Technology Assisted (guided) Physical therapy is the application of physical therapy combined with some form of technology to either elicit some effect or to allow for a response that would not be otherwise possible. The concept of technology assisted physical therapy is not “new”. Technology assistance ranges from the simple cold pack up to robotic exoskeletons. Technology assistance has been accelerating as society has advanced from the industrial to the “computer age”.
Cold Pack
Exoskeleton
The foundation of the practice of physical therapy has to do with biomechanics and restoration of these mechanics of the individual so he can interact in his environment in a pain free and as normal and independent fashion as possible. The Broad overview includes the following main categories:
1. Muscle Strength/ Control
2. Muscle length
3. Joint movement and mobility
4. Posture/alignment
These categories could be broken down further into subcategories or domains but is not necessary for this discussion.
It is well known starting from kinesiology up to the “day to day clinic trenches” that body mechanics include the patient’s center of mass (his predominate weight) as it moves over his Base of Support ( the surface area of the feet and space between the feet)
Screen shot of training activity on the assisted technology (Envision)
In most cases this aspect of physical and occupational therapies has not changed since the inception and progression of these disciplines. Yes, in some very high end clinics with massive endowments and budgets, very expensive technology exists for use only within the clinic setting.
$20 – 100+ thousand dollars and limited to clinic only assisted technology for gait training
Much of the domain of the practice of physical therapy and the vast area of occupational therapy can be distilled into the interplay of the biomechanics in the environment. This interplay as critical as it is, is chiefly a result of inference based on the “best guess”. The best guess is based on the observed response. In orthopedics and some medical types of patients, this interplay is generally not a relevant problem. The patient has an intact nervous system or more plainly, an accurate guidance system to help with the inference in providing treatment.
In neurology, the inference breaks down often to catastrophic proportions even with elite level therapists. Often, therapist and patient alike are keenly aware of the issue of lack of information. The patient’s nervous system has been damaged and altered. The clinician is manipulating the patient to drive a desired physical and functional outcome. Conveying it and facilitating the proper responses are markedly impeded by the damage. Therefore, even if the elite therapist is able to achieve a desired response, the response is nearly always fleeting. Why? Because the repetition, frequency, and duration to achieve the desired response as a primary motor and functional outcome is grossly inadequate to achieve it. Three hours per week for years is arguably “maintenance”. It at least prevents decline and further erosion of function.
Gait training without technology assistance(above).
In this case of post stroke training, it requires two people to gait train. The effort is maximal and can only safely occur in clinic. The mechanics are a best guess. When the gait pattern is assessed this is the image.
Altered Abnormal signal(above)
versus
Normal Universal Signal(below)
Ideally, a clinician and patient as well as caregivers need the proper information or feedback which is available all the time to rebuild the neurological pathways which allow for return of the physical and functional skills the patient lost(see normal signal). Unfortunately to achieve this a patient would need a caregiver and clinician for many more hours and/or the expensive equipment at a cost which is not possible for the vast majority of people and not practical in terms of societal resources. Necessity and technology though has solved the conundrum.
Image of biomechancial problems(above) - this informs the clinician to build a custom feedback program for the patient to use to recover.
Technology has advanced to allow for the acquisition of the needed information by the patient, clinician, and caregivers at a much reduced cost. The system is portable and available 24/7. The caregivers can be trained readily to work with the patient to practice accurate exercise – activity based upon normal mechanics. This allows the chance of recovery over maintaining. This feedback allows the perception of a patient’s balance field, reaction to posture and very specific muscle activity. The patient, caregivers and clinician now can see, hear, and feel (via vibration) critical body actions and reactions and act upon them. The patient and caregivers can learn the more ideal performance and practice these exercises and activities (walking, balance, leg, and postural control ) at home and with the therapist. This technology assisted guidance opens the possibility of continued restoration, not just maintenance. The quality and quantity of intervention increases by many factors.
Static view walking training
Anti-pusher training - Exercise
Dynamic scrolling training
This technology was developed to address the problem of compliance, relevance and understanding of therapeutic activity. Compliance is particularly difficult for the neurological patient. The scheduling function and prompting assist the patient with this critical aspect of rehabilitation. The patient, caregiver or clinician can now know the level of compliance with a self-directed program.
The relevance of an activity whether neurological, orthopedic, or general medical can be challenging. If the patient does not understand the relevance of the activity, compliance may be very low and the outcome poor. Standing balance for example, is a very tedious and fearful activity and often is poorly addressed. The feedback system allows the patient to see the balance field and to provide relevant and rich instant feedback during training. This improves compliance and allows for understanding by the patient, caregiver, and therapist.
Patient observes his performance of his balance training in real time to ensure he re-learns normal biomechanical technique. PT giving instruction to patient. (Above).
The feedback does not do anything to the patient. The feedback is critical information that is now available for the patient, clinician, and caregivers to use to recover. It merely allows the users to perceive the mechanics and act/react upon them. The technology then is in one regard another tool to assist with rehabilitation. What makes it truly unique is the potential power it has to change (in a novel way), how rehabilitation is delivered and achieved.
Envision is portable, inexpensive and allows for practice of normal skills every day. Combine the use of this information with the guidance of a professional and the traditional – conventional often unsatisfactory outcomes could soon be a bygone era. An era I will not miss.
Dr Michael J. Malawey, PT