By Melanie Brennan, PT, DPT
A continuous stream of requests from my clients to open a physical therapy gym for spinal cord-injured patients in the local area led me to seriously consider creating such a facility. Those clients were returning to outpatient rehab with avoidable secondary issues or regression in large enough numbers to make me realize something must be done. The acute rehabilitation center in the large medical center where I had once worked had become focused on short-term rehabilitation. It had lost focus on recovery and the needs of long-term rehabilitation, underscoring the need to create a facility that would help these individuals recover fully.
The journey to build this practice, now known as ExercisABILITIES Physical Therapy, Rochester, Minn, began in 2011. The facility has grown to what it is today because of a “big” idea. ExercisABILITIES is a neurologic recovery center and medical fitness facility that occupies 2,300 square feet of open warehouse space capped with 20-foot ceilings. As a physical therapist trained in the Neurologic Recovery Network philosophy of locomotor training, it was clear to me from the outset that this expanse of floor space and considerable inventory of capital equipment would be essential in serving the target population. With this vision in mind thus began my transition from working for a large company to building and operating my own practice and neurologic center.
Road to Reality
The first step in putting the foundation under what would necessarily be a large outpatient clinic was to secure a space that could house the program and equipment. An aquatics program would be needed for this population, but taking on the burden of building a pool facility would have to wait. The solution to this problem was to lease a small amount of space from the local YMCA fitness facility and pool. From a business perspective, this decision bought time to develop my business plan, begin to recruit patients, and secure financial support for the equipment.
Another component in making the new practice successful from the outset was to develop an income stream prior to opening. My client list began to grow rapidly as word circulated that I was going to provide a facility under the post-rehabilitation fitness model. And, as word spread, serendipity lent a hand. One of my first clients was a businessman who owned commercial buildings in town. He understood the value of the model of care the new practice would provide and wanted to help get it off the ground. As a result, he offered a location at low cost in one of his buildings. Together we established an incremental growth 5-year lease with yearly options to leave, since we both knew this idea could quickly grow. The incremental growth allowed him to eventually realize his full lease but gave me a cushion to get started.
[sidebar float = “right” width = “250”]Product Resources
The following companies offer a range of products for capital expenditure purchases:
APDM Wearable Technologies
Bailey Manufacturing Company
Battle Creek Equipment
Biodex Medical Systems Inc
Brookdale Medical Specialties Ltd
Chattanooga, a DJO Global Company
Clarke Health Care Products
GAITRite – CIR Systems Inc
Gorbel Inc-Medical Division
Hausmann Industries Inc
Med-Fit Systems Inc
Micromedical Technologies Inc
Mobility Research Inc
Natus Medical Inc (NeuroCom)
Perry Dynamics Inc
Pivotal Health Solutions
SureHands Lift & Care Systems
Toyota Motor Sales
Tri W-G Inc
Budgeting for the Big Idea
Starting out small and gradually increasing in size turned out to be key in making the new practice a success. Another critical early step was establishing the budget, which required knowing all costs up front. Once the budget had taken shape thus began the work of learning about, shopping for, and comparing capital equipment.
Working with several local vendors, a list of approximately $120,000 in new equipment costs was assembled. Part of the acquisition process included making the decision to lease or purchase with the decision to purchase winning out based on several factors. The first of those factors was to keep all processes as simple as possible and have only one bill to pay. Knowing that much of the equipment would remain in service for a considerable length of time if well cared for also made purchasing seem favorable.
Further tipping the decision toward purchase was the simple philosophy of making purchases as a long-term investment. When all the potential lease bills were added together the result showed leasing to be a much greater expense than a lump payment for a purchase loan.
Neuro Recovery: Equipping the Main Attraction
The clinic’s neurologic recovery programs reflect a commitment to provide exceptional care through investment in leading-edge rehab technologies.
Among this specialized equipment that the practice has purchased are functional electrical stimulation technologies such as the L300 Plus from Bioness, Valencia, Calif, and the RT300 from Restorative Therapies, Baltimore. These devices can help patients affected by multiple sclerosis reach their potential to regain or maintain strength, balance, and ability to walk independently. The L300 Plus for Thigh Weakness helps the practice’s neurologically involved patients move with a greater stability with the use of the device’s thigh cuff. It also activates nerves that control the leg muscles by sending low-level FES to those nerves. For the practice’s spinal cord-injured patients, the L300 Plus is helpful in gait pattern recovery. The RT300 is a motorized FES cycle that allows users to cycle with their arm or leg while sitting on a chair or wheelchair. Up to 12 channels of FES may be applied.
ExercisABILITIES has a full locomotor training recovery program called ABILITY and is working to become a community fitness and wellness center for the Christopher and Dana Reeve NRN Foundation. The locomotor training program is equipped with a Pneumex Double PneuWeight body weight support system stationary over a treadmill, and overground Pneumex PneuWalker unweighting system. Both devices are manufactured by Pneumex, headquartered in Sandpoint, Idaho. The PneuWalker is a mobility trainer designed to enable the user to engage in natural movement while working vertically on proper gait patterns. It is designed to unweight unilaterally to address hemiplegic conditions and allow unweighting from 0 pounds to 300 pounds. The Double PneuWeight can be placed over a treadmill as well as vibration platforms and balance equipment. It is engineered to allow users to engage in therapeutic activity while in an upright, functional pattern without altering gait patterns.
Several other manufacturers offer body weight support devices to the physical therapy market, including the Lokomat from Norwell, Mass-based Hocoma Inc USA. The Lokomat offers functional robotic therapy for highly repetitive gait training. It uses a dynamic orthosis over a treadmill and features real-time feedback to encourage active training participation by the patient and increased self-activation. Ceiling-mounted body weight support systems that can be used over ground are also available from several manufacturers for the US market. Among these sources are Gorbel Inc-Medical Division, Fishers, NY, which offers the SafeGait 360° Balance and Mobility Trainer. Another manufacturer is Aretech, Ashburn, Va, which offers the ZeroG Gait and Balance Training System, and still another source for this technology is Bioness, which offers the Vector Over-ground Gait and Safety System. These devices can play important roles in the recovery of walking ability after stroke.
ExercisABILITIES is also outfitted with the Pneumex PneuVibe industrial vibration platform. The platform is designed to support Olympic lifting and plyometric training but also can be effective for extremity massage and core exercises. The vibration platform is 32 inches x 40 inches, available with handlebars, and accommodates a maximum weight of 1,200 pounds.
In 4 years ExercisABILITIES has grown from a clinic with one therapist, eight clients, and 20 visits per week to a facility that has 14 employees, more than 400 clients, and 200 visits per week for neurologic, fall prevention, aquatic therapy, chronic pain recovery, and medical fitness services. The practice currently bills out more than $100,000/month in services. Among the staff are five physical therapists, one occupational therapist, two office staff, and six exercise/fitness professionals and technicians.
Of course, a facility this size that is growing at a fast pace does not continue to operate without incurring considerable expenses. Those expenses come not only from the purchase of specialized equipment for a patient population with a specific set of needs, but also from equipment that would be standard in any physical therapy clinic, such as treatment tables. One expense ExercisABILITIES had to manage was the outlay for tables that would be used for the average 200 visits the office schedules weekly. As a long-term investment, the clinic’s treatment tables had to be versatile and stand up to frequent use.
This staple of outpatient practice is available from several companies in a range of sizes with a wide variety of features. One source is Tri W-G, Valley City, ND, which offers tilt tables, mat tables, and treatment tables designed for use in the PT clinic. The company’s Smart Table is a motorized hi-lo treatment table built with a 750-pound weight capacity and engineered to adjust positions safely. Some models have up to five sections with a rising center, and bariatric motorized hi-lo models are available.
Another source is Everyway4all, Chino, Calif, which offers a contemporary line of products that includes therapeutic tables and traction tables. The company’s Caterpillar six-section therapeutic table has three motors with head and back rests that can be raised together for comfortable sitting.
Everyway4all also manufactures the Sorrento therapeutic table, which has seven sections, twin pillars for stability, supports a 496-pound load, and can be hand-controlled or foot-controlled. At the time ExercisABILITIES was opened, the clinic’s treatment tables were purchased from equipment distributor Arrowhead Medical, Grand Rapids, Minn.
Five years after the journey to create this facility began, one can reflect on the thought process behind the capital equipment purchase decisions that were made and conclude that those decisions provided a good return. This was far from a certainty when the practice was conceived. And, since there was no way to know in the early going how the business would grow and develop, it was difficult initially to calculate the return on investment (ROI) for this equipment. Looking back over the first 4 years, ROI for the equipment has been 15% based on income to cost, based on gross income.
In 2015 the business continued to transform and ExercisABILITIES became a nonprofit entity. The practice’s mission is to provide health and fitness opportunities through recovery rehabilitation to all people despite any physical, mental, or medical adversity or financial challenges. The staff members there work daily on gaining financial support to provide the practice’s low-cost adaptive fitness program, Forever Strong, to all who desire to continue their recovery goals and fitness health.
The clinic would not be the success it is today without having taken the leap into the big equipment and the big space. The leadership team currently is working with an architect and several philanthropists in our city to build a new building and attain new equipment—including a pool—to meet growing demand and lack of space concerns in the current facility. Part of the long-term strategy includes having sufficient space to expand the client populations that can be served, including pediatric and therapeutic recreation. My advice to anyone who may be thinking of building a neuro practice is simply this: Go big on space and equipment; you will use it all and will someday need more. PTP
Melanie Brennan, PT, DPT, is founder and executive director of ExercisABILITIES Physical Therapy, Rochester, Minn. Brennan received her Masters in Physical Therapy with honors in 1998 and her Doctor of Physical Therapy in 2008. Both degrees were awarded by the College of St Scholastica in Duluth, Minn. She has 14 years of experience working in a variety of fields, including more than 10 years in spinal cord injury and brain injury acute rehabilitation at Mayo Clinic in Rochester, Minn. For more information, contact [email protected].