Category Archives: technology

Motion Analysis Software

In the clinic I use my iPad and HudlTechnique (basic is free) for showing a patient what I’m noticing in their movement or for me to slow it down so i can see better.  I thought I would pass along a new one I just found that is Windows-based.  I haven’t played with it yet, but it looks like it would be a great resource so I’m passing it along –  Kinovea is open-source.


Telehealth, tech, and the older adult

64946580_88fb60c7f4_qI received a tweet this morning – “Telerehab+fall predict platform= Game changing. Effective?” (I tried to embed it but it wasn’t working).  The American Telemedicine Association is having their meeting in Minneapolis this week, and it will include telehealth platforms for seniors.  Two quick thoughts about the idea before I get ready for work (I’d love your comments and thoughts in the comments or on Twitter).

First, I agree with the author of the article that cost will be a huge issue.  Those on a fixed income are not going to have much wiggle room, and those who are poorer and rely on SS definitely will not.  This will be an increasing concern with the Baby Boomers given the data out there on their savings (or lack of) for retirement.

Second, will THEY want to wear it/ use it?  There is a great section of dialog in Jurassic Park where the grandfather is defending all he has done to the scientists, that he spared no expense, and Ian (Jeff Goldblum’s character) says something to the effect of your scientists were so busy asking if they could they didn’t ask if they should.  In the same vein, are we so busy asking if we can do all this great tech we aren’t asking whether they want it? Yes, there are those who love tech and will embrace the idea, but are those the ones that are having the falls, experiencing incontinence, not eating well, etc?  It reminds me of the Fitbit – those who use it are often the ones who are already fit.  Will they view it as an invasion of their privacy, of one extra step closer to an ALF or a nursing home, despite assurances that the tech is “to keep them as independent as possible for as long as possible”?

I think the technology has the potential to be effective, and to be a game changer for many.  But I think that for many others the financial cost and the resistance against the tech intrusion will require continued personal monitoring and involvement by family and the home health community.


Photo credit: “Old and New” by Sparky

Components of Being “Better” – Diligence

8947350623_2bcbb0538b_qThanks to a recent blog post on PT Think Tank by Kyle Ridgeway, I became aware of Better: A Surgeon’s Notes on Performance by Atul Gawande, MD, MPH.  I checked it out from the library and read it in just a few days, but am going back and digesting it more.  While he is a surgeon writing about the practice of medicine, I believe there is much in here we can apply as physical therapists.

In the book he writes that the practice of medicine is more than diagnosis, technical skills, or empathy, but you also have to wrestle with “systems, resources, people and ourselves.”  Still, we “must advance… refine… improve.” How much does that describe PT?  We may do differential diagnosis, be masters at manual therapy, stroke recovery, etc, and really connect with our patients, but we work within a system.  Most of us are within a corporation or organization, but we are all within a larger system as we face rules, regulations, and reimbursement issues.  Next, we may have difficult families, or coworkers having bad days.  And finally there is us – our virtues and our vices, the things that warm our hearts or set us off.  Our professional life is so much more than the basics of Netter to the mastery of motor control or manual therapy.

Why should we care about being better?  “Betterment is a perpetual labor.  The world is chaotic, disorganized and vexing, and medicine is nowhere spared that reality.  To complicate matters, we in medicine are also only human ourselves.  We are distractible, weak, and given to our own concerns. Yet still, to live as a doctor is to live so that one’s life is bound up in others and in science and in the messy, complicated connection between the two.  It is to live a life of responsibility.  The question, then, is not whether one accepts the responsibility. Just by doing this work, one has.  The question is, having accepted the responsibility, how one does such work well.” Substitute the word “medicine” with “physical therapy” and it may need a few tweaks but overall I think it describes well why we should work at betterment.

He believes there are three core requirements in any endeavor that involves risks and responsibility – the first of these is diligence. He defines diligence as the “necessity of giving sufficient attention to detail to avoid error and prevail against obstacles” and believes it is “central to performance and fiendishly hard.” He then goes on to tell three stories to demonstrate this: hand washing, eradication of polio, and the story of decreasing combat mortality.

In the chapter on hand washing, several things jumped out at me.  It is the approach to others with the lack of performance or knowledge that matters.  Don’t ask “why don’t you wash your hands” but “why can’t you wash your hands” – you will get two different responses and answers.  Here is where he presents the idea of positive deviance that Kyle mentions in his blog post (“the idea of building on capabilities people already had than telling them how they had to change”) – have others identify the ideal, then have them visit the ideal to see exactly what they are doing.  They involved everyone in this – from food service staff to MD’s to patients, having them identify ways of solving the problem.  In the groups, even if it was the 30th time they had heard the suggestion the facilitators treated them like group #1 “because it was the first time those people had been heard, the first time they had a chance to innovate for themselves.”  What a great way to solve a system problem.  In this case it impacted infection rates (as PT’s, how are we at washing hands?), but can we use the idea of positive deviance to help others follow clinical guidelines, or patients be more adherent or participate more fully?

The story of the work on the eradication of polio is inspiring.  One quote stuck out – “if the eradication of polio is our monument, it is a monument to the perfection of performance – to showing what can be achieved by diligent attention to detail coupled with great ambition.”  As PT’s we won’t have that type of public health impact.  But what can we achieve in our profession or in the systems we work in if we have diligence and great ambition?

The last story for diligence is about how military surgeons have dramatically reduced mortality rates in the wars in Iraq and Afghanistan.  By being observant and keeping statistics, 90% of those wounded in battle are saved.  Simple things like requiring the wearing of Kevlar vests and changing where and how the wounded are treated have made a great impact.  “Military doctors continued to transform their strategies for the treatment of war casualties.  They did so through  a commitment to making a science of performance, rather than waiting for new discoveries.” (the science of performance – “to investigate and improve how well they use the knowledge and technologies they already have on hand.”  Do you track data on your patients, taking into account who treated them, comorbidities, activities performed, codes and units used during the plan of care, etc?  Do you use everything at your disposal in your clinic, maybe being creative and changing how you do something to improve your patient outcomes?

Next up: Components of being “Better” – “Do Right”

Photo: NE130044.  LicenseAttributionNoncommercialShare Alike Some rights reserved by FlarePhot (When I searched for “diligence” on Creative Commons, this picture came up.  It reminded me that if you join the Naval Nuclear Power Program and don’t have a concept of diligence, they will drill it into you)

More technology for balance and older adults

Is gaming technology for balance impairments passe?  The Wii and video game rehab seems to have waned in popularity in rehab magazines and popular culture (our OT’s have one, not sure how much it is used).  I came across this study looking at step time using a similar idea to Dance Dance Revolution, and the Kinect system has a similar game (just not for the geriatric population).  I have used the Kinect for a research project in my residency – it is currently gathering dust in our family room. I would consider trying it out again, but one conclusion I had is that a therapist can get more reps of a balance challenging activity in using traditional methods compared to the video games I used.  Just because it is tech and new doesn’t mean it is relatively effective, although this study was something patients could do at home.  Another study would be how to motivate them for carryover instead of it becoming another piece of equipment gathering dust.

An exercise app for older adults

I love how the use of technology in the clinic and in everyday life can help patients.  I came across Motivating and assisting physical exercise in independently living older adults: a pilot study on Pubmed (no direct access to the study at the moment), but I found it interesting so I went to the app store and downloaded it (Active Lifestyle by Torino University).  Unfortunately it crashed on me twice when I tried it out tonight, but the concept and adherence rates intrigued me and I hope it continues to develop.  I’ll try it again at some future point when they fix the bug (maybe it is an IOS 7 issue?).  I’ll be curious to see a larger sample size in a future study, especially including a larger group of those who are or have a history of being more sedentary.


iPad use in the clinic, and Rehab Optima review

Smart phones and tablets seem to be becoming more common in the clinic.  Health care apps are continually being produced as well, mainly for reference or patient education, but also for documentation.  I have had an iPad for approximately 2 years, and regularly use it at work (I also recently graduated to a smart phone, but it is company policy to not allow the use of phones on the units).  I like the screen size of the iPad as it is easier to carry and less intrusive than a laptop when working with a patient as well as the touch screen feature (but that causes problems initially when I switch back to a laptop because I try to swipe the screen).  The UC Irvine Medical School has a great “mobile technology etiquette checklist” that has some great points about how to use such a device in a professional and considerate manner including general recommendations as well as for documentation or education.
As a part of the blog, I plan to occasionally review apps that I use.  As a disclaimer, I don’t get paid or compensated in any way, and these are my reflections on them.
We use Rehab Optima for documentation, which we call ROX.  Several of us use iPads and the touch and swipe feature is nice (I use a keyboard to make typing easier).  The first thing to note is that there are connectivity issues to the ROX server at times that the laptops don’t have for some reason.  Once you get your patient list for the day (I have to do it twice – once for TCU/SNF and once for outpatients), you are pretty much ready to go about your day.
Unfortunately, they do not have the capability to document evaluations on the iPad yet, so it requires planning in taking a laptop with you when your evaluation is scheduled (I have some issues with the evaluation ability for outpatients, but this is about the app, not ROX as a whole).  For documenting treatments, the iPad works great.   I like that I can swipe through the different codes and add generic statements, then type in specifics either right then or later.  It won’t let you validate without any billing, but it doesn’t check to make sure that the codes you bill and the codes you document on both occur (so you can accidentally bill for 97112 but document in 97116 for instance).   You can also enter your hours worked, but it doesn’t seem to allow you to account for your time like the browser/ laptop version does (drive time, documentation or project time, etc).
Overall, ROX works well on the iPad for daily documentation.  Navigation is easy, but a keyboard makes documentation quicker.  It will be nice when they work out the connectivity issues and add the capability to document evaluations on it.  I haven’t used an EMR since my internships so I don’t have anything to compare it to, but this app helps me get part of my job done a little bit easier.

Tools for therapists

I’ve made it almost all the way through my first semester in the residency.  While it is challenging, I am learning a lot and would highly recommend residencies to any new grad or new professional.  Over the past few years I’ve upgraded and purchased new equipment for personal use in the clinic, so I thought I would share what tools (physical items and technology) I’ve found helpful.

Physical Tools

  1. BP cuff: In PT school we were issued a generic (cheap, but not super-cheap) supply kit which included a BP cuff and a stethoscope.  Considering I take BP’s regularly throughout my day, and that I’d be learning more about cardio-pulmonary issues in the residency I thought I should upgrade my equipment before I got here.  I found out about a cool BP cuff that has the gauge and the bulb together (so one tube instead of two) from the medical director I used to work with, which reduces how much you are having to juggle – well worth the money, and it doesn’t cost that much.
  2. Stethoscope:  I searched for guidance on picking out a new stethoscope and didn’t found much online.  One tube or two?  What is the difference in the different materials for the head?  Bell and diaphragm, or just the diaphragm? What makes one over $200 vs. a $20?  I steered away from the 2-tube version (the tubes can rub, although there is debate if the overall quality is better).  I ended up going with the Littmann Master Classic II, and I was amazed at the improved quality over the cheap one from school.  Mine has a tunable diaphragm (light pressure = bell for higher pitches; apply more pressure it becomes the standard diaphragm for lower pitches).  Why this one, vs. a cheap one?  Some may say “do you really need one like that for PT?  Are you diagnosing a heart condition or lung disease?  Don’t you just take blood pressure?”  Yes, I do take BP’s, but I also listen to the lungs, not just of my SNF/TCU patients, but also of my outpatients.  Why?  Because we have the time, we can catch things before it becomes a problem, and we can document it and how it can impact outcomes.
  3. Pulse oximeter:  I haven’t gotten one yet, but they are cheap now.  A quick and easy way to get HR and O2 sats before, during, and after exercise.

Tech Tools

  1. “The cloud”:  Have you ever wished you had access to articles that are on your home computer (or vice-a-versa)?  I no longer have to carry a USB key, or email the article to my work email when I get home.  Evernote is a great tool to keep articles, tools, references, etc within easy reach wherever you are.  You can create folders to organize by topic.
  2. A dashboard: Have you ever been frustrated by staying on top of current evidence, or keep up with the blogs you read?  I was using Google Reader for subscribing to blogs, but my mentor introduced me to NetVibes.  On my dashboard, I have a page for blogs, a page for journals, and a page for news.  I also have some PubMed searches I keep track of (with my interests in exercise adherence and hip fractures).  Once you have it set up, it is just a matter of checking it once a week or so to see what is new.
  3. iPadWhat better way to work on coordination than through a game with the iPad?  Okay, that was a joke, although I’m sure I just gave someone a bad idea.  Seriously though, it is not only a great tool for reference (I have a basic phone that just makes phone calls), but also for patient education.  Some good/ great apps that I have: MB Anatomy, DrawMD Cardiology and Orthopedics, Bamboo Paper (for drawing), Medscape (GREAT for conditions, meds, and med interactions), 3D Brain, Evernote (the cloud!), CORE Clinical Orthopaedic Exam (haven’t purchased OMT’s Spine, UE, and LE apps, also by ClinicallyRelevant), Hootsuite for Twitter, and a BMI calculator.  I’m trying to convince the powers-that-be that allowing me to have wireless access would be a benefit to the clinic.  We’ll see how that goes.