Instant Video Feedback

I have been compiling a massive list of technological ideas I have been wanting to discuss on here between graduating and job searching and would like to start posting 2-3 times a month.  In fact I did my 4th site inservice on all these ideas, but kept it more brief during the presentation and will certainly elaborate more on here.

I recently just accepted a job in Wyoming, where I completed my 2nd clinical site, and I am very excited as it is in the setting I want to practice.  I have also been reviewing my orthopedic notes like crazy so I feel more confident going in day 1 while I am waiting on my license to come in the mail.

Anyways, in this post I want to discuss the use of video feedback.  In an earlier post I talked about the use of Coache's Eye to analyze client's movement and having the ability to time certain parts of the recording, use tools to measure angles, and playback in slow motion or even in reverse.

In my last Rehab setting for clinicals, I had a very large man for a patient who had thoracic surgery, that consequently decreased proprioception in his knee, and due to his large abdominal region or use of a stand aid he could not see his knee and ankle move during transfers or bed mobility.  We tried a mirror but still his view was obstructed by the stand aid.

I resorted to finding the app WiFi Camera which displays your iPhone's camera to your iPad's display when the app is open on both devices.  It works through bluetooth or WiFi and connects seamlessly.  I was able record the patient's knees while he was in the stand aid to work on knee extension while another therapist held the iPad in his view.  Another example was providing visual feedback while he moved his ankles to make transfers more effective with less physical assist needed from a therapist.  This method seemed to work fantastic for him and aided very well in improving his motor learning.  (I have also used this app to look for objects I accidently drop behind the washing machine without having to move it)

Recently the 3rd Generation Apple TV received a software update that allows iPhone/Mac to communicate directly rather than through a WiFi router, which has drastically reduced latency, when Air Displaying your TV.  This could be another great option is to get a 30"+ TV and display the iPhone's camera to it so you can show your patient parts of their body that are hard to see, even with the use of mirror.  I can't attest to how well using Chrome Cast is to display an Android phone to a TV in terms of latency.

Amazon has an incredibly cheap tripod I recently purchased (works on many phones) which could be a good stand to provide instant visual feedback with the methods I have described.  It's also great to take pictures to analyze posture or record movement which I will discuss further in a future post.  Apple Watch has a nifty tool to show you your camera's view and has a 3 second countdown timer for that perfect photo opportunity (such as your clinics Christmas Card).

I have tried the use of video calling each device through either Google Hangout's or FaceTime but there's too much latency for instantaneous visual feedback.  I foresee using this method with other patient populations to give them different perspectives of them moving out of certain planes during exercise.

Goniometer

There are 2 goniometer apps I have been played around with that I feel I might use from time to time in the clinic or out and about.

1) Goniometer Pro

This app utilizes the accelerometers in the phone to measure angles and acts essentially as an inclinometer.  The downside to this is that some phones are long and do not have a nice small base you can put against a patient.  I have seen somewhere, but currently cannot find it, some sort of phone case that has a base like a bubble inclinometer.  I am curious if just simply creating a makeshift base to attach to your phone case would be effective and should not matter when you zero out the application to measure.  The phone can either be used to measure on its side or on its back to help get better measurements for certain joints.  It's also great for leveling pictures or making sure a surface is precisely parallel to the ground.

This application gives you an arc of motion when measuring and may be difficult to get the correct measurement if you cannot start at the appropriate beginning point for measuring a motion such as hip flexion (i.e. the patient can be in slight hip flexion/extension and give you more/less than what is considered normal values).

This article by Tousignant-Laflamme et al. (2013) looks at the reliability and criteriorn validity of an accelerometer application and the use of the iPhone's magnetometer to measure cervical ROM in healthy patients and compared it to the use of a CROM.  The accelerometer app was used to measure cervical flexion, extension, and lateral flexion whereas the magnetometer was used to measure rotation.  All positions were seated.
Results

• Moderate intra-rater reliability for each movement (ICC = 0.65-0.85)
• Poor inter-rater reliability (ICC < 0.60)
• Criterion Validity moderate (ICC > 0.50) to good (ICC > 0.65) for movements of flexion, extension, lateral flexion and right rotation but poor (ICC < 0.50) for left rotation.

I am curious to why this study chose to use the magnetometer.  I imagine they would have had better results if the measured the subjects cervical rotation in supine using the accelerometer as currently phones do not measure rotation well when the phone's z axis is in line with gravity (hence why the magnetometer was used).  I would love to be apart of a team to standardize test positions for the use of phones to collect objective data.  Even though there is poor inter-rater reliability, the good intra-rater reliability should be acceptable as long as you keep your measurements consistent and are the only one who sees your patient.

Another article by Ockendon et al. (2012) looked at measuring slight knee flexion in healthy subjects with the use of an accelerometer compared to a telescoping goniometer.
Results

• Telescoping goniometer
• Intraobserver reliability ±9.6° (r=0.927)
• Interobserver reliability ±8.4° (r=0.952)
• iPhone
• Intraobserver reliability ±4.6° (r=0.982)
• Interobserver reliability ±2.7° (r=0.994)
• Both Instruments Correlation r=0.947 and have a mean difference of -0.4° (SD 3.86°)

This study shows using the iPhone's accelerometer as a goniometer can be reliable for measuring subtle knee flexion in patients with certain conditions such as an ACL repair.

2) DrGoniometer

This app you use your camera to snap a picture of your client and align the points to get a measurement (forgive me if my land marks are not spot on as I did this very quickly to get a screenshot of its use).  One thing I enjoy about this app is it shows the line of gravity while you are talking the photo to get your camera straight up and down.

This article by Ferriero et al. (2011) examines the reliability of this particular app in elbow ROM in healthy patients in comparison to a universal goniometer.
Results

• Intra-rater correlation (ICC = 0.998, 95% CI 0.998-0.999)
• Interrator correlation (ICC = 0.998, 95% CI 0.996-0.999)
• Width of 95% Limits of Agreement (LoA) between app and universal goniometer: 10.26° (LoA = +4.51°, -5.75°)

In this study they considered 10° to be an acceptable interval (width) within 95% difference between measurements expected to lie (LoA = ±5°).  I am very curious to how standardization of using photography to measure will play out in the future to decrease error as this is a very fast method of getting objective data without having to have that "third hand" to position the patient and place the goniometer.

Coach's Eye I discussed earlier has an angle tool you can utilize to measure dynamic motions.  Here is another video I took of examples on how to use it.

Older post videos have not had such high resolution sorry about that, I will be uploading videos to youtube and linking to them from now on to improve the quality of videos.

Video Exercises & Collaboration

Some exercises are really simple for patients to understand and providing VHI printed instructions is sufficient.  However, I find more complex exercises very difficult for patients to retain after leaving the clinic as they show me incorrect demonstrations on the next visit.  Strategies I've used is asking how the patient wants the instructions written down so they can remember their way.

I've tinkered with the idea of just video recording what I would like them to do so they can refer to that visual feedback to help with learning.  Today, it is still hard to share video of patients as file sizes are large and cannot be emailed easily.  Although most patients have an email address, having them sign up for video sharing services can be a hassle in order for them to see videos.  Providing them with a flash drive of their exercises can be difficult as they can be easily lost or not work correctly with the patient's computer.  At our pro bono clinic at UND, my partner and I decided to utilize Dropbox in order to share videos of our client performing exercises.  We could easily record a video with a tablet or smartphone and upload it directly to Dropbox.  Sharing on Dropbox is a breeze and only people with the URL it provides have access to the video.  We also used goo.gl to shorten the URL to make it typing it in the patients home device much more simple.  The beautiful thing about Dropbox is videos play nicely within a browser without having to download any files and works nicely on most smart phone devices.

There are other services such as Google Drive and Box that are capable of easy cloud sharing, but I'm sure you have heard all the hacking that has been going on in the news recently.  Also these services have risks for not complying with HIPAA currently as discussed on this website.  I plan on further discussing drawbacks such as HIPAA and data theft in a future post.

Although these may not be ideally used in the clinic for patients, I have found these to be marvelous for collaborating with classmates and colleagues.  We can share files, modify them, and see previous versions of files which was super helpful especially for group presentations.  Plus if you have the service installed on your computer, anything you edit within the service folder changes automatically online for everyone.  Using Google Drive had other services too such as Google Hangouts.  We could all simultaneously video chat for free and share real time of our computer monitor screen.  The beautiful thing about Google services is it can all be done from a browser without having to download and install any software (although these do work best using Google Chrome).  FaceTime and Skype are other video chatting alternatives.

Other Exercise/HEP Services (I also plan on comparing these services more later on):

• You could simply record a patient with your phone/tablet camera and email it to them
• WebExercises
• Physiotec
• Perfect Fit
• HEP2go - HEP2go has been a very awesome service I have been using on my 3rd clinical set I will be discussing more in the future due to how versatile it is for being a free service.

All the videos you record can be referred back to in order to assess if patients have improved and they love to see that they have made improvements as well.

Orthopedic Testing Apps

The other day I had a friend ask myself and a classmate of mine to check out his shoulder.  He reported getting pushed into the boards during hockey and his shoulder was sore as a result of it.  When we arrived we observed him holding his shoulder close to his arm in a self splinting fashion and had him remove his shirt to examine it.  There were no asymmetries or visible separations but he had a very tender joint AC joint to palpation.  In Exam & Eval we have not been instructed on any AC joint tests so I got out my iPhone and used an orthopedic testing app called Core - Clinical Orthopedic Exam.  It instructed me on how to perform the cross over test and even provided video (all videos can be found on there youtube channel).  We ended up getting a positive test and we looked up instructions on how to make a sling for our friend since we did not have any handy at this website and instructed him as to ice periodically.  Since our friend is an engineer student he was curious about what we thought his injury was so I used Zygote Body to educate him on the AC joint.  A few days later he reported he was feeling better as well as confirming his injury with imaging that he did have a grade I AC joint sprain.

On another note there is an iPad app by 3D4Medical with plenty of orthopedic education animations and 3D models called Orthopedic Patient Education.  I have yet to try it but I will most likely get it when it goes on sale.

Aslo my classmates and I had a very brief moment in an NSC 2014 video at 0:52!

Some of My Favorite Apps

3D4Medical makes some really awesome apps for patient education or to use as a studying tool.  My favorite app created by them is Muscle System Pro III as it was incredibly helpful when I took anatomy to visualize structures 3-dimensionally and to see individual muscle movement.  I found the joint specific apps like Shoulder Pro III to be helpful in educating patients on rotator cuff repairs as viewing arthroscopic images is not really intuitive to patients.  There are multiple surgical and pathology videos for many of the joints in the body that 3D4Medical has.

Zygote 3D Anatomy Atlas & Dissection Lab is a fantastic anatomy app and even has a free website called www.zygotebody.com (the website is best used in Google Chrome).  This particular app is a little more challenging to use but is super versatile.  Structures can be made transparent or removed altogether and there is even a cross section mode you can put in any plane.  I find that helpful to see the course of nerves and vessels.  I also love to use this when educating patients in the clinic to get the exact view of the structure I want instead of relying on the posters/books available in clinic.

Using Coach's Eye to assess and educate patients is spectacular.  When I started doing gait analysis in school it was incredible to record someone ambulating and then slow down the motion in order to picture the gait cycle and the deviations from normal.  My clinical instructor used this app as a visual feedback tool to help patients learn correct motions by recording the patient doing the exercise incorrectly and then doing a side by side comparison of the correct movement.

The beautiful thing about these apps is that they can be displayed to a larger TV by using Apple TV for iPhone/iPad/Mac users or Chrome Cast for Android users so patients don't have to stare at a substantially smaller phone screen.