Feature Physical Therapy and the Internet of Things Connected technologies are making patient-generated data increasingly accessible to health care providers. How this "Internet of Things" will be leveraged by physical therapists remains to be seen. By Chris Hayhurst | September 2016 Just a few years ago, there still was some question about how the Internet might make its mark on physical therapy. Many physical therapists (PTs) were using "cloud-based" electronic medical record (EMR) systems to store practice data on external servers accessed via the web. Other PTs, of course, relied on the Internet in their day-to-day activities in what might be termed "conventional" ways: to communicate with colleagues; as a tool, through patient portals, for connecting with patients and clients; and as a near-limitless source of useful information. Looking at the flip side of the coin—how patients might use the Internet to send data to providers—there was much speculation around health-focused apps for smartphone users. In 2012, for example, the Pew Research Center reported that of the 45% of US adults who owned a smartphone, only 1 in 5 ever had downloaded an app designed to track or manage their health.1 There was some talk about the "Internet of Things" (IoT)—the growing network of often everyday objects that are connected to the Internet and can send and receive data. (See "What Is the 'Internet of Things'?" on page 16.) But up for debate was the extent to which the IoT might influence health care in general, and physical therapy specifically.2 That's not the case today. "Anybody who knows about the Internet is going to tell you," asserts Robert Latz, PT, DPT, "that the IoT already is changing health care and that it's going to have a huge impact on therapy." Latz, chief information officer of Trinity Rehabilitation Services in Kentucky, was 1 of a half-dozen physical therapists who participated in 2 presentations on wearable technologies—1 aspect of IoT—at APTA's 2016 Combined Sections Meeting earlier this year. "Exponential" Potential Latz notes that any PT who's made the switch to an EMR from a paper-based system "would recognize the paradigm shift just in that piece, which now offers the capability for data analytics." The IoT, he says, "is going to take that step exponentially forward." Wearable technologies in particular, says Steven Wilkinson, PT, PhD, offer "a lot of possibilities." Wilkinson, who also presented at CSM and whose doctorate is in biomedical informatics, envisions a day in the near future when data that PTs pull from such devices are used not only to make decisions about patient care, but also to improve home-exercise adherence and identify the people who most need care. "Right now, all we get is a report from our patient: 'Yes, I did what you told me to do.' It's difficult to verify that information," Wilkinson notes. To have a device that can track what the patient is doing and can tell a PT that the patient actually followed the program—"that, to me, changes everything." Similarly, when it comes to prevention, says Wilkinson—associate director of the physical therapy program at Rocky Mountain University of Health Professions in Provo, Utah—Internet-connected wearables that collect data on how people move "could alert us when their gait speed is too slow, so we know we need to help them before they have a fall." The benefits of that type of wearables are twofold, he explains: Older adults, for example, might experience fewer injuries as a result, while PTs might see an uptick in wellness-related visits. "We might end up working with a lot of patients we wouldn't otherwise have the opportunity to see," Wilkinson says. Cavan Canavan is the co-founder and CEO of FocusMotion, which created a software development kit (SDK) that allows developers to produce usable data from movements captured by wearables and body sensors. "In the next 5 to 10 years," he told PT in Motion, "physical therapy will find complements and assistance from the emerging wearable ecosystem. Future wearables will be small, affordable, open, durable devices that will help patients, insurers, and PTs alike. These devices will be used to track patients both in and out of the clinic, while providing real-time interventions that prevent fatigue and injuries." While the IoT overall includes whiz-bang devices such as Wi-Fi-enabled refrigerators,3 self-driving cars,4 and robotic vacuum cleaners, its health care applications tend to be less glamorous. Think insulin pumps and fetal monitors, or implanted defibrillators and gait monitors. (See "A Closer Look at Health Care IoT Devices" on page 18.) Technology experts estimate that in 2016 there are 6.4 billion "things" in the IoT worldwide, with 5.5 million new objects joining the list every day.5 One report projects that the market for the IoT in health care will reach $117 billion by 2020.6 The mobile-health "wearables" to which Wilkinson, Latz, and Canavan refer include not only the Fitbits and Nike+s of the world (Fitbit sold more than 21 million devices in 2015, nearly doubling its sales from the previous year7), but many other lightweight, powerful, and increasingly affordable technologies that PTs might leverage in their work with patients. Among the more promising: socks equipped with pressure sensors that can monitor walking, an Internet-connected version of the Moore Balance Brace, and virtual-reality headsets that use software featuring avatars that provide real-time coaching during exercise.8 "One of the fascinating things about wearable technologies is how readily available they are to the general population," says Beth Ennis, PT, EdD, an associate professor at Bellarmine University in Louisville, Kentucky. "It's not the $20,000 device that we're looking at. It's, 'How do we take what Joe is using and make it work for this person who has a physical disability?' Or, 'How can we otherwise use the device to improve patient mobility?'" Ennis, who also works as an assistive-technology consultant and owns a pediatric practice, All About Families, offers as an example a device called the Myo.9 "It's basically an armband," she says. "You put it on, and it connects via Bluetooth to whatever device you want to use," such as a computer or a video game. "You control it by opening and closing your fingers, or flexing your wrist, or using small movements of your arm." Currently, she says, children with motor disabilities who want to use a computer typically rely on voice-activated technology. "But a lot of kids with motor issues also have speech issues," Ennis notes, "so [voice recognition] software like Dragon doesn't always understand their commands correctly." The Myo was developed for individuals with average motor-control function, she says. "But why not," she asks, "make it work for kids with speech issues, as well, by attaching it to the muscles that they can control? Why couldn't they use it to do all the things they need to do every day, like turn the lights on and off, or open and close the garage door?" IoT Challenges Finding ways to turn the latest "connected" consumer products into practical devices that can be used in patient care is just 1 of many challenges associated with the IoT. For instance, says George Fulk, PT, PhD, associate professor and chair of the Physical Therapy Department at Clarkson University in New York, some PTs may be tempted to see activity monitors as a panacea. "I've used some of these devices with my patients," says Fulk, who in addition to teaching works with patient who have neurological disorders such as Parkinson disease and stroke. "You can't just say 'Here, take this Fitbit' and assume you're good to go." Rather, to put that wearable device to work, it has to be part of a broader picture. For example, Fulk says, how a patient might use it to increase his or her walking "depends on the individual. You have to use your clinical judgment and skills, and understand what the barriers are for that particular person." A Fitbit might provide its user with valuable information, and that data might be useful to the PT, but that's just the beginning. "It's a tool you can use, but it's just 1 of many," Fulk advises. Canavan predicts that the tool will become far more powerful. "Companies like Fitbit can use a simple algorithm to track steps. However, with a more advanced and powerful algorithm, the data can be analyzed to reveal specifically what a user is doing—translating, tracking, counting, and analyzing movements," he notes. "Once this is enabled, a PT will be able to track a user's recovery and know what was done, how many times it was done, and how well it matched what the user was instructed to do." Then it's up to the PT to advance the process. Latz puts it this way: "The data we can gather can take us a certain distance. But what we pick up between our hands-on work and our face-to-face communication is what we really need in order to carry us the rest of the way." Fulk says that in his research, he's always been interested in outcomes measures and in "how we know when our patients are improving, or what their status is at any given moment." Traditionally, he notes, such questions have been answered through performance-based measures conducted in the clinic (the Berg Balance Scale, for instance) or through patient self-reporting. "But all of those measures have limitations," Fulk notes. "The patient's gait speed might be one thing in the clinic, but how can we know if it's the same at home?" Measures taken in the clinic might reflect a patient's status under certain conditions but might not apply when that patient has to climb stairs or is walking around town. For that reason, Fulk says, IoT devices such as activity monitors "have real potential." "To know how many steps that patient is taking at home, or where the patient was when taking them, or how the patient's balance is over the course of a day—all that information is potentially more helpful than what you can learn by doing tests in the clinic," Fulk points out. The challenge for PTs, he says, will be combining that patient-generated data with traditional data that PTs gather in the clinic, and then using all of it to modify a treatment plan. Security and Privacy There are other potential challenges connected with IoT devices, from security concerns about a wearable's "hackability," to matters of privacy and what patients may not want to share, to the potential for connected technologies to overwhelm health care providers with more data than they can handle. Regarding information overload, Wilkinson sees promise in data analytics—using software to help sift the important data from the noise. "Back-end" companies, he says, citing Validic, offer simple ways to take data from a variety of devices—each of which may capture information in different formats—and bring it all into a single portal. "You'd see all of your patient's information in 1 place, making it much easier to actually use it." When it comes to privacy-related issues, Wilkinson again cites companies such as Validic, Fitbit, and a lesser-known—if no less promising—data-organizing app called Nudge. "Certainly any company that wants to be a player in this industry has taken steps to be HIPAA compliant," he says, although PTs must do their own due diligence to confirm such compliance. When patients sign up to use such a program as part of a treatment in a formal health care setting, he notes, "they have to agree to let their data flow" to their health care providers. Latz says privacy and security are both "real IoT concerns" that must be addressed across the health care professions. When people automatically sign the user agreements that come with most mobile fitness apps, they often unwittingly give the companies unfettered access to all of their data, he notes. That can include "their phone ID, their running route, the food they're eating, their sleep patterns—even where they are at any given moment." Likewise, he says, most Internet-connected devices theoretically are vulnerable to hackers, so there always is the potential that someone might try to access sensitive information for criminal purposes. "But, do I think that should stop you or your patients from using these technologies?" Latz asks. "Not necessarily." Read the fine print on those user agreements, he advises, and do a risk-benefit analysis before proceeding. He gives an example from his own family: "My mom wears a glucose monitor that tells her when she needs an insulin injection. Sure, there's a chance it could be hacked, but the benefits she gets from using it far outweigh the risks." Mary Rodgers, PT, PhD, a professor of physical therapy at the University of Maryland School of Medicine and an advisor to the National Institute for Biomedical Imaging and Bioengineering, agrees that privacy and security are both important IoT issues. "Those are areas of primary concern in any kind of technology use and development," she says. When it comes to wearables, "there are tradeoffs we have to make if we want them to be useful." That includes patients being comfortable sharing their information, including details about their activity outside of the clinic. "It's something," she notes, "that you really can't get around." Looking Ahead Whatever the uncertainties that come with the IoT, 1 thing is for sure: As the world of interconnected devices grows, its impact on health care will grow, too. Especially, Rodgers says, "as we figure out reimbursement." Currently, she notes, whether PTs can be reimbursed for activities such as remote patient monitoring depends on the state in which they practice. That presents the obvious issue of what needs to happen when a PT in one state provides telehealth services to a patient in another state. "What if those states each have different requirements?" Rodgers asks. "That's an area that has to be ironed out." When those questions are resolved, she predicts, more PTs will actively encourage their patients to strap on monitoring devices that can track their heart rate and their walking, and can record and report data on other health-related metrics that then can be used to make decisions in the clinic. She's heard some PTs express fears that the ever-expanding IoT might take away business—that, for instance, more patients will decide they'd rather work with their programs' online avatars than with real-life clinicians. But that's not what Rogers foresees. "I don't see these technologies as replacements at all. In fact, I think it's going to be the opposite. These technologies will enable PTs to reach more people—for instance, patients whose location is remote enough that it's hard for them to get to a clinic. These technologies will make home programs much more effective." Rodgers also sees potential for the IoT to make collaboration between providers much more efficient. "If a patient presents with something that isn't within your area of expertise, you could use a telehealth approach to get input from another professional," she notes. And finally, she says, patient evaluation and "progressing people as appropriate" always will be the PT's job—no matter how the evidence is obtained. "The need for direct physical therapy involvement will never go away." Beth Ennis is equally optimistic about the IoT. "Right now we spend so much time collecting information, storing information, moving it around, and accessing it later. I think wearables will simplify everything," she says. She foresees a day not too far off when PTs will conduct range-of-motion measurements "without even having to put a goniometer on a patient." Instead, she predicts, the only things they'll need will be the patient's phone, the right app for the job, and their clinical expertise. "We'll put our hands on them, and facilitate a movement pattern or guide a functional movement, or whatever else we need to do, but those other activities that merely take up our time will be out of the way," Ennis believes. "I see it as a way to streamline what we do and make that interaction time more focused and more skilled." Cavan Canavan describes nearly the identical scenario, with the benefits extending well beyond the patient interaction. "When a therapist walks the patient through the assessment, all of the data are recorded automatically to the preferred EMR or clinic platform. These assessments will be logged and tracked over time," he says, "following the patient through the entire physical therapy process. Some at-home assessments also may occur, with the patient performing them with a PT via teletherapy." Looking slightly further into the future, Canavan sees some fascinating new opportunities for PTs. For instance, PTs might have the data not just to rehabilitate a patient, but to help restore the patient's earlier movement. He explains, "Over enough time, and with enough usage, we'll be able to build personal movement profiles around how everyone moves. Using monitors as we age, we'd be able to save our unique movement dialects and body language profiles so that if we were to be injured, a PT or prosthetic provider would be able to reference this movement profile to 'rebuild' a person. It's one thing to replace a limb or joint. It's another thing entirely to return a person to feeling like him or herself." The way Latz sees it, the IoT now is part of health care, and for that reason it also will become a part of physical therapy. PTs who wish to further the profession should ride these new technologies as far as they can go, he says, keeping in mind that technology has many limitations and certainly isn't the answer to every patient's needs. "Is everything about [the IoT] good, or black and white? I don't think so," he says. "Just like with anything, we're going to run into challenges and differences in opinion, and some of those differences may be significant." Still, Latz observes, PTs as a rule seem to thrive on such challenges. "I have no doubt we'll be able to work our way through them," he says.What Is The 'Internet of Things'?Simply put, the "Internet of Things" includes all devices that connect to the Internet. More specifically, IoT devices use the Internet to communicate with people or machines.Here are some more-detailed descriptions:"This is the concept of basically connecting any device with an on and off switch to the Internet (and/or to each other). This includes everything from cellphones, coffee makers, washing machines, headphones, lamps, wearable devices and almost anything else you can think of. This also applies to components of machines, for example a jet engine of an airplane or the drill of an oil rig." Morgan J. A simple explanation of the "Internet of Things." Forbes. May 13, 2014. http://www.forbes.com/sites/jacobmorgan/2014/05/13/simple-explanation-internet-things-that-anyone-can-understand/#11f1b46a6828. Accessed June 30, 2016."The Internet of Things is about connecting Internet-enabled devices that relay information back to us, to cloud-based applications, and to each other (device to device). These 'smart' devices can be anything from mobile phones, fridges, washing machines to wearables, medical equipment, or jet engines. In the Internet of Things, objects use the web and unique identifiers such as RFID tags or processors in order to exist as part of the Internet. "But the Internet of Things is not as simple at it seems. The standard definition of the IoT fails to properly define which 'things' actually are IoT devices. 'A better approach is by recognizing an IoT device through the presence of 4 capabilities: connected, intelligent, interactive, and autonomous,' says Constellation Research VP and Analyst Andy Mulholland."Mercer C. What is the Internet of Things? Everything you need to know about IoT. Techworld. December 7, 2015. http://www.techworld.com/big-data/what-is-internet-of-things-3631109/. Accessed June 30, 2016.A Closer Look at Health Care IoT DevicesThis article briefly mentions a number of IoT health care devices. To illustrate the scope, here's information on a few items that either are available commercially or are being developed.Smart Sock Walking AppSensoria Inc has developed "smart socks" that connect to a Bluetooth-enabled electronic anklet. These socks, coupled with an app, monitor walking activity even when slow cadence, short stride length, or use of walking aids is required. A "virtual coach" can provide real-time audio and video feedback. The sensors measure plantar pressure and force. The connected anklet can wirelessly transmit the data to anything from a mobile device to a cloud-based HIPAA-compliant repository system for analytics and behavioral feedback.Jolt Concussion SensorThe Jolt Sensor is a small (10- x 36- x 18-millimeter) device, weighing 7 grams, that attaches to a helmet, headband, or anything else that can be worn on the head. When it detects a significant impact—something that might cause a concussion—it vibrates to alert the player. It also sends an alert to parents and coaches to remove the athlete from play for evaluation. The sensor remains in constant communication with the app, with a range of more than 200 yards. It uses Bluetooth to communicate and is compatible with both Apple and Android devices. The app automatically "checks in" after a few days to see if a concussion has been diagnosed, and it continues, with daily follow-up, to track symptoms.ExoskeletonsRobotic exoskeletons are ready-to-wear, battery-powered robots that are strapped over the user's clothing, enabling people to achieve mobility, strength, and/or endurance not otherwise possible. The Ekso GT was designed for use in clinical environments. It's FDA-approved for use with patients poststroke and with spinal cord injuries. Ekso recently reached an agreement with Vodafone to connect the exoskeleton to the Internet so that the exoskeletons can be monitored in real time—providing therapists with data on the progress of patient rehabilitation.Another exoskeleton is Indego by Parker Hannifin. It's available as Indego Personal, for users with spinal cord injuries, and Indego Therapy, intended for clinicians to offer overground gait therapy for patients with impaired mobility. It weighs 26 pounds and provides variable assist. An Indego app can be installed on a patient's or PT's mobile device to control operation, change settings in real time, and capture data without the need for tethered controls.