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The Future is Now

New technology may revolutionize the way PTs practice in the 21st Century. 

By Sheri Waldrop  

• A physical therapist dictates clinical notes into his computer, which processes the information using sophisticated clinical and voice recognition software. The computer transcribes the notes and sends a copy to the third-party insurer with an invoice for billing purposes.           
• Physical therapist students gather around an ICU patient on a ventilator, practicing interventions. The O₂ saturation drops, and they closely monitor vital signs. As they perform range-of-motion exercises to a lower extremity, the patient's heart rate rises. They lose the signal from the limb lead. The "patient" is a computerized robot, and the students are learning in a simulation lab.           
• A patient recovering from stroke enters a virtual reality world and flies an airplane through a storm. Another patient in a second virtual world tries snowboarding. A third, with a balance problem, walks through a computer-generated grocery store.

Clinical documentation software and systems offer a wide range of technology solutions. The growth in usage of the software is partially due to the large number of available and developing technology options. It's also driven by the number and types of tasks performed by the system. 

Core documentation software is likely to include such items as procedure charting, evaluation reporting, and chart notes. However, complete documentation suites may also incorporate such functions as: 

• Patient registration           
• Patient scheduling           
• Therapist scheduling           
• Resource scheduling           
• CPT code selection           
• Billing unit calculation           
• Management reporting

Other documentation systems run not only on desktop computers but also on touch-screen computers, "tablet" or "slate" computers, and PDAs (personal digital assistants) such as Palm, Handspring, or Sony. With touch-screen computers, mouse-based "point and click" operations are replaced by the PT entering his or her data by touching the computer screen. PDAs pose a challenge because they are too small to have conventional keyboards. Generic PDAs typically have a tiny touch-screen keyboard and handwriting recognition capabilities. But some system designers have developed or adapted other methods of data input. For example, several offer customized touch screens. Others incorporate a bar code scanner so that the PT can scan necessary items of information. Often, the documentation software then takes data entered with touch screens or bar codes and uses a template--similar to a form letter--to "write" drafts of reports that the PT then reviews and edits. 

A portable system, whether it's a laptop PC or a PDA, allows a PT to enter information while with the patient. Another recent innovation--wireless communication--allows the PT to both enter data and instantly retrieve the patient's record electronically. 

Also making its mark on practice management is voice recognition software. In some cases, general-purpose voice recognition software has been linked to electronic documentation systems. However, the particular requirements of health care have led to development of profession-specific programs, including some designed specifically for physical therapists. No voice recognition system is perfect, of course, although the accuracy rate can reach 95%-98%. They also can "learn" the voice of an individual user. Typically, a physical therapist dictates patient notes. The computer transcribes the tape. Then someone on the PT's staff reviews the dictated text while listening to the PT's audio notes. The edited transcript can be placed in the patient's electronic file. 

Another emerging option is the use of digital cameras to supplement written documentation. "It's already being used to document wound care, replacing a reliance on subjective measurements," notes Kathy Lewis, PT, MAPT, JD, associate professor in the graduate program in physical therapy at Wichita State University and president of the APTA Section on Health Policy and Administration's Technology Special Interest Group. Lewis explains: "A picture taken digitally easily can be inserted into electronic notes, and I've seen health care providers who were reimbursed quickly as a result. There are fewer of the 'can you send us more information' requests with photos." Another advantage of digital documentation is the objective nature of the information. "Research shows that what we think our eyes are seeing isn't always what's there. A digital camera does see and record accurately," Lewis says. 

Human Patient Simulators:
Computerized "Patients" 

Charlotte Chatto, PT, MS, NCS, an assistant professor in the Medical College of Georgia's Department of Physical Therapy, has a unique subject for her physical therapy students' critical care course component. They go to a lab where a realistic patient awaits. "He" is on a ventilator, has a Swann-Ganz catheter, and electrodes monitoring his heart rate. The patient is a highly sophisticated computerized mannequin known as the Human Patient Simulator (HPS), made by Medical Education Technologies Inc (METI), Sarasota, Florida. The HPS can be found in more than 250 hospitals, medical and nursing schools, community colleges, and military bases. 

"I've been using an HPS since 1997 to teach my students, and they enjoy it," says Chatto. She works closely with an engineer who programs the "patient" to respond to different scenarios, while Chatto instructs and gives students feedback. For example, one scenario involves having the leg EKG lead "fall off" if the leg is moved too far. 

Sinclair Community College in Dayton, Ohio, also uses an HPS. The case scenario used by the school is that of a 64 year old male with COPD. Students assess vital signs and identify and analyze lung sounds. The case includes past medical and social histories along with current medications to stimulate problem solving. Classes of PT and PTA students from nearby Andrews University in Dayton, Ohio, also have participated in the instruction. The school ultimately hopes to expand the HPS experience beyond that of its students. According to Colleen Whittington, PT, chairperson of the PTA program at Sinclair Community College, "The challenge is to expand the use of the HPS to benefit not only the PTA and PT students, but also the clinicians in the community through continuing education opportunities." (For more information on the Sinclair program, go to PT Magazine's Web site at www.apta.org/ptmagazine.) 

Jane Cox, PTA, manager of education and training at METI, also uses the HPS to set up a "virtual ICU" for students. She likes not only the realism of this computerized patient, but also its ability to mimic illnesses students might not see often in the clinical setting. "I can program in Guillain-Barr‚ syndrome, and they can see how a patient with this disease might respond," she says. She believes that using the HPS encourages critical thinking skills that students will employ throughout their careers. "The student assesses the 'patient,' and learns how to decide if 'he' is stable enough for physical therapy, or if he or she should modify the approach that day, just as a PT would do in the clinical setting," she explains. "It really helps to increase student confidence when working with critically ill patients." 

Robotic-Assisted Physical Therapy 

At Spaulding Rehab Hospital in Boston, stroke recovery patients may find that one element of their physical therapy session involves a robot that can deliver up to 1,000 movement exercises in a 45-minute session. 

Neville Hogan, PhD, a mechanical engineer in the Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, in Cambridge, Massachusetts, developed this application of robotics in 1994. His original goal was to design a method for safe interaction between humans and machines. He decided to apply it to a clinical setting and developed the robotic Manus (from MIT's Latin motto "mens et manus" meaning "mind and hand") to deliver the repetitive movements needed by patients recovering from stroke. 

"I view my robot as a tool that therapists can use to allow them to accomplish more," Hogan says. Indeed, the robot is programmed according to a PT's assessment of the needs of the patient. During a session, the patient sits in front of a screen displaying a video game. The goal is to connect dots using a hand cursor. The dots change color, indicating in which direction the patient should move the cursor--and the targeted limb. "A patient might have little or no movement," Hogan says. "Within a pre-set delay of a second or so, the patient must initiate movement. If not, the robot will initiate the movement and do it for the patient; it gently will pull the arm or hand through the expected movement." 

Richard Hughes, PT, NCS, works with Manus at Spaulding and is excited about the future of robotic-assisted therapy. "We're starting to use the robot for patients outside of the study; I took it into the clinic twice for patients who wanted to try it, and we got good results. It's been cleared by the FDA for clinic use. We're working on more sophisticated versions for the arm that will work the shoulder, hand, wrist, and fingers and will add vertical movement of the shoulder." 

Both Hughes and Hogan see another value of robotic therapy. Not only does the robot deliver repetitive movements, it also measures and delivers clinical data that are helping scientists better understand how healing occurs after a stroke. "Healing may not be linear, as was once thought," Neville states. "Healing may resemble the learning curve instead, with gains and plateaus, then more gains." 

Virtual Reality 

Virtual reality (VR) is a computer simulation of a real or imaginary world. At the University of Pittsburgh's Center for Rehab Services, Sue Whitney, PT, PhD, NCS, ATC, conducts research into the role of VR in helping patients with balance problems. She is looking at methods of helping patients with chronic balance difficulties due to vestibular problems from conditions such as ear infections and labyrinthitis. 

"The National Institutes of Health and National Institute on Deafness and other Communication Disorders (NIDCD) are funding our research into vestibular problems and space/motion problems in this population," she says. "We started out creating a virtual-reality 'cave' that I've turned into a 'virtual grocery store.'" 

Whitney explains, "These patients often have difficulty shopping, for instance, because they have difficulty processing a large amount of information." Whitney starts patients out with minimal data to process: "I 'blank out' most of the items in the store, so it's very simple," she states. "I then gradually add items and monitor their tolerance." Her research is finding that large amounts of sensory and motion input can trigger dizziness, so her goal is to build up tolerance to increasing amounts. 

Although Whitney's VR shopping program today is just a prototype, she says her research soon could have applications in physical therapy. "We're learning what people can tolerate," she states. "We'll be able to build a database for a population that up until now hasn't had much information, or many guidelines, for their treatment. I believe that we'll see headset versions in more general clinical practice within the next 5 years." 

At the University of Washington's Harborview Burn Center, a patient who once resisted range of motion (ROM) therapy across a burned limb now looks forward to his sessions and sometimes even asks when he is scheduled for physical therapy. The patient uses a VR program that allows him to become immersed in "SnowWorld," distracting him from the pain. 

Hunter Hoffman, PhD, is a cognitive psychologist and one of the developers of the program. "Virtual reality is a type of dissociative experience," explains Hoffman. "You're virtually taken to a place where your body isn't, and this fits into what we know about how pain is perceived: that it's a combination of the actual pain signal and the mind's perception of that signal." 

Kristie Bombaro, PT, has worked with the research team at Harborview for the past 2 years. She says the patients enjoy SnowWorld. Although the equipment is still being developed and is somewhat large and ungainly, Bombaro hopes to see it become smaller and easier to use in preparation for increased availability. 

A number of virtual reality products already are available commercially for physical therapists. For example, IREX of Port Jefferson, New York, offers 12 applications that address a wide range of functional movements. These applications place the patient in various environments where they engage in such activities as snowboarding, soccer, and volleyball. Patients stand in front of a green screen that is electronically replaced on a television monitor by the selected environment and background. The patient watches himself or herself on the screen and interacts with objects in a virtual environment. IREX guides the patient through a clinician-prescribed on-screen routine. 

Flying virtual planes with haptics
In New Jersey, Judith Deutsch, PT, PhD, an associate professor in the doctoral program for physical therapy at the University of Medicine and Dentistry of New Jersey, is conducting research on a special form of virtual reality known as haptics-defined as relating to the sense of touch. Although conventional VR uses headsets or video screens in an enclosed space to form an illusion, haptics has a different twist: the patient places his or her feet in a device that provides not only visual and auditory information, but also tactile stimulation. "It's called the 'Rutger's Ankle ' because it was developed in collaboration with Grigore Burdea, PhD, at Rutgers University," Deutsch says. She works with patients who are 10 months to 7 years post-stroke. For physical therapy sessions, the patients sit in a chair and watch a screen while moving their feet inside the special haptic device. 

"They fly a plane past targets and try to avoid them," Deutsch says. "If by chance they hit the object, not only is there noise on the screen, but they also feel a small jolt, as if it actually occurred. This increases the illusion of reality." Another feature of the haptic device is that variables can be changed to increase the challenge for patients using it. "You can add a storm, decrease visibility, and 'feel' the wind and other changes with the haptic device." 

Patient response is positive to this form of intervention, which exercises and strengthens the ankle and foot. "People like the funny things we can make the airplanes do," says Deutsch. "And patients are seeing gains in both strength and range of motion using the haptic device." 

Deutsch expects that the apparatus soon will be available for testing in a clinical setting. "We're still working on the utility of the system, such as having it output data that the physical therapist can use for documentation. "We have already successfully monitored patients remotely using telerehab," she says, indicating the possibility of using devices in home care or other distant settings. 

A Video Game to Help Patients Post-Stroke
Another innovative use of virtual reality can be found at the University of Medicine and Dentistry in New Jersey. Combining VR with a computerized video game, this VR application is helping patients with stroke perform a series of repetitive hand or ankle movements. Alma Merians, PT, PhD, a professor and chairperson of the Department of Development and Rehabilitative Sciences, has worked in collaboration with a team of researchers during the past 4 years to create an innovative method of delivering exercise to stroke patients. 

This process helps patients who have some ability to move their wrists, hands, or ankles to work the repetitions themselves. "It's difficult to do physical therapy one-on-one with the amount of movement practice that these clients need," says Merians. 

"The patients sit in front of a computer monitor, and play a video game that walks them through the movements that they need. It can be set to work on their range of motion, their flexination, their strength, and a variety of other factors," says Merians. 

This program, like others described above, also holds the potential of being used during telerehabilitation. "The physical therapist can monitor subjects in the lab from another room at a console that lets the PT see them, talk to them, monitor their progress, and obtain data on how they're doing," Merians says. 

And she says that patients enjoy this form of physical therapy: "They like socializing with each other, since there are several patients at a time using the game. And the game drives them to use their weaker hand. They get immediate feedback-such as a firecracker going off, or music-when they succeed." 

Merians foresees this intervention as a way to enhance the physical therapist's capabilities. She says that faculty members learned quickly how to use this device and saw its benefits for patients. "It also delivers multiple layers of data," Merians says. "We can look at the kinematics of movement and combine evidence-based practice measures with the hard data we're getting back. The computerized program allows the physical therapist to obtain hard data almost immediately on how effective the therapeutic program is, and to adjust it to the patient's needs." 

New Technology Is Here 

The use of technology in many forms is increasing in physical therapy. "Often therapists are afraid that technology is going to replace them," Lewis states. "That simply isn't true. It can increase our practice scope, and it is a tool. I hope that more PTs will take an interest in technology and how it can help us improve the care we provide." 

Deutsch identifies another reason why PTs should take an interest in technology: "Who else can develop the devices that we need? Instead of taking devices that others have developed, then adapting them for physical therapy, why not be the ones to help engineers develop new devices from the start?" She believes that mutual collaboration with engineers could pave the way for even more advances to benefit the profession.
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Sheri Waldrop is a freelance writer.

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