The DPA Med® is a medical device used in functional rehabilitation to mobilize the lower limbs and the trunk in the supine position. It facilitates the osteoarticular mobility of the lower limbs, the pelvis and the spine, by performing shoulder-pelvis girdles dissociation and pelvic mobility similar to normal gait. It is mainly designed for patients suffering from joint and/or neuromuscular diseases that modify their functional mobility and autonomy.
Useful for early mobilization, the device helps to reduce the complications brought upon by prolonged bed rest. Mobilizing the patient’s lower limbs and trunk prevents the consequences of prolonged immobilization, by maintaining a level of joint, muscular and respiratory activity. This technique increases the patient’s functional recovery potential by facilitating early rehabilitation.
The DPA Med® is used to treat painful conditions like common chronic lower back pain. A multi-modal approach is necessary, combining physical activity, physical therapy and manual or robotic mobilization techniques, to enhance the patient’s functional capacities, posture, pain management and autonomy.
The DPA Med® is also used to treat people with gait and balance disorders (Post Fall or Psycho motor Regression Syndrome—PRS, arthrosis and neurological diseases) with the goal of reducing dependency and increasing patient walking distance and autonomy.
LOWER LIMB AND TRUNK MOBILIZATION
Used in functional rehabilitation, the DPA Med® is designed to mobilize the lumbar-pelvic-femoral and thoracic-lumbar complexes in the supine position. It enhances osteoarticular mobility (Dardilhac, 2008).
Using the device allows to:
• Generate shoulder-pelvis girdles dissociation through a three-dimensional movement of the pelvis and lower limbs (Bensoussan et al., 2021).
• Induce a pelvic mobilization frequency and joint range of motion similar to normal gait (Bensoussan et al., 2021).
The DPA Med® offers the possibility for very early functional rehabilitation because it can be used in the acute phases of patient treatment, and with the patient’s bed. It combines the two distinct goals of reducing the complications of prolonged bed rest (respiratory, joint and muscular complications) and increasing the recovery potential of the patient’s functional capacities, in both conscious and unconscious patients.
Despite a limited level of scientific evidence supporting it, early mobilization seems to be beneficial for patients admitted to intensive care units (Doiron et al., 2018). Indeed, there are many obstacles to performing robust research studies: too small sample size, absence of double-blinded conditions, lack of available collaborators, absence of standardized protocols, lack of active staff training, poor medical team management and communication and excessive patient sedation. In spite of these setbacks, an international consensus currently favors the use of early mobilization (Lang, 2020). The HAS—Haute Autorité de Santé (French high authority for healthcare) also recommends passive joint mobilization and postural exercises to limit joint stiffness and skin complications (HAS, 2020). Mobilization also seems capable of limiting the iatrogenic dependency in elderly patients, responsible for an increase in the risk of falls, loss of muscle strength and urinary incontinence (HAS, 2017). Other studies have also shown that therapists, patients and their families are becoming more aware of the benefits of early mobilization and have a favorable attitude toward its use (Akhtar et al., 2021, Fontela et al., 2018). It would also seem that early mobilization may reduce intensive care acquired complications, enhance functional capacities and reduce the time spent on mechanical ventilation (Zhang 2019, Zang 2019, Hu 2019). It is now proven that early mobilization is a safe technique, easy to use with children and adults (Mayer, 2020, Cuello-garcia, 2018), including with mechanical devices, like ergocycles (Nickels, 2020). Furthermore, this technique does not increase the mortality rate (Zang, 2019) and may be applied as soon as 24–48 hours after admission (Ding, 2019).
In conclusion: The DPA Med® permits early mobilization for hospitalized patients, admitted for several days, and notably those with mobility restrictions. As such, the DPA Med® is an effective, safe tool that limits the complications of prolonged bed rest.
The HAS (French high authority for healthcare) describes common chronic lower back pain as pain in the lumbar region for more than three months, without a precisely identifiable cause (paresthesia, spinal deformation, neurological disorders…). It is both a public health issue, with substantial economic and social implications, as well as an occupational health issue, with a high risk of professional deintegration.
Treating chronic lower back pain must be a comprehensive undertaking. The patient’s experience must be assessed while integrating somatic, psychological, social and professional factors. With the exception of pharmacological treatments, physical activity and physical therapy are the main therapeutic avenues when treating chronic lower back pain. Furthermore, manual mobilization techniques are recommended by the HAS for treating lower back pain, associated with physical therapy and physical activity sessions (HAS, 2019). Spinal mobilization was proven to also be effective and safe when treating adolescent patients with vertebral disc deterioration (protrusions/extrusions) (Kuligowski et al., 2020).
There is a considerable lack of research in the scientific literature pertaining to lower limb, pelvic and spinal mobilization, performed by devices such as the DPA Med®. Nevertheless, a recent study has brought to light the importance of associating vertebral mobilization with lower limb movements in improving: back or leg pain, the level of disability, the lower limb range of motion and short- and medium-term patient satisfaction concerning lumbar radicular diseases (Satpute et al., 2019). Another study has also shown that mobilization focused on the lumbosacral region, combined with stretching and trunk muscle motor control exercises stimulates the parasympathetic nervous system and modulates pain perception in patients with subacute common lower back pain (Abuin-Porras et al., 2021).
Regardless of the therapeutic choice, active exercises and trunk core and muscle strength exercises are particularly recommended. Stimulating fascias, combined with trunk core strength exercises, is an effective therapeutic avenue for elderly patients suffering from common chronic lower back pain (Ozsoy et al., 2019). Trunk core strength exercises and hip stretching techniques are also effective in improving patient functional capacities and autonomy, when treating common lower back pain (Kim et al., 2020). As for the intensity of the exercises with the goal of decreasing pain levels, a study recommends between 3 and 5 times a week, for 20 to 30 minutes (Mueller 2020). Core strengthening exercises also seem more effective than conventional therapy in reducing the degree of disability in patients suffering from lower back pain (Waseem et al., 2019).
In 2019, a controlled, randomized trial studying lower back pain in adults demonstrated the effectiveness of the DPA Med®, compared to a control group that only performed spinal muscle reinforcement exercises. Improvements were observed in pain levels (VAS), functional capacity (Oswestry disability index) and postural parameters: lateral pelvic tilt, lateral spinal deviation, anterior and posterior pelvic tilt (Poiron, 2019).
Another study demonstrated the benefits of a DPA Med® spinal mobilization program, on the spinal mobility of sedentary individuals that work in a seated position for long periods of time (Dardilhac, 2008). Joint range of motion gains in spinal flexion/extension as well as rotation were observed immediately after the DPA Med® session. These results tended to last in the medium term, with a significant improvement still detectable 2 weeks after applying the protocol (Dardilhac, 2008). Even though this study did not address individuals suffering from lower back pain, it still demonstrated the articular benefits of a DPA Med® session for the spine. This conclusion substantiates the utility of the DPA Med® device for spinal disorders with diminished range of motion.
Furthermore, another study quantified the forces generated by the DPA Med® on the joints of the lower limbs and spine (Touzé, 2021). Alternating forces were observed at the lower limbs and spine, a manifestation of the same alternating forces at their respective joints. The DPA Med® artificially induces an alternating compression of the disc, which occurs naturally during normal gait. This alternating pressure is responsible for the trophism of the annulus fibrosus, a part of the intervertebral disc, and is the only mechanism that maintains it (Delamarche et al., 2018). By stimulating the alternating pressures in the intervertebral discs and inducing a pumping effect, the DPA Med® could benefit individuals with lower back pain caused by a damaged disc.
In conclusion: The treatment of common chronic lower back pain implies joint mobilization and muscle reinforcement techniques, mainly for the spine and pelvis. Taking into account current recommendations for the treatment of this disease, the DPA Med® emerges as a relevant tool to help patients suffering from common chronic lower back pain, notably to reduce pain, and to enhance the patient’s posture and autonomy.
Gait is a vital human function and a number of diseases modify it, notably stroke, cerebral palsy, Parkinson’s disease, spinal disorders (disc herniation, radiculalgia, spinal cord injury), or arthrosis and falls. These diseases provoke functional (gait, balance) and neurological (motor patterns) complications.
- Joint Diseases
In the case of the lower limbs, hip and knee arthrosis (coxarthrosis and gonarthrosis, respectively) can cause joint impingement, provoking intense pain and modifying the gait pattern. To reduce this phenomenon, hip and knee mobilization has proven effective in reducing pain, increasing joint range of motion and enhancing the functional capacities of elderly subjects (Beselga et al., 2016, Hoeksma et al., 2004). Hip decoaptation techniques (techniques that use traction forces to increase the space between articular surfaces) have shown to be effective and there is a direct link between the degree of decoaptation and pain intensity, enhanced functional capacities and joint range of motion (Estébanez-de-Miguel et al., 2019). It would seem that intermediate intensity mobilization is best used to reduce pain, whereas high intensity mobilization is more effective on enhancing functional capacities and balance (Estébanez-de-Miguel et al., 2019). Furthermore, a study also demonstrated that early mobilization following knee or hip arthroplasty reduces the length of hospital stay by 1.8 days. It can be performed within 24 hours after surgery, without any negative effects (Guerra et al., 2015).
This kind of mobilization can be performed with the DPA Med®, without changing the patient’s position (lying down) and with hip flexion at 20°, thus facilitating joint mobilization (Estébanez-de-Miguel et al., 2019). Mobilization intensity is similar to current manual mobilization techniques. The traction forces generated by the DPA Med® range between 70 N and 100 N at each lower limb (Touzé, 2021).
- Neurological Diseases
The core of neurological rehabilitation consists of restoring the patients’ functional capacities with a plethora of techniques, and robotic devices are a part of that tool set. These devices are increasingly used in rehabilitation because they save time and reduce the therapists’ physical workload. Robot-assisted gait training, combined with physiotherapy and body-weight support training, seems to be an effective tool for gait recovery after a stroke (Moucheboeuf et al., 2020). The contribution of the robotic elements has been proven effective on post-stroke spatial and temporal parameters like speed, cadence and step length (Bang and Shin, 2016, Cho et al., 2018). A meta-analysis confirms those benefits on the functional parameters (Bruni et al., 2018). Other studies have demonstrated that this treatment choice is more effective than gait rehabilitation on a treadmill (Gama et al., 2017) and as effective, or even more so, than conventional rehabilitation (Tedla et al., 2019). Finally, a study comparing the use of a robotic device with manual therapy showed greater results in favor of the robotic group (Kumar et al., 2020).
Robot-assisted gait training may improve spasticity and gait capabilities in individuals with spinal cord injuries. Improvements in muscle tone and lower limb function have been seen in those patients, without causing additional pain (Fang et al., 2020). Similar conclusions are found in favor of robot-assisted rehabilitation for other disorders like multiple sclerosis (Yeh et al., 2020). It would also seem that two weeks of robot-assisted training is beneficial for patients with pusher syndrome (Bergmann et al., 2018).
Recently, the same trend in favor of robot-assisted rehabilitation has been observed for Parkinson’s disease (Capecci et al., 2019). Similar conclusions were observed for children suffering from cerebral palsy (Van hedel, 2016, Yazici, 2019) and adults with bilateral spastic cerebral palsy (Klobucka et al., 2020) but multiple treatment sessions are necessary to generate those improvements (Ammann-Reiffer et al., 2020). Contrary to human therapists, robot-assisted rehabilitation allows for an infinite number of movement repetitions, and it seems effective in stimulating neural plasticity (Masiero et al., 2008).
- Balance Disorders and Falls
In addition to the osteoarticular benefits, the DPA Med® generates shoulder-pelvis girdles dissociation, a key element in normal gait (Bensoussan et al., 2021). The dissociation, a result of the movement initiated by the device, stimulates normal gait patterns in patients that lost their motor capabilities.
All of the previously listed pathologies can trigger a post-fall syndrome, defined by a great fear of walking again, after a fall. It is usually a result of a psychological block and affects particularly elderly people. This implies that rehabilitation must also invest time and effort into fall prevention, through mobilization, proprioceptive stimulation and muscle reinforcement exercises (Pfitzenmeyer et al., 2001, Nyberg & Gustafson, 1995). This can be done easily and safely with the DPA Med® because the patient is lying down, suppressing the risk of falling.
In conclusion: There are a large number of diseases associated with gait and balance disorders and they require a substantial rehabilitation effort, through joint mobilization and gait improvement. Robotic devices are increasingly frequent in rehabilitation, allowing for constant and regular joint mobilization, and faster semi-assisted gait recovery. Thus, the use of the DPA Med® seems relevant to increasing the patient’s walking range and autonomy, and reducing the patient’s level of disability.
1. Abuín-Porras V, Clemente-Suárez VJ, Jaén-Crespo G, Navarro-Flores E, Pareja-Galeano H, Romero-Morales C. Effect of Physiotherapy Treatment in the Autonomic Activation and Pain Perception in Male Patients with Non-Specific Subacute Low Back Pain. J Clin Med. 2021; 10(8):1793.
2. Akhtar PM, Deshmukh PK. Knowledge, Attitudes, and Perceived Barriers of Healthcare Providers toward Early Mobilization of Adult Critically Ill Patients in Intensive Care Unit. Indian J Crit Care Med. 2021; 25(5):512–518.
3. Bang DH, Shin WS. Effects of robot-assisted gait training on spatiotemporal gait parameters and balance in patients with chronic stroke: A randomized controlled pilot trial. NeuroRehabilitation. 2016; 38(4):343–349.
4. Bensoussan C, Champclou A, Galarraga O, et al., Assessing the contribution of pelvic and spinal mobilization, in the supine position, on shoulder-pelvic girdles dissociation. Gait & Posture. Published online December 2020:S0966636220306767.
5. Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: A randomised controlled trial. Man Ther. 2016; 22:80-85.
6. Capecci M, Pournajaf S, Galafate D, et al., Clinical effects of robot-assisted gait training and treadmill training for Parkinson’s disease. A randomized controlled trial. Ann Phys Rehabil Med. 2019; 62(5):303–312.
7. Cuello-Garcia CA, Mai SHC, Simpson R, Al-Harbi S, Choong K. Early Mobilization in Critically Ill Children: A Systematic Review. J Pediatr. 2018; 203:25-33.e6.
8. Doiron KA, Hoffmann TC, Beller EM. Early intervention (mobilization or active exercise) for critically ill adults in the intensive care unit. Cochrane Database of Systematic Reviews. 2018; (3).
9. Ehsani F, Hedayati R, Bagheri R, Jaberzadeh S. The Effects of Stabilization Exercise on the Thickness of Lateral Abdominal Muscles During Standing Tasks in Women With Chronic Low Back Pain: A Randomized Triple-Blinded Clinical Trial Study. J Sport Rehabil. 2020; 29(7):942–951.
10. Estébanez-de-Miguel E, Jimenez-del-Barrio S, Fortún — Agud M, et al., Comparison of high, medium and low mobilization forces for reducing pain and improving physical function in patients with hip osteoarthritis: Secondary analysis of a randomized controlled trial. Musculoskeletal Science and Practice. 2019; 41:43-48.
11. Gama GL, Celestino ML, Barela JA, Forrester L, Whitall J, Barela AM. Effects of Gait Training With Body Weight Support on a Treadmill Versus Overground in Individuals With Stroke. Arch Phys Med Rehabil. 2017; 98(4):738–745.
12. Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. Clin Rehabil. 2015; 29(9):844–854.
13. Hoeksma HL, Dekker J, Ronday HK, et al., Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. 2004; 51(5):722–729.
14. Kim B, Yim J. Core Stability and Hip Exercises Improve Physical Function and Activity in Patients with Non-Specific Low Back Pain: A Randomized Controlled Trial. Tohoku J Exp Med. 2020; 251 (3):193–206.
15. Kuligowski T, Dȩbiec-Ba K A, Skrzek A. Mobilisation efficacy in young patients with different stages of degenerative disc disease. J Back Musculoskelet Rehabil. 2020; 33(6):913–918.
16. Kumar S, Yadav R, Aafreen null. Comparison between Erigo tilt-table exercise and conventional physiotherapy exercises in acute stroke patients: a randomized trial. Arch Physiother. 2020; 10:3.
17. Laëtitia LG. Réponse rapide dans le cadre du COVID-19 Prise en charge précoce de Médecine Physique et de Réadaptation (MPR) en réanimation, en soins continus ou en service de rééducation post-réanimation (SRPR). Published online 2020:9.
18. Masiero S, Carraro E. Upper limb movements and cerebral plasticity in post-stroke rehabilitation. Aging Clin Exp Res. 2008; 20(2):103–108.
19. Mayer KP, Joseph-Isang E, Robinson LE, Parry SM, Morris PE, Neyra JA. Safety and Feasibility of Physical Rehabilitation and Active Mobilization in Patients Requiring Continuous Renal Replacement Therapy: A Systematic Review. Crit Care Med. 2020; 48(11): e1112-e1120.
20. Mueller J, Niederer D. Dose-response-relationship of stabilisation exercises in patients with chronic non-specific low back pain: a systematic review with meta-regression. Sci Rep. 2020; 10(1):16921.
21. Narouei S, Barati AH, Akuzawa H, et al., Effects of core stabilization exercises on thickness and activity of trunk and hip muscles in subjects with non-specific chronic low back pain. J Bodyw Mov Ther. 2020; 24(4):138–146.
22. Nickels MR, Aitken LM, Barnett AG, Walsham J, McPhail SM. Acceptability, safety, and feasibility of in-bed cycling with critically ill patients. Aust Crit Care. 2020; 33(3):236–243.
23. Nyberg L, Gustafson Y. Patient Falls in Stroke Rehabilitation. Stroke. 1995; 26(5):838–842.
24. Ozsoy G, Ilcin N, Ozsoy I, et al., The Effects Of Myofascial Release Technique Combined With Core Stabilization Exercise In Elderly With Non-Specific Low Back Pain: A Randomized Controlled, Single-Blind Study. Clin Interv Aging. 2019; 14:1729-1740.
25. Pfitzenmeyer P, Mourey F, Mischis-Troussard C, Bonneval P. Rehabilitation of serious postural insufficiency after falling in very elderly subjects. Arch Gerontol Geriatr. 2001; 33(3):211–218.
26. Satpute K, Hall T, Bisen R, Lokhande P. The Effect of Spinal Mobilization With Leg Movement in Patients With Lumbar Radiculopathy-A Double-Blind Randomized Controlled Trial. Arch Phys Med Rehabil. 2019; 100 (5):828–836.
27. van Hedel HJA, Meyer-Heim A, Rüsch-Bohtz C. Robot-assisted gait training might be beneficial for more severely affected children with cerebral palsy. Dev Neurorehabil. 2016; 19(6):410–415.
28. Waseem M, Karimi H, Gilani SA, Hassan D. Treatment of disability associated with chronic non-specific low back pain using core stabilization exercises in Pakistani population. J Back Musculoskelet Rehabil. 2019; 32(1):149–154.
29. Yazıcı M, Livanelioğlu A, Gücüyener K, Tekin L, Sümer E, Yakut Y. Effects of robotic rehabilitation on walking and balance in pediatric patients with hemiparetic cerebral palsy. Gait & Posture. 2019; 70:397-402.
30. Zhang L, Hu W, Cai Z, et al., Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis. PLoS One. 2019; 14(10): e0223185.
31. Zou L, Zhang Y, Liu Y, et al., The Effects of Tai Chi Chuan Versus Core Stability Training on Lower-Limb Neuromuscular Function in Aging Individuals with Non-Specific Chronic Lower Back Pain. Medicina (Kaunas). 2019; 55(3):60.
32. Prévenir la dépendance iatrogène liée à l’hospitalisation chez les personnes âgées. Haute Autorité de Santé. Accessed October 19, 2021.
33. Prise en charge du patient présentant une lombalgie commune. Haute Autorité de Santé. Accessed September 9, 2021.