Bounce benefits

Rebound therapy is taking off. Denise Roberts finds out why it works on many levels

Bouncing on a trampoline may sound more like fun than therapy, but the modality, known as rebound therapy, has developed in leaps and bounds over the past 20 years.Physiotherapists use the trampoline to introduce adults and children with learning disabilities to structured sessions of both passive and active bounding in a variety of positions, such as lying, sitting, kneeling and standing. The experience is so liberating that 'clients do not realise how hard they are working' says Sally Smith, a physiotherapist based at Nottinghamshire healthcare trust and a pioneer who has been working with rebound therapy for over two decades.' The trampoline is a really motivating piece of equipment where you can use many of your physiotherapy techniques and equipment,' she told Frontline. 'It challenges you as a physio to be creative, and as I am working in adult learning disability nothing is straightforward. It's an uplifting medium to work on.' Rebound therapy began in Hartlepool, County Durham, in the early 1980s with physiotherapist and remedial gymnast Eddie Anderson. 'Eddie developed rebound with children with physical and learning disabilities when he was headmaster of Springwell special school,' said Debbi Cook, a Derbyshire-based physio. Debbi, with Sally Smith, built on Eddie's work by pioneering the technique with adults with learning disabilities. Eddie is 'the godfather of rebound', she says. Five years ago, the pair received an ACPPLD award for their innovative chapter in Jeanette Rennie's book, Learning Disability: Physical Therapy, Treatment and Management - A Collaborative Approach. Debbie notes: 'Sally and I got interested because we could see the potential, particularly with adults with a learning disability. We were trained by Eddie and assisted him with a couple of his courses. Then we started teaching it ourselves.' Since then Debbi has taken the technique to New Zealand and has also had interest from a priest working with disabled children in Nigeria. Sally Smith says rebound is now used throughout the UK, and cites a survey by the Association of Chartered Physiotherapists for People with Learning Disabilities (ACPPLD), which found that about 45 per cent of those members who work with adults use rebound therapy. Rebound is increasingly being developed with new client groups, such as children with cystic fibrosis and patients with developmental coordination disorders, dyspraxia and multiple sclerosis. Work is also going on with coma patients, who are hoisted on to the trampoline, although a trampoline coach not a physiotherapist is pioneering this development.  'To the physio, the trampoline is a giant "wobble board", which in active ways can disturb balance and stimulate balance reactions,' Sally explains. 'It can raise low tone (flaccidity) and lower increased tone (spasticity) because the bounce is similar to when physios use shaking or vibrating techniques on "dry land". Rebound has been seen to affect body part awareness, spatial awareness, proprioception and sensory awareness.' Looking at the range of perceived benefits, it is easy to see why rebound therapy has become popular. Some of the results are unexpected. For patients with little vocal ability it can be a gateway to communication as they begin to vocalise, sometimes giving squeals of delight, while the gasps and intakes of breath that the bouncing also provokes act to stimulate the cough reflex. Numeracy can improve too, as patients are encouraged to count their bounces. 'The beauty of this treatment is that it is not hands-on,' comments Sally. 'This is important for those with autism, challenging behaviours and other multiple and profound physical conditions when [handling] is not always appropriate or tolerated.' Paediatric physiotherapist Nikki Wright, who has been using rebound therapy at Carlton Digby School in Nottingham for the past 15 years concurs with this. 'The trampoline gives you the ability to work with a patient without being hands-on, as you can affect their bodies from a distance just by transferring your weight or increasing the bounce level.' 'I feel this is very important for profoundly disabled people because they spend their whole day being handled, in one way or another, for personal care and positioning. Rebound therapy, like hydrotherapy, must give them a sense of freedom and independence for a short while.' Like many physiotherapists using the therapy in the UK, Nikki attended one of the courses run by Sally Smith and Debbi Cook. At the time, she was looking for more therapies to use with children and young people. 'I have used rebound therapy with children and young people aged from three to 20, from profoundly multiply disabled patients who are totally dependent and wheelchair-bound to those who are mobile but have low tone and poor balance reactions, as well as with those with challenging behaviour and sensory modulation difficulties,' she says. 'I have found it beneficial to all of them.' Rebound therapy obviously requires a trampoline, and some physiotherapists use those at sports centres, day centres and schools. A good trampoline costs around £2,000 and while second-hand frames come cheaper, these need rigorous safety checks. One or two therapists are needed on the trampoline to impart their energy to clients. For safety, a minimum of between two to four 'spotters' are needed at the trampoline's edges: numbers depend on the client's position and other equipment. The trampoline is also easily used in conjunction with other physiotherapy equipment. Its unstable surface means that therapy rolls, balls and wedges produce more dynamic effects. And the risk of injury from falls, which physiotherapists sometimes face when working with patients on balance skills, are reduced by the more forgiving surface of the trampoline. 'It's easier to work on balance, as a small movement on the bed results in a large movement by the body,' says Nikki. 'It also increases the patient's confidence: every child is able to achieve, which is a great benefit for those with reduced abilities and limited experiences.' The rise in rebound therapy's popularity, however, brings with it concerns about training, consistency and evidence-based practice. Debbi Cook says those physios now using the therapy vary widely in their knowledge and skill, with some even practising with no training at all. Former guidance on training and safe practice, called the Good Practice Booklet, was first published by the ACPPLD. This is now being revised by a rebound therapy working party and will be republished with the CSP. The new draft guidance will be available on the CSP interactive website, and members will be encouraged to provide feedback. 'As with any physiotherapy modality, you have to be trained and competent to practise,' says Sally. 'There are now over 30 experienced rebound physiotherapy trainers around the country who are themselves all trained to a common standard, and they offer basic courses for those who are new to rebound therapy.' Training, competence to practice, safety, and evidencing rebound therapy through research, these are the four main issues for rebound therapy currently, stresses Sally. With these four securely in place, rebound therapy will finally have a firm footing, enabling it to continue to grow in leaps and bounds.

Firming up the foundations

Rebound's research base, like the trampoline itself, is wobbly. This needs to change. There has been little research into rebound therapy to date and larger, more rigorous studies are urgently required. Most of the work so far is anecdotal and based on single cases, much of it by final-year students recording the benefits as perceived by those using the therapy. One student study at Nottingham University found that benefits included improved balance and fitness, increased joint range and muscle tone, and improved posture, and relaxation. Greater confidence and eye contact; better vocalisation and behaviour, as well as pain relief were also noted. Another study into rebound therapy for clients with learning disabilities, carried out by physiotherapist Richard Watterston, came up with similar findings. Louise Mara used the Berg Balance Scale for her case study of the benefits of rebound therapy on balance in a client with a mild learning disability and cerebral palsy, while Andrea Greaves, a student at the University of Wales, used the Goldsmith index for windswept deformity and the Physical Ability Scale to look at the effects of rebound therapy on joint control and bowel function. In 2002, rebound therapy was identified by the CSP as one of 10 research priorities in the area of learning disability. Establishing a rigorous evidence base is now more important than ever, says Sally Smith. CSP professional adviser Leonie Dawson concurs with this. She says: 'I welcome the impetus in raising the profile of research in rebound therapy. I hope the National Physiotherapy Research Network [NPRN] will support research projects in this field.' The message is clear, if the ups and downs of rebound therapy appeal to you, get in touch with your local NPRN hub as well as getting on the trampoline.

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