, "and exercise bands to add resistance to knee-extension exercises. We continue to use them for fitness." "These types of low-tech items come down to the physical and interpersonal dimensions that are inherent to physical therapy," says Ryan Bussman, director of marketing at OPTP. "The profession and its practitioners are all about 1-on-1 interaction. Physical therapy is about touch. The simplicity of these tactile tools is key when it comes to things like increasing people's movement and motivating them to address core therapeutic needs." It's not just the marketer in him who's talking, he emphasizes. As it is with Norman and Maley, endorsing low-tech tools is personal for the Bussmans. "My wife's currently working with a physical therapist to rehab from a wrist injury," Bussman says. "She is using hand exercisers, which are color-coded by the degree of resistance they provide." Bussman himself experiences the simple benefits of low-tech tools whenever he sits down. "There's a lumbar roll strapped to my chair at all times," he says. "That's an item from which a lot of people benefit." "The geometric shapes of many of these simple tools facilitates our using them in ways that draw upon the sensory motor learning we originally explored as children," observes Stacy Barrows, PT, DPT, co-owner of Century City Physical Therapy in Los Angeles. "They encourage self-care by connecting us with our environment. This may be done by releasing our fascia, affording us better postural support after we've been sitting for a while, or just waking us up to variability of movement that can go dormant in our sedentary adult lives. "That's why gym balls have lasted, and why foam rollers will continue to be used," Barrows adds. "They recreate an environment that's three-dimensional and has a gravitational influence, like the toys that helped us develop agency when we were kids. And not only do these low-tech items provide sensory feedback, but they also leave a little something to the user's creativity and curiosity, which encourages their continued use." In the 1980s, Barrows became an early PT user of foam rollers because of her interest in the Feldenkrais Method®, in which she is certified. Feldenkrais is designed to reeducate the nervous system and improve motor ability by promoting awareness of movement and how the body is being used. Its creator, Moshe Feldenkrais, employed foam rollers as educational and therapeutic tools in his work. Barrows, however, found their standard round shape, height, and firmness problematic for a range of its potential users. She ultimately designed and patented her own foam roller, called the Smartroller®. Like Bussman, Barrows, is constantly reminded of the practical utility of low-tech items even when she's not on the job. Traffic is a daily part of life in Los Angeles, but so, too, for Barrows, are her offshoot product Smartroller Sits. The foam pads—placed under the sit bones to "create sensory feedback on your bottom and wake up your posture"—literally support her efforts to tease out some benefit from vehicular gridlock. Take It From "Team Hands" Shirley Sahrmann, PT, PhD, FAPTA, captained "Team Hands" during the Oxford Debate at APTA's NEXT Conference & Exposition in 2016. She and 2 other PTs defeated the debate's resolution that "Technology will advance the physical therapy profession more than our hands and eyes will." While the Oxford Debates are designed in part for fun and spectacle—opposing "Team Tech" captain Christopher Powers, PT, PhD, FAPTA, for instance, was dressed as Doc Brown from the Back to the Future films—Sahrmann sees a serious connection between the hands-and-eyes foundation of physical therapy and the low-tech items that typically are used by PTs and physical therapist assistants (PTAs). "There are advantages to both low- and higher- tech items, but what's particularly valuable about low-tech products—foam rollers, resistance bands, those sorts of things—is that they are means of exercise," says Sahrmann, a professor of physical therapy, cell biology, and physiology at the Washington University School of Medicine in St Louis. "They're used by individuals for their own exercise programs—not just in the physical therapy clinic, but at home, because they're practical and affordable." "When someone's lying on a foam roller, that person can tell you how the item feels against his or her back," Sahrmann adds. "The therapist, in turn, can tell whether the right muscles are working, whether the right joints are moving in the appropriate way. The roller facilitates precise analysis." Physical exams don't play as prominent a role in medicine as they once did, Sahrmann says. "There's more of a tendency now to just say 'Go get an MRI' or 'Go get your bloodwork.' I hope physical therapy never goes down the road of believing that all aspects of analyzing movement and exercise technique can be done by high-tech implements. Such items won't provide the same details or context as will PTs' hands and eyes—aided by low-tech tools." Sahrmann's comments hit on several of the main advantages of products referenced by the PTs interviewed for this article. Utility and effectiveness. "What I like about these kinds of low-tech, cheaper, portable products—like stability balls, resistance loops, and myofascial rollers—is that with 1 product I can affect the muscular system and the fascial system, and have neural input, as well," Baker says. "I can use that product in the clinic with patients, and then they can take it home." "People love these products," she adds. "Especially the rollers, the stability balls, and the little peanut massagers—they're peanut-shaped and have little bumps on them. I treated a fencer for a hip injury and showed her how to use the massager on her IT band. I saw her several months later and she said with great enthusiasm, 'I don't go anywhere without my peanut!' She was keeping it in her fencing bag." "We use therapy balls all the time," reports Stacy Menz, PT, DPT, owner of Starfish Therapies in the San Francisco area. "I love therapy balls not just for core strength and balance reactions but also for righting reactions." Menz is a board-certified clinical specialist in pediatric physical therapy. "I've had a lot of success with Kinesio Tape®—I've seen a lot of kids do well with it," says Barbara Pizzutillo, PT, DPT, MBA, an early-intervention PT in the Philadelphia suburbs. "It facilitates movements that often are difficult—for instance, in children with brachial plexus injuries, getting the scapula to stay retracted rather than abducted." It's also particularly useful, she says, in helping children with Down syndrome stand, by "putting a little tension behind their knees in promoting flexion for better postural alignment." Pizzutillo notes, however, that early-intervention PTs typically extend the definition of "low-tech" to whatever already is in the home. "If you bring in something like a therapy ball, but there are 5 children in the house and it doesn't fit with the family's physical circumstances or lifestyle, it's not going to get used," she says. Accordingly, Pizzutillo has instructed family members to use armrests, animal-shaped plush rockers, and inflated cartoon figures as stand-ins for therapy balls. Similarly, pool noodles often assume the roles of foam rollers. "I can use noodles for tons of stuff," she says. "I often cut them in half." Portability. "A foam mat and a pack of sanitary wipes ride shotgun in my car all day long for both my home health and mobile therapy cash-pay patients," says F. Scott Feil, PT, DPT, EdD, who works for Elite Home Therapy in Waco, Texas, and also operates his own business, Epic Therapy and Wellness. "It's a square mat, about 12 inches by 12 inches, and 2 inches thick. It's durable, easily transportable, and versatile, in that it can be used for balance in my older patients and as a noncompliant surface for exercise progression in my higher-level patients—those who are slightly younger, healthier, have few or no comorbidities, and may work out a few days a week." Like Eva Norman's staff in Minnesota, "I've got a treatment table in my trunk and a bunch of low-tech equipment and tools there and in the back of the car," Feil says. Ease of use. The simplicity of low-tech tools makes it easy for PTs and PTAs to demonstrate and instruct patients and clients in their proper use, those interviewed for this article note. Bussman adds that many such products come with illustrated instructions for safe home use. "So," he says, "a PT can open up the instruction booklet, circle specific exercises, and tell the person, 'That's where you should focus your efforts.'" Per Feil's mention of sanitary wipes, low-tech items also are easy to clean. "A matter that's popped up more often in the last few years is infection control," Magister's Maley says. "We get asked, "How should I clean your [elastic] bands?' Our stuff can be cleaned simply and easily with an antibacterial wipe." OPTP recently tweaked the composition of a popular slant board, switching from open- to closed-cell foam, Bussman says. "Now there are no open pores. It's a smooth surface that's easy to wipe down. If a product is working fine, we don't touch it," he adds. "But sometimes we feel as if it can work slightly better. We talk with clinicians and may make modifications." Cost. "Most people don't have the space in their house for a Pilates reformer or the money to afford it," Baker observes, referencing a large apparatus built on a bed-like frame that retails, per a quick internet search, from about $3,000 on up. "But these smaller, low-tech items can cost as little as $10, to maybe $60 for foam roller." "There are some amazing things out there, technology-wise," Menz says. "Sales reps come in and show us stuff all the time. But there are a lot of things that, as the owner of a small business, I can't afford. Low-tech items fill a lot of needs in physical therapy. Even bigger clinics that have anti-gravity treadmills and things like that—equipment that has great value but can cost tens of thousands of dollars—still rely on basic tools." "I think the most expensive items we carry," says Barrows, who sells some products onsite at her clinic, "cost no more than $50. That's my breakpoint. I recognize the importance of affordability when I'm recommending that people purchase a particular item." Back to the Future Maley and Bussman—both of whose businesses literally are banking on it—are confident that whatever the future brings for physical therapy, from sensors and robotics to genomics and regenerative medicine, low-tech tools will retain their importance. "Physical therapists always will prioritize putting their hands on patients, and the sorts of tactile tools that go along with that," Bussman says. "Will they still have uses for the 'sexy' stuff? Absolutely. Those things have their time and place. But the simple stuff will always be around." "If these items weren't effective, PTs wouldn't continue using them and we wouldn't continue selling them," Maley says. "I don't see that changing anytime soon. These products are always going to be mainstays in physical therapy." "They're never going to go away," Eva Norman agrees. "These tools that have been so important to me personally will play important roles in the lives of our patients and clients for generations to come." Eric Ries is the associate editor of PT in Motion.