Redefining physiotherapy

How new technology will transform physiotherapy, elevate it

to the level of other medical disciplines, produce systematic
treatment results and financial viability
Contents
3 A word from the founder - a 30 year vision

4 Musculoskeletal pain

4 Paradigm shift in musculoskeletal care

5 Inherent problems with traditional active physiotherapy

6 David's intelligent solution

7 Movement as medicine

8 Joint-specific/targeted vs. functional training

9 Cloud-based EVE platform

11 Big Data analytics - Artificial Intelligence

12 Wide range of applications

13 Scientific evidence

16 Solution used worldwide - preferred reimbursements

17 Collaboration models

18 Space allocation

19 Financial viability

20 Education and support

21 Complete physiotherapy pathways

22 List of research

2
A word from the founder - a 30 year vision
Already 30 years ago, I was convinced that healthcare take a long
the best way to treat musculoskeletal pain was time. We had a strong
targeted and controlled training using specially belief that the time will
designed devices. come when our solution
Before reaching this conclusion, there were will be accepted and de-
several years of intense development and re- cided to invest heavily in
search building biomechanically optimal train- the development of new
ing devices for each joint. To our amazement, generation rehabilitation
it was possible to start movement and training technology, cloud based Arno Parviainen
Founder, CEO
even with patients with severe pain as long as IT solutions and more
the devices had the correct loading curves, joint advanced treatment protocols.
alignment and fixations. The key was to design New scientific findings and escalating health-
devices that were gentle for the joints but de- care costs have forced the medical industry to
manding for the muscles. re-evaluate the efficacy of existing methods
Over time evidence accumulated, demon- and it has started to increasingly embrace our
strating how effective the method was in restor- approach, activating the patient as early in the
ing the function of the joints and muscles. The treatment program as possible.
restored function resulted in the reduction of In this little booklet, we have put together
pain in almost all cases. We understood that we the most important factors to understand the op-
had a unique solution on our hands. portunity that exists in the musculoskeletal space
But even having the best solution does not and how to achieve both medical and economical
necessarily mean instant success. Changes in success in this growing market.

New generation 2015 –Nordic Health Full software suite

device family Clinic chain with HL7

Founder Founder
bought back sold

2008 1999

Cloud-based Treatment concept

software platform for the spine

Biomechanics – Rehabilitation and Spine rehabilitation

training technology testing technology method

Figure 1:  The current solution is a combination of over three decades of cumulated know-how in training and testing technology and its application
in health care and modern cloud based data managements system. The founder was out of the company from 1999 until 2008 when he bought it back
together with his son and daughter.

3
Musculoskeletal pain
Musculoskeletal pain is the main reason for Musculoskeletal pain affects everyone, white-
1
people to live in disability . The global economic and blue-collar workers, specialist professions
burden caused by musculoskeletal problems in like pilots, or drivers and even sports persons
terms of healthcare costs and lost productivity is who regularly exercise.
huge. In Europe alone it is estimated to cost up
to €300 billion 1/3 of which are direct healthcare
costs and the rest through loss of production2.
Despite the billions spent in treatment of
musculoskeletal problems the situation is just
getting worse due to sedentary lifestyle, health
problems like obesity and aging population.
1  WHO methods and data sources for global burden of disease
estimates 2010-2011, WHO, Geneva November 2013

2  OSH in figures: Work-related musculoskeletal disorders in the Figure 2:  WHO statistics show that low back pain is the number one
EU — Facts and figures, European Agency for Safety and Health cause for people to live in disability. People suffer in the same way regard-
at Work 2010 less of the economic development or location of the countries they live in.

Paradigm shift in musculoskeletal care

The continuously escalating healthcare cost Value-based Healthcare

has forced both healthcare providers and payers

to question the fundamentals of the current sys- Passive Active
Pain
Surgery Imaging pysio- physio-
tem. The “fee for service” -model incentivizes to therapy
injections
therapy

do more. The more procedures that are ordered

for the patient, the more money is being made. Figure 3:  Research findings and insurance policies are discouraging the
The new approach is to turn the focus to use of expensive and invasive treatments before conservative methods are
tried. For chronic and recurrent problems active therapy is the first choice.
the value produced for the patient and use only
methods that are evidence-based to be the most
cost-effective and safe. A critical component is tive rehabilitation is at least equally effective with
the ability to measure results in ways that make significantly less costs and risks of complications.
sense for the patients and third party payers. New medical guidelines have been published
Several recent studies have shown that for in many countries including Australia, Canada
certain pathologies, surgery does not produce and UK for back pain, which recommend abstain-
better outcomes than physiotherapy with many ing from any expensive procedures including
3
joint problems including shoulder impingement , MRI's within the first 12 weeks of the pain epi-
4
degenerative knee problems and spine instabil- sode unless red flags are present. Instead active
5
ity . Instead, it has been demonstrated that ac- therapy is recommended as the primary method
of treatment.
3  No evidence of long-term benefits of arthroscopic acromioplasty
in the treatment of shoulder impingement syndrome, S. Ketola & al,
But here comes the major question: what is
Bone Joint Res 2013;2 active physiotherapy? This will be covered in the
4  A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of
the Knee, Alexandra Kirkley, M.D & al, N Engl J Med 2008 next chapter.
5  Spinal fusion for lumbar instability: does it have a scientific ba-
sis? Muggleton JM1, Kondracki M, Allen R. J Spinal Disord. 2000
4
Inherent problems with traditional active physiotherapy
Being the preferred treatment does not mean
that the current active physiotherapy methods
are optimal. In fact, there are several inherent
flaws with these methods which cause fluctuat-
ing results, high costs and a lack of documenta-
tion.
Poor biomechanics
A critical, but poorly understood factor in suc-
cessful active physiotherapy are the biomechan-
ical properties of the exercises. A well-designed
exercise prevents any harmful movements, is
gentle for the joints but highly fatiguing for the
muscles and can be easily fine-tuned for each
individual.
In this regard, many current tools are quite
rudimentary and ineffective. For example, the
widely-used rubber band exercises for outer and
inner rotation of the shoulder have exactly the
opposite loading curve in comparison to the mus-
cles' strength curve: the loading is at the highest
at the end of the movement where the muscles
are the weakest. This puts unnecessary stress on
the joint while providing a poor training effect.
Figure 4:  This widely used exercise for the outer rotation of the shoulder
is a typical example of poor biomechanics: the load increases when the band
is stretched whereas the strength of the muscles decrease.
Random approach
A generally accepted fact is that the ran-
domness of these programs is a problem. There
are no set standards for what exercises to use,
how often and how intensely etc. Programs are
planned by physiotherapists based on their pref-
erences and experience. This means that the
system can never really learn and gradually im-
5
prove. This can also lead to inconsistent results
from patient to patient and therapist to therapist.
High cost
Physiotherapy is very often provided as a
one-to-one treatment, which means that an in-
crease in patient volume will lead to an increase
in costs. For this reason, physiotherapy is often
not regarded by providers as profitable. It can
also, in many cases, lead to a limit to the pre-
scribed treatment time, which could be detri-
mental to the long-term results.
Figure 5:  Traditional physiotherapy is difficult if not impossible to scale
profitably. When the patient numbers increase, also therapist resources must
increase.
Lack of documentation
A key area that is often identified as a weak-
ness in traditional physiotherapy practise, which
in turn can effect levels of reimbursement for
treatment, is poor documentation. Some metrics
may be used to evaluate the pre and post status
of the patient, but there is rarely good documen-
tation of the actual content of the programs. And
even in cases where some description is docu-
mented, quantitative data of the various param-
eters is missing. No real learning and optimiza-
tion can occur when critical data is missing.
Figure 6:  The poor level of documentation is one of the main reasons why
physiotherapy is not highly regarded or well paid
David's intelligent solution
David’s intelligent solution provides answers
to these problems using advanced training tech-
nology and cloud-based software for guidance,
control and data gathering.
Optimized biomechanics minimizing planning time while providing high
The solution includes joint specific devic-
es with optimized biomechanical properties for
spine, hip & knee and shoulder joints. With the
correct joint and axis positioning, scientifically
6
proven loading curves and target area isolation
enabled by effective fixations, these devices are
remarkably gentle to the joints yet providing the
highest possible neuromuscular training effect.
Figure 7:  Specially designed training and testing devices include opti-
mized joint angles, body fixation and variable loading that initially feels very
light and easy, but after number of repetitions proves to be very fatiguing
and effective.
In each device, a computer terminal guides
and motivates the patients to follow exactly the
given parameters prescribed in their individu-
alized programs. Parameters include for exam-
ple, selected movements, adjustments, loading,
range of motion, repetitions, movement speed,
progression, session numbers and frequencies.
These parameters are automatically designed
and fine-tuned with the use of the cloud-based
software and patients get immediate feedback
on their compliance level.
6  Effects of fatiguing loading with a variable resistance equipment
on neural activation and force production of the knee extensor , K.
Häkkinen, H. Kauhanen and P. V. Komi, Electromyogr. Clin. Neuro-
physiol. 1988, 28, 79-87.
6
Structured approach
Individualized programs can be applied in a
structured and systematic way, because all pa-
rameters are quantified and controlled, Programs
are based on diagnose- and test-based templates
higher level predictability in outcomes.
High compliance
All training variables are monitored and the
system calculates instantly compliance percent-
age from correct speed, range of motion and
workload. This helps with patient motivation.
Monitoring patient and center level compliance is
an important part of quality control.
High productivity
With all the technical features in the devic-
es and software, David devices are easy to use.
Registering on each device is done with an RFID
card. Seats and other support elements are auto-
matically adjusted and the program is retrieved
from the cloud. During the initial instructed
sessions, patients learn quickly the use of the
system freeing human resources for more crit-
ical tasks. One physiotherapist can control 3-6
patients simultaneously without any reduction in
the quality of care. Also, self-care is possible and
has been proven both medically and economical-
ly very effective.
Figure 8:  Each device is wirelessly connected to the cloud and with a
touch of an RFID card training program with individual settings are retrieved.
Seat adjustments are automatic and patients do not need any help in enter-
ing or using the system.
Comprehensive data collection
All relevant data is collected automatically
from several sources: e-mail links, tablets, mo-
bile phones, the Info-Kiosk and David devices.
Data gathering is pre-programmed according to
each treatment pathway, which ensures that all
information is collected with minimal human in-
tervention. Data is collected from questionnaires,
tests, pain drawings and exercises.
All information is instantly available for re-
porting and analysis. With one click, the up-to-
date status of any patient can be retrieved. All
relevant center- or network-level statistics are
available at all times for managers.
With David's intelligent solution most of the
shortcomings in traditional active physical thera-
py have been resolved and new business oppor-
tunities have emerged.
Movement as medicine
Movement can be very effective in the treat-
ment of musculoskeletal problems but like with
any medicine too much can be harmful while too
little has no effect. With over 25 years of experi-
ence, multiple studies and extensive data collec-
tion, we have learned how to prescribe correct
dosages of movement and loading for each pa-
tient and disorder.
Figure 9:  With a click of a button a report can be printed showing both
progression in loading and mobility and pain reduction and selected ques-
tionnaire indices.
The main component for successful treat-
ment is the ability to control loading and range
of motion very precisely. This is possible if the
devices are correctly designed to provide smooth
and easy-to-handle loading over the full range
of movement. The movement and speed are ac-
curately controlled by the responsive graphical
feedback system which ensures that an individu-
ally prescribed, safe range is followed.
Figure 10 below provides a schematic view
of the process. It is critical that enough time is
given for the tissue to heal before loading is in-
creased and the functional capacity is normal-
ized. Every joint and every individual has its own
rate of recovery. David’s software solution can in-
telligently adjust the program parameters based
upon feedback- and pre-programmed pain-rules.

Figure 10:  Painful joints and tissue are the critical limiting factors in how much loading and range of motion can be used. This schematic picture shows how
loading progression is controlled during the treatment. It is critical to always keep the loading under the aggravation threshold while at the same time aiming
to cause adaptive changes in the muscles and tissue. In this example pain tracking prompted a load decrease, until the situation stabilized.

7
Joint-specific/targeted vs. functional training
One area often discussed in connection to
device-based rehabilitation is whether close-
ly controlled and guided exercises are a better
option than functional training. This question is
especially relevant for physiotherapists who are
used to using simple tools and a high level of
personal supervision.
Figure 11:  In this compound exercise both hip and back extensors are
activated. Weaker back is protected by using isometric force (or eccentric
where back is giving in) while the actual work is performed with hip exten-
sors. This kind of exercise requires good coordination and can become
quickly dangerous when loads are increased.
To understand our approach, it is important
to first consider some basics in strength training.
Every movement with load requires some amount
of coordination. The more “functional” the move-
ment is (more muscles and joints included), the
more coordination is required. For example, the
"dead-lift" (figure 11) is an effective exercise but
requires a lot of coordinative skills. When loading
increases, the exercise becomes more demand-
ing and therefore the risk is increased, having
obvious implications for patients.
In such functional movements the weaker
muscles and painful joints tend to be protect-
ed by the use of isometric (static) muscle force
while strong surrounding muscles are doing the
actual work. With most so called back extension
machines the training has very little to do with
8
the spine, but is rather a hip extension exercise.
In addition to being ineffective for the spine,
this includes a potential danger because weaker
spine muscles can easily be overloaded causing
loss of spine control.
David devices include technology to eliminate
the effect of the dominating muscles and target
the training effect towards the weak and often
painful joints and muscles. Figure 12 shows how
proper fixation helps the weaker spine muscles
to work dynamically facilitating a unique verte-
brae by vertebrae movement and activating the
small, critical inter-vertebral muscles.
Instead of using a more demanding func-
tional training, where dominating muscles and
compensating movements can easily destroy the
intended training, our approach uses targeted,
safe and highly effective, guided exercises. This
allows early activation of even painful joints with
high level of precision. This also quickly empow-
ers the patient as they learn that movements are
not painful. Training provides gratifying sensation
in the muscles surrounding the troubled joints,
which strengthens their motivation to continue.
Once the “weak link” is removed, return to
normal functionality is possible and more func-
tional exercises are then safe to perform.
Figure 12:  The Hip-Fix solution is a good example of how correct fixation
makes it possible to target the training effect exactly where required. This
exercise is safe and forces the spine to move vertebrae by vertebrae, which
is very difficult to do in a controlled way with any other method. Critical small
spinal muscles and multifidus are trained effectively.
Cloud-based EVE platform
The EVE platform manages the whole treat- tracked hand-gestures. Patients can easily mark
ment process, guides through individual exercis- what exercises they have performed and if they
es and collects all the data for reporting. It helps had issues with performing those exercises.
therapists in making better treatment choices EVE Cloud Service is the heart of the whole
and motivates clients in their recovery. It also
acts as the controlling tool for the center man-
agement to oversee the clinic the operation, in-
cluding monitoring individual therapists, all on-
line and in real-time.

EVE platform components:

EVE Terminals All treatment devices have a
colour touch screen monitor where patients can
log-in with an RFID card and see the correct
training settings. It adjusts most of the settings
of the device automatically with actuators based
on preferences stored by the therapists. During
the training it shows the safe movement range
which is derived from the patient’s own pain free
mobility measurement values. The terminal also
guides the correct training speed and constant- Figure 13:  The EVE platform connects every device wirelessly to the cen-
tral Info-kiosk which is connected to the cloud. Training program and device
ly monitors the coordination of training. Patients settings are retrieved with an RFID tag and all test results, questionnaires
get immediate feedback as to how well they and all training data are automatically store in the cloud. Access to this data
is possible with various web based devices.
were able to follow the designed exercise based
upon range of motion, work amount, coordina- EVE platform. All the training information is
tion and speed. stored on the server software allowing for a com-
EVE Info-Kiosk This is used by the patients to plete analysis of the treatment data. True to a
log-in to the training session. It shows possible full cloud service, the system can be accessed
messages from the therapists and asks for pain with a web browser from any location. The cloud
information and other questionnaires that have service offers treatment professionals and clients
been pre-programmed. Customers can view their the following functionality:
current /past/future training programs. Thera- • Functional profile analysis for creating an op-
pists can easily modify patients' programs at the timal treatment programme;
kiosk. • Treatment templates and programmes for
EVE Exercise-Kiosk - The EVE system is not individualized approach;
limited to only device exercises. Any exercise or • Quality tracking of each movement for de-
treatment can be added to patients' training pro- tailed training analysis;
grams with pictures, videos and written instruc- • Questionnaires from easy-to-analyse treat-
tions. The Exercise-Kiosk has a large 42-inch ment feedback;
touch-screen and can be operated with Kinect- • Intervention engine for additional exercises

9
 based on achievements and progress;
• Total treatment tracking for evaluating treat-
ment success
• Quality and quantitative data for center
management
• Full integration to any patient records sys-
tem via HL7 interface
David collaborates with multiple centres
around the globe with unified data collection, in
searching for better, faster and more cost-effec-
tive ways of reaching desirable outcomes. The
collected data can be extracted from the EVE
database and analyzed with mathematical tools
like Matlab. In order to increase the efficiency,
machine learning algorithms are applied to the
extracted data identifying critical factors that are
most crucial in achieving treatment success.
Real-time monitoring
The EVE Cloud Service provides a real-time
view of everything that takes place in the center.
For persons with access to the center data, it is
Figure 14:  Therapists and managers have real-time access to all relevant data including an overview of the daily visits. With a single glance it is possible
to see the quality of each visit and to drill down for more detailed data.
10
easy to monitor daily volumes and quality. Any
anomalies can be identified by examining indi-
vidual visits.
All relevant data is collected automatically
without any additional effort. This means that
the data is always complete, without holes. The
availability of this kind of instant, real-time in-
formation enables a proactive approach to areas
such as economic factors, service level and med-
ical quality.
On the patient level, comprehensive reports
can be printed with one click collecting all avail-
able data with calculated indices and graphical
improvements. With the flexibility of the system,
reporting can contain any set of parameters re-
quired by each health system.
From the R & D point of view, this kind of
data is invaluable in understanding the problems
and finding the most effective solutions. To max-
imize the use of the data, David has started to
use data analytics tools and machine learning
methods.
Big Data analytics - Artificial Intelligence
David’s modern cloud based data gathering program will not be beneficial during future ses-
platform has opened up new, unprecedented sions either and therefore further consultation is
opportunities in musculoskeletal care. Using the needed. This kind of information saves both pay-
platform, diverse data sets during an exercise ers’ money and patients’ efforts.
treatment period can be now collected from With this kind of high quality, comprehen-
patients world-wide describing general health sive data, David is now moving to the next level
status, demographics and other relevant back- in data analytics which utilizes Artificial Intelli-
ground information, treatment progress, detailed gence (AI). Using advanced machine learning
exercise parameters and treatment outcome. algorithms and rapidly growing patient data, the
The platform generates an accumulating data- David’s AI-engine optimizes the data collection
base of invaluable informa- procedure, finds subgroups
tion with exciting potential of patients with similar
for new knowledge. treatment responses, pre-
Even with our extensive dicts treatment outcomes,
experience in treating back and optimizes treatment
and other joint pain in Da- during different stages of
vid clinics, recently collect- the treatment period. This
ed data has produced new way the AI-engine can pro-
insights into optimal treat- vide mass-individualised
ment of musculoskeletal treatment programs, high-
pain. As an example, com- er success rate and better
parison of patient groups with successful and un- predictability. Success is not anymore based
successful treatment outcomes revealed that if upon chance or experience of the therapist, but
no improvement occurs in pain levels during the on accumulating evidence and sophistication of
first five treatment sessions, it is likely that the the system.

Figure 15:  All training parameters are quantified and collected together with the rest of the patient data for analysis. Machine learning algorithms provide
increasingly accurate suggestions for treatment and the platform can convert this quantified data into exact parameters patients can follow in the devices and
additional treatment modules.

11
Wide range of applications
With its background in sports science, David
technology was built to meet the most demand-
ing needs of elite athletes. This required uncom-
promising biomechanical solutions that allowed
athletes to train at extreme intensities with min-
imal risk of injury. Soon it became clear that the
exact same technical principles worked perfectly
also in rehabilitation: high intensities with low
joint stress and risk of injury. However, historical-
ly our rehabilitation devices (as with most devic-
es today) were complicated to use and had nu-
merous adjustments. It was therefore necessary
to have one type of devices for normal training
and another type for rehabilitation.
The latest evolution of the David devices are
based upon new, innovative technology with au-
tomated adjustments and very simple fixation.
With just 1-2 adjustments (compared to indus-
try standard of 5-6) it is now possible to under-
Spine
Figure 16:  Optmized biomechanical properties of the devices and ease of use of the devices and the IT system enable many applications.
take demanding rehabilitation and high intensity
sports training with the same device. Devices are
so user friendly that no supervision is needed
after a few initial guided visits.
With the cloud-based EVE guidance solution,
the David system can have variety of applica-
tions from rehabilitation, injury prevention or
sports training without any compromise in effi-
cacy and safety.
In many cases, all three can be offered in the
same location. For example, an elite athlete is
rehabilitated and continues without a break with
the same system to enhance performance. The
same goes with any patient who finds the sys-
tem so appealing that he/she wants to stay as
a member. Our innovative solution opens many
new business opportunities and could transform
the whole health market in this segment.
Hip & Knee Shoulder
12
Scientific evidence
Studies conducted with the David devices and
concepts can be divided in two categories: 1)
validation studies, 2) medical and econom-
ic outcome studies. Some of the studies have
been initiated by us, but all studies have been
carried out by third parties such as universities,
insurance companies and car companies, and
most are published in peer reviewed magazines.
Validation studies
The variable resistance method developed
by us has been examined via a set of studies
under the supervision of Professor Paavo Komi,
comparing David to other methods and using
EMG to validate the correctness of the loading
curves and efficacy of training. Outcomes sup-
ported our theory: the David loading principle is
working optimally and has great fatiguing effect
1
on muscles (see box 1) .
In conclusion, the present findings
1 suggest that the repeated concen-
tric contractions of the knee extensor
muscles against the variable resistance
may create optimal loading conditions
that results in great fatiguing effects on
the neuromuscular performance.
Figure 17:  Study1 showed that the David's variable loading generated
high EMG activity distributed evenly over the whole range of motion. Similar
effort using isokinetic devices produced 40% lower level of activity.
1  E.g. Effects of fatiguing loading with a variable resistance equip-
ment on neural activation and force production of the knee exten-
sor , K. Häkkinen, H. Kauhanen and P. V. Komi, Electromyogr. Clin.
Neurophysiol. 1988, 28, 79-87.
13
These were followed by several studies ana-
lysing the intra- and inter tester reliability of
the isometric strength testing method (Germa-
ny 1992, Sweden 2001, Austria 2014) which all
showed high level of reliability (see box 2).
The results showed that neck
2 strength in an upright position
measured with David neck equipment
has almost perfect intra- and inter-tester
reliability.
EMG validation studies were undertaken
in collaboration with the university of Cologne,
Germany to find out if David’s isolation principle
really fatigued the target muscles and blocked
the strong surrounding muscles2. These stud-
ies demonstrated clearly that not only were the
strong hip extensors blocked but were in fact in-
hibited creating a high level of activation in the
spinal target muscles.
A set of fatigability studies with back pa-
tients and healthy persons were conducted using
EMG spectral analysis to find out if these meth-
ods could be used as diagnostic and outcome
tools. The first study clearly demonstrated that
back patients are both weaker and fatigue easier
than healthy individuals3.
A follow-up study tested if the MFP (EMG
mean power frequency) is a valid post-rehabil-
itation outcome measure4.
Another study in Sweden (2002) analysed if
EMG can be used as a classification tool to differ-
entiate between healthy and back pain patient.
Result showed that classification power was 80%
accurate.
2  The Spinal Muscular Profile, Achim Denner, Springer 1992
3  Back and Hip Extensor Fatigability in Chronic Low Back Pain
Patients and Controls, Markku Kankaanpää, BM, Simo Taimela,
DrMedSci, David Laaksonen, MD, Osmo Hänninen, DrMedSci, PhD,
Olavi Airaksinen, DrMedSci, Arch Phys Med Rehabil Vol 79, April
1998
4  Reference change limits of the paraspinal spectral EMG in eval-
uation of low back pain rehabilitation, Markku Kankaanpää, Simo
Taimela, Olavi Airaksinen, Pathophysiology 5 (1998) 217–224
 Two studies were conduct-
ed in the 00’s to find out more
about optimal loading meth-
ods. The first study looked at
variable vs. constant resistance
in a leg press exercise and found
out that the best training effect
can be obtained with slightly
increasing loading with a varia-
ble resistance method (used in
David G210 Multifunctional Leg
Press)5.
The second study compared Figure 19:  EMG measurements show clearly that with David's Hip-Fix system, spine extensor
muscles are highly activated while the strong hip extensors are effectively inhibited.
the David variable resistance
against artificial (pneumatic)
loading (HUR). The findings
showed that with correct variable loading it is mostly with back problems. Some of the best
possible to provide higher fatiguing, which is es- studies have been published in the leading med-
6
sential in restoring the function of any joint . ical journals such as Spine.
One randomized study compared the results
Medical and economic outcomes of active rehabilitation and passive control treat-
There are several studies analysing the med- ment in patients with chronic low back pain with
ical and economic efficacy of the David system, follow-up at 6 months and 1 year. The active pro-
gressive treatment program was more successful
in reducing pain and self-experienced disability
and also in improving lumbar endurance than the
passive control treatment7.
Another study analyzed the role of physical
exercise and inactivity on the long-term out-
come after active outpatient low back rehabili-
tation. Subjects received an active program for
12 weeks and the average drop in self-perceived
VAS pain was -30 mm. After the program, part of
the group maintained some activity while others
Figure 18:  Survival patterns (Kaplan–Maier) without work absentee-
ism, due to low back pain, of physical exercise groups after the active were passive. Result shows clearly that some ac-
outpatient rehabilitation. Solid line (above) denotes the group with any tivity helps to maintain effectively the achieved
physical activity; dotted line (below) denotes the physically inactive
group. The group difference was statistically significant (P 0.01). results and therefore is highly recommended for
patients. Figure 16 shows how the active group
5  Kinetic and electromyographic analysis of single repetition con- had significantly less sick leave days while the
stant and variable resistance leg press actions, Simon Walker, Heik-
ki Peltonen, Janne Avela, Keijo Häkkinen, Journal of Electromyogra-
phy and Kinesiology 21 (2011) 262–269 7  The Efficacy of Active Rehabilitation in Chronic Low Back Pain,
6  Neuromuscular responses to different resistance loading pro- Effect on Pain Intensity, Self-Experienced Disability, and Lumbar
tocols using pneumatic and weight stack devices, Heikki Peltonen, Fatigability, Markku Kankaanpää, BM,Simo Taimela, MD, Olavi
Keijo Häkkinen, Janne Avela, Journal of Electromyography and Ki- Airaksinen, MD and Osmo Hänninen, MD, PhD, SPINE Volume 24,
nesiology (2012) Number 10, pp 1034–1042
14
passive group started to have more and more
8
absent days from work .
There is a set of three published outcome re-
ports by FPZ, a chain of over 200 licensed back
centers in Germany. The treatment method is
the same standardized method that David uses
with the exception that the Germans put more
emphasis in increasing strength. These publica-
tions are looking at various outcome measures,
like pain intensity, pain frequency, sick leave
days, visits to doctors, etc. The N’s in these data
sets are very large, ranging from 4.559 to 37.943
subjects. Results are excellent. For example,
41% of the patients were pain free after the pro-
gram and of the rest 88% had significant pain
reduction (the start pain levels were not as high
as in some other studies)9.
Some of the studies have been initiated or
conducted by insurance companies in Germany.
Gothaer insurance company: "The
3 return of investment for the back
concept is 4.7:1, meaning that every
Euro invested in the back concept ser-
vices leads to savings of 4.70 Euro”
Gothaer insurance discovered that by in-
vesting in back treatment, the insurance compa-
ny saved almost 5 times more in medical and sick
leave costs (see box 3)10.
AOK insurance in Baden-Württemberg had
a randomised study with 1936 insured back pain
customers in an intervention group and 548 con-
trols. All costs incurred by these subjects were
analysed over a two-year prior and two years
post of the intervention. After deducting the cost
of running the program, the study showed that
each person in the intervention group saved over
8  The Role of Physical Exercise and Inactivity in Pain Recurrence
and Absenteeism From Work After Active Outpatient Rehabilitation
for Recurrent or Chronic Low Back Pain, Simo Taimela, MD, DMSc,
Carlo Diederich, PT, Marc Hubsch, PT, and Michel Heinricy,
9  E.g. Integrierte Versorgung Rückenschmerz, Wissenschaftliche
documentation 2006 – 2008, Dr. Frank Schifferdecker-Hoch, FPZ
10  Manuelle Medizin 2006, 44:308–312, Springer Medizin
15
EUR1.300 in a two year follow-up period.
A randomised study conducted at Frankfurt
airport compared sick-leave days of an inter-
vention groups and control group. The outcome
showed that one year following the program the
intervention group had 7,3 days less sick-days
than before while the control group had 1,1 days
more11.
Daimler Chrysler initiated a special pro-
gram, “Kraftwerk” at their factories in which a
David back extension device was transported
around the car factory and employees trained
during working hours once a week. This small
amount of training per week resulted in a 48%
reduction in sick leave cases12.
Figure 20:  Due to the huge size of the factory it was easier to move the
training platform to workers than have them walk the long distances at the
Daimler Chrysler factory. Even one extension exercise once a week reduced
sick leave incidences by 48%.
A recent study at the Mercedes factory in
Vittoria, Spain, used a slightly more extensive
program. A container sized room was put in the
middle of the factory and workers trained once a
week in this location for one extension and flex-
ion exercise for the spine. The overall program
also included education and ergonomic advice.
The program produced outstanding results re-
ducing back related sick-leave days by 78%.
11  Reduktion von diagnosespezifi scher Arbeitsunfähigkeit bei La-
dearbeitern durch eine gezielte mediziniche rainingstherapie für die
Wirbelsäule, B. Sappich, W. Gaber, S. Caspar und K. Baum, Arbeits-
medizin 8/2001, 371-377
12  Evaluation des Wirbelsäulenkonzeptes Kraftwek, Daimler-
Chrysler AG Werk Wörth, Prof. Dr. Huber, Institut Für Sport und
Sportwissenschaft der Universität Heidelberg 2003-2005

Figure 21:  At Mercedes factory in Spain, back related absenteeism was
reduced by as much as 78% with only 16 training sessions during working
hours once a week that lasted 10-15 minutes each. In a survey conducted
afterwards 95% of the workers wanted to continue the program.
A medical center in Vienna, Austria uses David
Spine concept to treat patients paid by social in-
surance system. The program includes a 12-week
Solution used worldwide - preferred reimbursements
Our platform has been installed in more than
30 countries with very different medical and eco-
nomic conditions. Each month around 5-6 new
installations are carried out somewhere in the
world. This accumulating experience has taught
us that medical needs are quite similar every-
where and that successful business set-ups can
be developed in very different environments.
In the long-term our aim in each market is to
16
phase two times a week and an on-going program
of 12 weeks once a week. One of the periodic
reports to the government with 360 back patients
shows an average pain reduction from VAS 49 mm
to 17 mm, and Roland-Morris from 8,8 to 5,813.
We added a hip & knee solution in 2015 and
a shoulder solution in 2016. It appears that the
medical results with these solutions are equal to
those with the spine, but no published results are
yet available. The same loading and progression
principles are in use, and these solutions can
therefore be considered safe and effective tools in
fighting musculoskeletal problems in these areas.
13  Medical Therapy in Austria, Dr. Thomas Kienbacher, Karl-Land-
steiner-Institut für ambulante Reha-Forschung, David World Forum
2014
seek a preferred position with third party payers.
This has already been successful in some Euro-
pean countries and work is ongoing in others.
The efficacy and level of documentation available
with the David platform is favored by third party
payers. As the data quantities increase and an-
alytic power improves, we can help our partners
to make a compelling case towards insurance
companies and social insurance systems.
Collaboration models
Traditionally we have operated as a supplier
to health care providers by selling our hardware
and licensing our software. In 2015 we launched
a new brand called “Nordic Health” which targets
consumers with a network of our own centers.
Our flagship center is in Helsinki and a network
of Nordic Health centers is expanding in the
Netherlands. Currently there are several Nordic
Health projects in different countries.
The company continues to sell its solutions
through distributors and directly all around the
world. This solution is sold under the brand name
of David and it contains all necessary tools and
know-how to run a successful service. Device in-
stallation, education and support is carried out
by either a certified distributor or our own team.
In a typical setting a new center can become op-
erational in one week.
Various partnership models can be offered in
selected countries under the
Nordic Health brand. These
models include the same
tools and support as used
by the company's own Nordic Health centers. An
example is a model that utilizes volume based
rental and requires smaller investment. Typical-
ly, this model is for hospitals, which fulfil the re-
quired criteria, as a "shop-in-shop" arrangement
to cover all musculoskeletal needs.
With the Nordic Health collaboration model,
our aim is to build a network of centers operating
under the same quality control and data gath-
ering procedures. With this development it will
be easier to negotiate preferred rates with insur-
ance companies and have a stronger marketing
position toward the consumers and companies.
Table 1 below gives an outline of the different
elements for each model.

Table 1:  David's solution is offered to patients through three different channels: David's own Nordic Health centers, partnering hospitals using the Nordic
Health treatment protocols and third-party operators using the David technology and SaaS.
DAVID/NH COLLABORATION MODELS
Description Nordic Health Partnership Investment + SaaS
Owner of the business DAVID/Nordic Health Client Client
Devices NH devices* NH -devices* DAVID -devices
Sofware Cloud Cloud Cloud or standalone
Testing and treatment module YES YES YES
Intelligent templates YES YES YES
Artificial Intelligence module** YES YES NO
Questionnaire module YES YES Orderd separately
Treatment process automation** YES YES NO
Additional exercise module YES YES Orderd separately
Calendar functionality** YES YES NO
HR management** YES YES NO
Network management* YES YES NO
CRM - patients / doctors / companies** YES YES NO
Client portal / mobile app** YES YES NO
Business suite** YES NO NO
API integration YES YES Separate integration project
Premises Nordic Health Client Client
Employees Nordic Health NH or client as agreed Client
Payment Fee for service Volume based rental w. agreed minimums Investment + sofware license fees
Brand Nordic Health NH "inside" DAVID
Ability to use NH web site engine YES YES NO
NH wikipedia for process documentation YES YES NO
Data sharing / bechmaring YES YES NO
Qualiry control YES YES NO
Warranty Lifetime Lifetime Two years
Device maintenance YES YES Separate service agreement
Device upgrades YES (if upgradeable) YES (if upgradeable) NO (new parts may be for sale)
Sofware support YES YES Separate license
* Different logotypes on devices + future differentiation
** Under development
** Depends on on who's payroll empoyees are

17
Space allocation
A complete physical therapy center set-up can
be very space efficient. The space allocation ex-
ample below contains all the elements of the con-
cept and can fit into 150 m2. When other facilities
exist, only 75 m2 is needed for the training area.
When higher volumes are expected, through-
put can be increased by doubling up some of the
bifunctional devices (e.g left/right rotation). In
that case more space is needed.

18
Financial viability
A key reason why David's Solution is more
profitable than traditional physiotherapy is the
ability to provide an equal or superior service
level with fewer physiotherapists.
Additional cost savings can be achieved when
trained physical therapy assistants are used in
the normal patient care. This is also critical in
some countries where availability of physical
therapists is limited.
Depending on the country, payer policies and
center setting, one therapist can handle 3-6 pa-
tients simultaneously and also self-care is widely
used with minimal intervention and the therapist
just present.
The David technology is built to last for dec-
ades. The oldest, perfectly functioning David sys-
tems in operation, are over 25 years old. Devices
Figure 22:  Center activity report from a center that has similar set-up as on page 18. The report shows how only about 5% of the visits are 1:1 with a
physiotherapist. The rest are visits where the patients are independently able to handle the process under the supervision of the physiotherapists.
19
can be conservatively depreciated over 10 years.
With a full system, the yearly cost is less than the
salary of one therapist in most countries.
A growing trend with many of our clients is
to offer on-going prevention for their custom-
ers, especially during off-peak hours. This can
be charged per visit or per month with typically
one or two visits per week. This can provide im-
portant additional income to the center and will
increase customer loyalty as well as providing a
valuable service to customers.
If volumes permit, a practical solution is to
open satellite locations off-site, where customers
can continue as members. With the EVE connec-
tivity, all activity and customer well-being can be
closely monitored.
A center set-up on the opposite page can
handle 1500 – 2000 patient visits / month (see
chart below). In most cases, less than half of
that volume is enough to reach economic break-
even level.
We have experience in developing financial
models for new centers in different countries. We
are happy to help by providing calculation tem-
plates and advice.
Education and support
Education
Our primary motivation is a happy patient
that may be converted into a lifetime member.
With a combination of technical knowledge and
positive human interaction this can be achieved,
in a systematic way.
Our education process aims at transferring
this knowledge and attitude as effectively as
possible to our client organizations. Education is
hands-on and it will take place at our education
center in Helsinki or at the client site. Typically,
there is a start-up education for basic skills and
then a follow-up education on-site.
With our Nordic Health partners, our expert
therapists will stay extended periods on-site to
ensure top quality competence and ability to use
all the evolving features of the EVE-software
suite.
An extensive on-line Knowledge Base is avail-
able with instructions and videos. For Nordic
Health partners, there is an on-line documen-
tation for all treatment and business processes
with the ability on tailor-make them for different
regions or sites.
An expert forum provides a platform for dis-
cussions and idea exchange.
20
Support
Support needs are diverse ranging from tech-
nical to software issues or requirements for vari-
ous materials and marketing support.
Our distributors have certified service peo-
ple who are qualified to calibrate and service all
products. In countries where we are directly in-
volved with our clients, we contract and educate
a local service organization to provide immediate
help. Service organizations are equipped with
spare parts that may be needed. As the table 1
on page 17 shows, warranty covers all replace-
ment parts up to two years and with the Nordic
Health devices as long as the contract runs.
The EVE software system runs very reliably.
There are seldom any issues that are related to
the software itself. Software support is typical-
ly provided remotely. This means very fast re-
sponse times. Most issues can be handled by our
local service people but our team in Finland is
always ready to help and has access to the sys-
tems remotely.
With the abundance of materials for pres-
entations, hand-outs and videos, we are happy
to help with any material and marketing needs.
Materials and web sites are being developed for
Nordic Health and are provided for
free to our partners.
We are also willing to attend im-
portant meetings with payers, com-
panies or other organizations criti-
cal to our clients' success to present
the global view and latest findings
in musculoskeletal care.
Complete physiotherapy pathways
Over the past 25 years we have demonstrated
that controlled and quantified active training can
be a great tool in the hands of therapists. Howev-
er, David’s solutions have in the majority of cases,
been used in addition to other treatment methods
or utilized in stand-alone units, treating just the
spine.
This is now changing. With the addition of the
hip & knee and shoulder solutions and the software
tools for additional and home exercises, DAVID Ac-
tive Therapy Solution is ready to form complete
pathways in physical therapy for patients, that are
indicated for training. According to some estimates
this could be up to 85% of all physiotherapy cases.
The picture below highlights the elements
of the pathway. It is clear that all these options
may have a role in the pathway, but it is not yet
been determined which components each element
should ideally contain and what is the relative im-
portance of each element.
For example, depending on the patient case,
medication and some manual therapy may be
required at the beginning of the program. The
degree to which this should be applied is as yet
uncertain, hence the dotted line with arrows. In
practise, it appears that activation programs can
be initiated earlier than previously thought, often
right away.
Figure 23:  DAVID Active Therapy Solution contains all elements needed for a complete physiotherapy pathway for musculoskeletal problems.
21
Another open issue is the role of additional ex-
ercise, relaxation and some other supplementary
treatments. The new EVE software module, al-
lows systematic application of any other additional
treatments. But how much and to what degree,
require further evidence.
The EVE additional exercise module also allows
the creation of home programs which can be indi-
vidualised and printed out (later with an App) for
the patients.
The long-term success of any treatment pro-
gram is the ability to continue some level of activi-
ty afterwards as shown in the study referred to on
page 14 (footnote 7). We have seen in our own pi-
lot center that when the same technology is used,
it is easy to transfer patients on to self-training
programs. What makes this option cost effective
is that after just 1-4 treatment sessions, patients
can undertake self-training. With the ongoing data
collection and collaboration with a world-wide net-
work of centers, our objective is to find answer to
the questions above. It seems most likely that the
answer will be that pathways need to be highly
individualized.
Based on the initial response from experts
and clients, it seems that the DAVID Active Ther-
apy Solution could be a game changer in the way
physiotherapy will be practised in the future.
 Validity and reliability studies
Background and validation studies for spine devices and for various resistance methods
Name of the study Year Type Objective Country n Set-up Outcome Publication
Isometric reliability test 1992 Reliability Reliability of isometric testing Germany 22 untrained individuals Reliability in mobility and r=0.97-0.99 Muskuläre Profil Der
study isom strength in David Wirbelsäule, Springer 1995
spine units
Reliability of Isometric Trunk Moment 2014 Reliability Short- and long term test- Austria 42 over 50 yrs. (44 under 50 as Isometric retest after 2 As reliable with over 50 as with Journal of Rehabilitation
Measurement in Healthy Persons Over 50 study retest reliability controls) days and 6 weeks under 50 Medicine 2014
Years of Age
List of research

Intra- and inter-tester reliability and reference 2001 Reliability Reliablity of David F140 + Sweden 30 (reliability), 101 (reference Repeat tests with three David F140 has almost perfect intra- Physiotherapy Research
values for isometric neck strength study reference data values) testers and inter-tester reliability. International, 6, 2001

Muscle activation study 1992 Validation To analyse the activity of Germany 22 untrained individuals Using EMG to test the Fixation is devices effectively Muskuläre Profil Der
study target vs, other muscl. isolation of target muscles activate target muscles and inhibt Wirbelsäule, Springer 1995
others
Reference change limits of the paraspinal 1998 Validation To validate EMG fatigue test Finland 14 healthy females (15 patient Testing the MPF of EMG MPF (mean power frequencyanalysis Pathophysiology 5 (1998)
spectral EMG in evaluation of low back pain study after rehabilitation controls) pre and post rehabilitation is a valid measure for fatigue)
rehabilitation
Lumbar paraspinal muscle fatigability in 1997 Validation Develop a valid fatigue test Finland 10 healthy individuals 30 repetition to fatigue Highly repeatable MPF parameters Eur J Appl Physiol 76 (1997)
repetitive isoinertial loading: EMG spectral study with EMG with David F110 device with high correlation to self

22
indices.. preceived Borg scale
Lumbar muscle fatigue and recovery 2002 Validation Evaluate EMG to estimate Sweden 57 patients (55 controls) Repeated 80% MVC 45 80% classification power Disseration from Karolinska
study lumb. fatigue sec. Institut 2002
Kinetic and electromyographic analysis of 2011 Validation Best resistance pattern Finland 9 healthy individuals, not training To full fatigue with various Variable loading proved to be most Journal of Electromyography and
single repetition constant and variable study backgr. loading patterns effective Kinesiology 21 (2011)
resistance
Impaired Lumbar Movement Perception 2002 Descriptive Ability to sense change in Finland 26 spinal stenosis patients Slow spine rotation with Impaired proprioceptive abilities SPINE Volume 27, Number 9,
study lumbar position by motor in David F120 (increased risk) 2002

Scientific evaluation of specific of knee 1986 Comparison Most effective musle Finland 5 athletes Maximal 1RM with David, David provided highest neural Medicine and Sports Science,
extension with variable resistance… study activation squat and isokinetic activation throughout the range of Kargel, Basel 1987
motion
Effects of fatiguing loading with a variable 1988 Comparison Most effective musle Finland 7 athletes 60% submaximum High muscle fatigue with full range Electromyog. clin. Neurophysiol.
resistance equipment on neural activation… study activation training to full fatigue to end vs. shortening range with 1988,28
comp. device
Back and Hip Extensor Fatigability in Chronic 1998 Comparison Compare EMG fatigue btw. Finland 20 LBP females (15 healthy Isometric MVC and 50% Especially in Gluteus Maximus LBP American Congress of
Low Back Pain Patients and Controls study LBP and controls controls) of MVC patients fatigued faster Rehabilitation Medicine 1998

Neuromuscular responses to different 2012 Comparison Most effective fatiguing Finland 15 healthy individuals, not To full fatigue at several Variable resistance (David) induces Journal of Electromyography and
resistance loading protocols (weight vs. study training backgr. loading levels greater levels of peripheral fatigue Kinesiology. 2012
pneum.)
 Outcome studies
Name of the study Year Type Objective Country n Set-up Outcome Publication
Gother insurance comp. 2001-2003 RCT1 Economic savings Germany 95 (205 controls) 24 sessions in 12 weeks, Savings ratio € 1/ € 4,7 Manuelle Medizin 2006 ·
DSC 44:308–312, Springer Medizin
The Efficacy of Active Rehabilitation (comp. to 1999 RCT Pain reduction, funct. disab,one Finland 30 (24 control) 24 sessions in 12 weeks, At one year VAS 55-->22 (48.5-- SPINE Volume 24, Number 10,
massage, thermal) year follow-up DSC >45.5 cntrl) 1999
The Role of Physical Exercise and Inactivity in 2000 RCT Long term benefits of active Luxembourg 125 24 sessions in 12 weeks, VAS - 30, signifacntly better SPINE Volume 25, Number 14,
Pain Recurrence and Absenteeism From Work therapy DSC "survival" for ongoing active group 2000
AOK insurance comp. 2013 RCT Economic savings Germany 1936 (548 controls) 34 session in 12 weeks, Direct savings of 1.307 € / 24 m. Kosten-Nutzen-Analyse, AOK /
DSC2 /person Universität Karlsruhe
Kraftwerk (DaimlerChrysler) 2003-2005 RCT Reduction of sick days Germany 398 (610 controls) 32 sessions in 32 weeks 35% reduction in sick days, 48% Der Universität Heidelberg 2005
(one device / David) in sick leave cases
Frankfurt airport / AOK 2001 RCT Reduction in sick days Germany 95 24 sessions in 12 weeks, Rreduction of sick days by an Arbeitsmedizin 8/2001
(85 controls) DSC average of 7.3 days per worker in
a year
Company prevention with coal mine workers 2014 CCS4 Reduction of sick days Russia 725 Back training (DSC) 3 to 6 34.98% reduction in sick leave Siberian Coal and Energy Comp-
m. cases 2014
EVE / non-EVE comparison 2009-2012 CCS Pain reduction USA 261 (454 controls) 24 sessions in 12 weeks, With EVE system pain reduction David internal data analysis
DSC 20% higher (81% vs. 63%)

23
FPZ economic study 1 2006-2008 CCS Economic savings in medical Germany 9,455 24 sessions in 12 weeks € 1.562 savings / patient / year FPZ 2009
costs
FPZ economic study 2 2014 CCS Reduction in sick days Germany 4,559 24 sessions in 12 weeks, 50.81 % reduction is sick days FPZ Schifferdecker-Hoch, F.,
DSC et ál (9.8--> 5.6) Hollmann, M., Hoppe, M. 2014
FPZ economic study 3 2015 CCS Reduction in doctor visits Germany 13,009 24 sessions in 12 weeks, 57.09 % reduction is doctor visits
FPZ Schifferdecker-Hoch, F.,
DSC et ál (1.9-->0.8) Hollmann, M., Hoppe, M. 2014
FPZ integrated health study 2011 CCS Pain reduction Germany 37,943 24 sessions in 12 weeks, 41% pain free / from the rest 78%
Aktuelle Zahlen und
DSC et ál signific. less pain Erkenntnisse zue
Medizinischen...(FPZ 2014)
Insurance back patients 2014 CCS Pain reduction Austria 360 12 w (2xw) + 12 w (1xw) VAS 49->17, EQ-5D 58.3 --> Reporting to Austrian social
73.2, RMQ 8.8 -->5.8 insurance
Texas Workmans Comp comparison 2005 CCS Cost reduction USA 23 random selected (X control) 24 sessions in 12 weeks, DSC cost of care $4.100, similar Texas Workers Compensation
DSC average case $10.000 Commission Open Records
Report #2004563/2005
Mercedes company prevention 2014 CCS Reduction of sick days Spain 950 16 sessions, once a 78% reduction is sick days Athlon (Spinn-0ff of Monrdagon
week, two devices University) 2014
1
Randomised controlled trial
2
David Spine Concept
3
AOK included all levels of pain patients (1-4 Korff scale), if only 3-4 included savings would have been even higher
4
Consecutive Case Serier
David Health Solutions Ltd.
Address MANNERHEIMINTIE 113
00280 Helsinki
Finland
Phone +358   20  759  7300
Fax +358  20  759  7301
EMAIL info@david.fi
Web www.david.fi

24