CAPS® Systems
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The CAPS® (Comprehensive Assessment of Postural Systems) is the best type of equipment for clinically managing persons with balance dysfunctions.
Browse this reference page to find out why.
And feel free to download our white paper on the subject.
There are two quite different approaches to clinically managing persons with balance dysfunctions: a traditional approach and a modern approach.
These approaches differ in the screening of the general population, in the management in primary care settings and in the management of residents of institutional facilities.
The CAPS® systems are the perfect tool for screening, diagnose and treat patients with balance and postural control issues.
What should be the role of balance testing and posturography in the clinical practice? In other words, how can they be used effectively from a clinical and economic perspective to improve the health and function of humankind? We believe there are very different schools of thought in this matter.
Several of those involved in balance, be they researchers, clinicians or engineers developing medical devices, apparently believe that balance testing can and should be used for diagnostic purposes, i.e. to find out where a balance dysfunction originates. This has lead to the creation of long and complicated observation‑based test protocols that are expensive to use in terms of time (and time is money), as well as to the development of costly, large and sophisticated posturography equipment with moving platforms, moving visual environments and other ways of perturbing or confusing the subject's balance. And as a consequence, it usually takes a long time to test a person. Years and years of research and hundreds of scientific studies have been performed in an attempt to validate their diagnostic capabilities, unfortunately without much success. In fact, after decades of research, posturography (the only balance testing that is not based on observation and provides documented, automated measures and therefore has a specific procedural and reimbursement codes) is still considered experimental by many health organizations. In our opinion, using posturography as a diagnostic tool is faulted because, as previously discussed, balance depends on the functioning of the entire body, and therefore balance testing is intrinsically non‑specific. Although attempts can be made to isolate the effect of the different body systems, so many parts of the body are still involved that there is no way to make the test results specific enough for a diagnosis except in very few cases.
Some of those involved in balance studies understand that balance testing is non‑specific and therefore of limited diagnostic value. But they also realize that balance testing can be useful in the screening and identification of persons affected by balance dysfunctions which relate to the health status of a person and to falls (a major health issue in the elderly population). Again, this has lead to the creation of long and complicated observation‑based test protocols (e.g. the Berg Balance Scale, the Tinetti Balance Test of the Performance‑Oriented Assessment of Mobility Problems). But the real problem with this approach is, in our opinion, the fact that it neglects the simple fact that balance can change very quickly. We believe that the usefulness of these balance testing protocols is very limited simply because they take too much time, and therefore they can not be repeated as often as the changes in a persons' balance would require. The assumption behind these test protocols is that an assessment performed at a specific point in time can be representative of the person's balance for a long time, i.e. that the balance will not change significantly for some time. Some researchers go as far as trying to correlate, either retrospectively or prospectively, the results of a single balance assessment with balance issues and falls 3, 6 o even 12 months away.
We believe that balance testing is non‑specific and therefore of limited diagnostic value, but that is a superior tool and is essential for the screening and identification of persons affected by balance dysfunctions. We also believe that balance can change in a short time and that a person should be tested very often to detect any changes in balance with the goal of catching dysfunctions as soon as they appear, ideally before they result in falls and injuries. All of this made us realize that to be really useful clinically any balance testing has to be extremely fast, sensitive and accurate enough to detect any change in balance, not require highly trained personnel to perform or interpret, and have very low direct and indirect cost per test (i.e. not only the initial costs to purchase the necessary tools, but also the material and personnel costs necessary for the training and those to perform the testing, including the costs associated with the space required if dedicated to the balance testing). We believe that this is possible by using a computerized force platform and a dynamic posturography version of a subset of the tests of the old Modified Romberg's balance test, i.e. using one or more of the tests that constitute the mCTSIB. This solution allows to combine the proven characteristics of the Romberg's with the objectivity, sensitivity, accuracy and automated analysis of posturography, eliminating the need of highly trained personnel and allowing to test a person in a very short time. This is the basic philosophy behind our CAPS® systems. This seems obvious, but in fact it is far from being so, and in fact we were awarded a patent by the U.S. Patent office on the ability to assess a person's balance, weight and BMI in 60s or less.
Whereas screenings for many other conditions (e.g. weight and Body Mass Index, vision deficits, high cholesterol and hypertension) are offered at pharmacies, health fairs and other community settings, there is currently no screening of the general population for balance dysfunction.
In primary care settings, balance is seldom evaluated. Unfortunately, many primary care clinicians are infrequently educated and trained in managing balance patients. If the patient reports dizziness and/or repeated falls, a basic evaluation using some observational based balance tests might be performed. In case of persistent dizziness and sometimes when a vestibular dysfunction is suspected, the patient might be referred to a specialist (usually an otolaryngologists or sometimes an audiologist or a neurologist). In case of transient dizziness and vertigo (e.g. BBPV), rather than diagnosing the actual cause, the patient is often prescribed antivertigo/antiemetic medications (e.g. Meclizine) and told to take it when an vertigo occurs to help waiting it pass. In case of apparent neuromuscular issues, the patient is prescribed general physical therapy non specific for balance issue. When medication is prescribed for any reason, only in rare instances the effect of the medication regimen on the patient's balance is considered or evaluated. Even in case of primary care clinician trained in balance issues, balance is seldom evaluated, unless the patient reports dizziness or falls. However, at least when presenting these symptoms, the patient is usually further tested and evaluated and is often referred for vestibular testing and/or other diagnostic procedures that relate mostly to the vestibular system or its central nervous system pathways. But even when the primary care clinician is somewhat trained to deal with balance pathologies, unless the subject is symptomatic, balance deficits are often not assessed, nor the possible effects of medications and pathologies on balance are evaluated and explained to the patient.
In institutional settings, because of the pressure by accrediting institutions like The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations or JCAHO) to prevent falls, patients are usually evaluated for balance dysfunctions and fall risk. This is usually done using observational based balance tests, questionnaires and other tools developed to evaluate the risk of falls. In presence of acute or severely debilitating pathologies and in non‑ambulatory patients, sometimes the only thing that can realistically be done is to take preventive measures rather than addressing the underlying balance deficit. Unfortunately, in less severe situations when a patient is ambulatory, balance dysfunctions, even if identified, are often undiagnosed and untreated, or at most only general rehabilitative measures are taken. This is frequently the case in assisted living settings. The major issue regarding the current approach to the management of balance impairments in institutional settings is the fact that balance testing is not performed often enough. The main reasons are that observational based balance tests take too long, and the speed at which changes in balance can occur is underestimated.
The reasons why balance impairments are conventionally managed this way are several. Among them are: an insufficient knowledge of the issues regarding balance; insufficient sensibility to the consequences of balance dysfunctions; the almost complete absence of specific training of medical personnel; the fact that balance issues are seen as the domain and responsibility of specialists; the fact that balance testing as it usually done, be it using observation based tests or posturography, is too expensive in terms of time and training. This last is in our opinion possibly the main reason. In other words, the lack of fast, objective and automated ways to test balance is one of the main causes of why balance dysfunctions are currently managed the way they are.
This approach is leaving unidentified, and therefore untreated, almost all persons with balance dysfunctions that do not present with obvious manifestations (as indicated earlier about 50% of those with balance problems and approximately 16% of the adult population younger than 65 years and 33% of the population aged 65 and older). It also leaves many of those with an identified balance deficit without diagnosis and therefore without a real and effective treatment.
This approach also wastes the opportunity offered by balance testing to provide a general and quite comprehensive assessment of a person's general health and therefore to be used as a screening tool for providing an early indication of the insurgence of pathologies. Finally, the difficulties of frequently assessing balance severely hinders efforts to reduce falls.
In the modern approach to clinically managing persons with balance dysfunctions, the general population is offered balance screening in conjunction with other health screening in many community settings and the general population is educated and aware of balance dysfunctions, fall and the possible consequences.
In primary care settings, balance is tested and evaluated as regularly as blood pressure and weight or even more often, ideally as part of the intake procedures of every visit. Balance is used as an indicator of the insurgence and progress of pathologies. Those persons with balance dysfunction are further evaluated or referred to specialists for vestibular and other diagnostic testing until the etiology of the balance dysfunctions are identified. Unlike in the traditional approach, balance is not synonymous of vestibular, therefore the evaluation includes a review of the medications as well as nutrition, physical condition, lifestyle, neurological conditions and in general an evaluation of the entire well being of the patient. If possible, the underlying cause of the dysfunction is treated and changes in balance are monitored throughout the entire treatment. Patients are referred for specialized balance rehabilitation and their treatment does not end until their balancing ability is maximized given their general health conditions. The possible effects that pathologies, medications and treatments might have on balance are explained to the patient and are actually evaluated and quantified for every patient by following up with repeated balance testings. Patients and their families are then educated as to the possible future consequences of balance dysfunctions, including the increased risk of falls later in life. Patients whose balance cannot be restored to the levels of a healthy person or that are at an increased risk of injuries from falls are educated using an occupational therapy approach (e.g., they are instructed to wear proper shoes, to recognize and avoid situations where their balance might be challenged to its limits, to remove as much as possible from their homes and workplaces things that might cause them to fall).
In institutional settings, the balance of ambulatory persons is regularly evaluated, possibly as often as their blood pressure or other health condition indicators are evaluated (even multiple times a day) to notice changes in their health status and their risk of falls. Changes in balance are quickly noticed and their cause ascertained (just like for blood pressure or body temperature), and patients are informed of the status of their balance and warned of the associated fall risks. The etiology of the balance dysfunctions is identified, if necessary, by further clinical evaluations (including a review of the medications as well as nutrition, physical condition, lifestyle, neurological conditions and in general an evaluation of the entire well being of the patient) or referral to specialists for vestibular, neurologic and other diagnostic testing. If possible, the underlying cause of the dysfunction are treated and changes in balance are monitored throughout the entire treatment. Patients are referred for specialized balance and vestibular rehabilitation and their treatment does not end until their balancing ability is maximized given their general health conditions. Persons whose balance cannot be restored to the levels of a healthy person or that are at an increased risk of injuries from falls are educated as to what to do and what to avoid in their daily routines (e.g. do not shuffle their feet, place their walking aids appropriately so not to trip over them, use rails whenever they are available, do not move around in the dark), active interventions on their environment are performed to remove as much as possible any external, potentially fall causing obstacles (rugs, small tables, power cords), and close monitoring of their daily activities is performed to assess the effectiveness of these preventive measures and avoid as much as possible the devastating consequences of falls.
This approach requires great educational efforts to increase the general awareness of balance dysfunctions and the associated increased risks of falls in an advanced age, and especially to train clinical personnel to identify and manage balance issues. But what this approach really depends upon is the availability of ways to assess and quantify balance that are similar to the technology available to quantify blood pressure, body temperature or blood oxygen saturation level. In other words, devices that are easy to use, fast, accurate, sensitive to minimal changes, do not require particular skills to be used and to interpret the results thus do not require to be used only by highly trained personnel, and have a negligible cost per use.
The CAPS® was developed specifically to address the needs of the modern approach to the clinical management of balance dysfunctions. Several unique characteristics make the CAPS® different and better than other posturography devices for this purpose.
The CAPS® force platform was designed to be highly portable. It was the first posturographic device and one of the first medical devices in general capable of being run from a battery powered portable computer without even requiring a power line; and it was the first and still is one of the few balance assessing tools that does not require any special setup such as leveling of the platform on the floor. The extreme portability and power considerations allows it to be used wherever the need for a balance test or screening might arise, and when used in a fixed location it takes up as little room as possible (similarly to a clinician's scale), without occupying too much of the space that in a clinical environment is often at a premium.
The CAPS® force platform was also designed to be extremely sensitive and accurate, allowing to detect even minute changes in balance that might provide an early indication of changes in a person's body before these become important and difficult to revert.
Most importantly, the CAPS® was designed for usability and speed. Whereas all other balance testing equipments were designed mostly for diagnostic purposes, requiring relatively long set‑up and testing times, the CAPS® force platform and software were developed to objectively and quantitatively assess a subject's balance, weight and BMI in less than 60s without requiring any special training and to automatically compare the results with reference values established for healthy subjects. This does not mean that the CAPS® can not be used as all other balance testing equipment to conduct advanced balance, neuromotor, and physical performance testing for more in depth evaluations when these are needed. Several of the characteristics of the CAPS® are in fact unique enough that several patents were granted to protect some of its design features and technology.
The portability, usability and speed are consequences of having realized that posturography is much more useful for non‑specific balance testing assessments than for diagnostic purposes. Unlike our competitors that created devices with sliding and/or tilting platforms and moving visual environments to see how the different sensory inputs affect balance, we concentrated on marrying the traditional Modified Romberg tests with modern posturographic technology replacing the role of the trained observer and creating a sort of instrumented Modified Romberg that is much more sensitive, accurate and objective than the original observational tests and can be performed faster.
See for yourself the applications of the CAPS® in various clincial settings.
However, for all its unique features, the CAPS® is nothing but a very sophisticated and user friendly posturography device that measures a subject's Center of Pressure (CoP) movements during standing. Hundreds of scientific and clinical publications have been written on the applications of these type of measurements in clinical practice. Most, if not all, of that literature applies to the CAPS® as well as to any other posturography devices that measure the subject's sway by means of Center of Pressure movement detection, with the only caveat that few of the instruments used in the past had the resolution of the CAPS®. Therefore, if any earlier research concluded that certain applications of posturography were not successful, it might have been because the instruments were not good enough in terms of sensitivity, resolution and noise. This is a crucial point, so it warrants expressing the concept in another way. Think of MRI or CT machines: any application and study done on a model of MRI or CT machine is applicable to any equal or better model of MRI or CT machine (i.e. a machine having similar or more resolution and/or faster acquisition times), but not vice‑versa, since something that can be see and appreciated on a high resolution imaging scanner might not be visible in lower resolution models. The same holds true for posturography and the CAPS® (and any other type of medical instrument, from EKG to microscopes): research performed on one machine is applicable to any machine that is equal or better than the one used in the original research.
It is also important to realize that almost all the research on posturography tried to use the instruments for diagnostic purposes to see if the results could be used to differentiate between pathologies. As stated before, this is almost impossible because balance is an all‑encompassing measure that is non‑specific. Furthermore, in many studies, the conditions (e.g. subject population and their characteristics, presence of multiple pathologies, when and how the testing was conducted during the progress of the pathology) appear to have been poorly controlled, making the results somewhat questionable.
