U.S. patent application number 10/854400 was filed with the patent office on 2004-12-09 for system for medical protocol management.
This patent application is currently assigned to IZEX Technology, Inc.. Invention is credited to Backes, Steven, Hanson, Timothy J. B., Manninen, Gary, Oyen, Duane, Stark, John G., Tracey, Timothy.
Application Number | 20040249675 10/854400 |
Document ID | / |
Family ID | 23648962 |
Filed Date | 2004-12-09 |
United States Patent
Application |
20040249675 |
Kind Code |
A1 |
Stark, John G. ; et
al. |
December 9, 2004 |
System for medical protocol management
Abstract
A system for treating orthopedic injuries by presenting a set of
treatment protocols; approving a treatment protocol from among the
presented set of treatment protocols; capturing information
identifying the approved treatment protocol from among the set of
presented protocols; and generating information from the captured
information into a form compatible with a handheld computer adapted
for connection to an orthopedic sensor system. The generated
information includes parameters of the identified approved
treatment protocol. The process may also include the steps of
basing the presented set of treatment protocols upon a database of
historic patients, orthopedic injuries, treatment protocols and
outcomes, and retaining information about the current patient, the
patient's injury, treatment protocol and outcome.
Inventors: |
Stark, John G.; (Minnetonka,
MN) ; Oyen, Duane; (Maple Grove, MN) ; Hanson,
Timothy J. B.; (Plymouth, MN) ; Tracey, Timothy;
(Wayzata, MN) ; Backes, Steven; (Minneapolis,
MN) ; Manninen, Gary; (Maple Grove, MN) |
Correspondence
Address: |
Patterson, Thuente, Skaar & Christensen, P.A.
4800 IDS Center
80 South 8th Street
Minneapolis
MN
55402-2100
US
|
Assignee: |
IZEX Technology, Inc.
|
Family ID: |
23648962 |
Appl. No.: |
10/854400 |
Filed: |
May 26, 2004 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
10854400 |
May 26, 2004 |
|
|
|
09416192 |
Oct 11, 1999 |
|
|
|
Current U.S.
Class: |
705/2 |
Current CPC
Class: |
G16H 15/00 20180101;
A61H 2201/5007 20130101; G16H 50/20 20180101; A61H 2201/5015
20130101; G16H 50/70 20180101; G16H 70/20 20180101; Y10S 482/90
20130101; A61H 2201/5012 20130101; A61H 1/00 20130101; G16H 10/60
20180101; G16H 20/00 20180101 |
Class at
Publication: |
705/002 |
International
Class: |
G06F 017/60 |
Claims
What is claimed is:
1. A method of treating a patient using an instrumented treatment
system based on a treatment protocol, the method comprising:
automatically evaluating and updating the patient's treatment
protocol from a remote central computer.
2. The method of claim 1 wherein the instrumented treatment system
comprises a treatment system computer and a communication system
allowing communication between the treatment system computer and
the central computer.
3. The method of claim 2 wherein the treatment system computer is
an ambulatory computer.
4. The method of claim 2 wherein the communication system is
selected from the group consisting of wireless communication, hard
wired communication, phone modem communication, private network
communication, public network communication, and Internet
communications.
5. The method of claim 1 further comprising monitoring a patient's
activity relative to a selected treatment protocol and storing
monitored data in the treatment system computer.
6. The method of claim 5 further comprising processing the stored
monitoring data and communicating the stored monitoring data to the
central computer.
7. The method of claim 5 wherein the monitoring of the patient's
activity is performed with an instrumented orthosis.
8. The method of claim 7 wherein the instrumented orthosis fits
around two flexibly connected body portions of the patient.
9. The method of claim 5 wherein the monitoring of the patient's
activities is performed with a strain gauge.
10. The method of claim 6 wherein the processing of the stored
monitoring data is performed at the central computer to produce
processed patient data.
11. The method of claim 10 further comprising updating a historic
database with the processed patient data.
12. The method of claim 11 further comprising comparing the
processed patient data with historic data stored in the historic
database using an analysis interaction algorithm.
13. The method of claim 12 wherein the evaluating and updating of
the patient's treatment protocol comprises analysis of the
processed patient data and the historic data stored within the
historic database.
14. The method of claim 11 wherein the historic database comprises
historic data on previous patients.
15. A method of treating a patient using an instrumented treatment
system operated based on a treatment protocol, the method
comprising: generating information for a specific treatment
protocol into a form compatible with an ambulatory computer wherein
the specific treatment protocol was selected from a set of
treatment protocols.
16. The method of claim 15 further comprising loading the generated
information into the ambulatory computer.
17. The method of claim 15 further comprising monitoring patient
activity relative to an approved treatment protocol and storing
data resulting from the monitoring in the ambulatory computer.
18. The method of claim 17 further comprising communicating data
obtained from the monitoring to a central computer.
19. The method of claim 18 further comprising evaluating compliance
from the data relative to the approved treatment protocol.
20. The method of claim 18 wherein the communicating to the central
computer is performed by wireless communication.
21. The method of claim 18 wherein the communicating to the central
computer is performed by Internet communications.
22. The method of claim 16 further comprising processing the
monitoring data at the central processor to produce processed
data.
23. The method of claim 22 further comprising updating a patient's
treatment protocol based upon analysis of the processed data.
24. The method of claim 23 wherein the updating of the patient's
treatment protocol is performed automatically.
25. The method of claim 24 wherein updating a patient's treatment
protocol comprises selecting a treatment protocol from a set of
treatment protocols.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] The current application is a continuation of U.S. patent
application Ser. No. 09/416,192, filed on Oct. 11, 1999, entitled
"SYSTEM FOR ORTHOPEDIC TREATMENT," as renamed "SYSTEM FOR MEDICAL
PROTOCOL MANAGEMENT," which is hereby incorporated by reference
herein.
[0002] The present invention relates to orthopedic treatment and,
in particular, the present invention relates to systems for
orthopedic treatment in which patient treatment protocols are
reduced to digitalized representations for use in conjunction with
portable computerized or digitalized orthopedic treatment devices.
The present invention also relates to selection or creation of an
appropriate patient treatment protocol, as well as intervention and
control to modify the patient treatment protocol. In particular,
this aspect of the present invention also relates to modification
of a patient treatment protocol when the modification is contingent
upon certain events related to feed-back data recorded by a
computerized orthopedic treatment device.
[0003] Orthopedic treatment historically involved a treatment
professional, normally a physician, examining and diagnosing an
orthopedic injury in a patient, prescribing a treatment protocol of
activities or exercises for the patient to follow in order to
facilitate healing, and subsequent re-examination to assess patient
progress. Additionally, the patient was traditionally guided and
assisted in following the prescribed treatment protocol by other
treatment professionals, such as physical therapists, who could
inform and advise the attending physician concerning patient
compliance with the protocol and communicate and assist with the
patient to provide desired activity details and elicit patient
response. The traditional treatment path often included either
hospitalization or patient visits at a physical therapy
facility.
[0004] In modern times, financial pressure upon the medical arts
and the surrounding medical industry has increased the number of
patients each physician must treat and reduced the rate of
hospitalization. There is a tendency to employ physical therapy
facilities, as well as reduce the direct supervision of the patient
activities by the physical therapist. Computerized devices have
been developed that at least augment the physical therapist
contact, and monitor patient activities under a treatment protocol.
One particularly innovative device system, the IZEX
sensor-instrumented orthosis and associated hand-held Smart
IDEA.TM. computer/communicator, not only replaces some of the
physical therapist's function of (1) advising and instructing the
patient and (2) advising the attending physician of patient outcome
and compliance, but also allow an improved (quantitative) measuring
and monitoring of patient rehabilitation activities and exercise
parameters, such as effort exerted in rehabilitation exercises or
stress applied to the orthopedic injury. This improved monitoring
enables exploitation of a long observed and literature-documented
phenomenon of improved recovery in response to appropriately
applied exercises to orthopedic injuries. The topic of accelerated
and improved recovery through the use of controlled bio-feedback
based rehabilitation has been reviewed extensively by one of the
present inventors in patents U.S. Pat. No. 5,052,375; U.S. Pat. No.
5,368,546; U.S. Pat. No. 5,484,389; U.S. Pat. No. 5,823,975; and
U.S. Pat. No. 5,929,782 and the entire disclosures of these patents
are incorporated herein by reference.
[0005] In spite of advances such as the IZEX SmartIDEA.TM., the
ultimate goal of efficiently achieving an optimal yet accelerated
recovery outcome has remained elusive. This is, at least in part,
because the utilization of the IZEX.TM. orthosis brace system and
SmartIDEA.TM. computer/communicator previously have continued to
rely upon a treatment professional performing an examination,
generating a diagnosis and subsequently providing a treatment
protocol for the injured patient. The SmartIDEA.TM. hand-held
computer was then programmed based upon the protocol. The treatment
professional may not readily know nor have available information
concerning the optimal treatment protocol for an accurately
diagnosed injury. It would be a significant advance in orthopedic
treatment if a physician or other treatment professional could be
rapidly advised concerning optimal treatment information based upon
up-to-date experiential outcomes of similar treated injuries. It
would also be a significant advance if the physician or treatment
professional could leverage their own expertise and their
colleagues' most recent knowledge to appropriately modify and adapt
previously successful protocols for a new patient. It would also be
a significant advance if the protocol could be installed in a
handheld computer (monitoring device/computer/communicator) device
with ease and efficiency. Additionally, it would be a significant
advance to allow appropriate progress-based and time-based
modification of the patient's protocol. Modification may be best
thought of as intervention. Intervention, most particularly
real-time modification, into rehabilitation exercise protocols by a
patient or in response to a patient request or by a treatment
professional or by an automated computer algorithm, where such
modification is limited by reasonable constraints, would also offer
further progress toward the goal of efficiently achieving an
optimal, yet accelerated, orthopedic recovery outcome. A system
which provides real-time intervention can also allow delayed
intervention. Intervention can be initiated by the patient, by the
treatment professional, or by the automated computer system. The
following system provides such advances to the orthopedic arts.
BRIEF DESCRIPTION OF THE FIGURES
[0006] FIG. 1 is a schematic diagram of the relationship between
patient and treating professional, as process participants, and
schematically indicating equipment of a prior art treatment
process;
[0007] FIG. 2 is a schematic diagram of the relationship between
patient and treating professional, as process participants, and
schematically indicating equipment used in another prior art
treatment process;
[0008] FIG. 3 is a schematic diagram of the relationship between
patient and treating professional, as process participants, and
schematically indicating equipment used in still another prior art
treatment process;
[0009] FIG. 4 is a schematic diagram of the relationship between
multiple patients and a treating professional, as process
participants, and schematically indicating equipment and
relationships in a treatment system according to the present
invention;
[0010] FIG. 5 is a schematic diagram of the relationship between
multiple patients and multiple treating professionals, as process
participants, and schematically indicating equipment and
relationships in a treatment system according to another embodiment
of the present invention;
[0011] FIG. 6 is a schematic diagram of the relationship between
patient and treating professional, as process participants, and
schematically indicating equipment and participants as used in a
treatment system according to yet another embodiment of the present
invention;
[0012] FIG. 7 is a schematic diagram of the relationship between
multiple patients and multiple treating professionals, as process
participants, and schematically indicating equipment and
participants in a treatment system according to still another
embodiment of the present invention;
[0013] FIG. 8 is a schematic diagram of another embodiment of the
present invention involving data storage and use of data from an
historic database in an embodiment of the present invention;
[0014] FIG. 9 is a schematic of information processing systems
within the present invention in order to effect treatment of an
orthopedic injury, through operations such as data generation,
collection, signaling, analysis, modification, review and
reporting;
[0015] FIG. 10 is a more detailed view of portions of FIG. 9
concerning creating an exercise protocol;
[0016] FIG. 11 is a representative compliance report for a
hypothetical patient;
[0017] FIG. 12 is a set of representative patient recovery reports
for a hypothetical patient, with FIG. 12A presenting range of
motion plotted against exercise session number, FIG. 12B presenting
strength plotted against exercise session number, FIG. 12C
presenting fine motor recovery plotted against exercise session
number, and FIG. 12D presenting neuromotor and muscular hits
plotted against exercise session number;
[0018] FIG. 13 is a representive recovery goal analysis for a
hypothetical patient;
[0019] FIG. 14 is a representative graphical presentation report
for a hypothetical patient being treated with a protocol modified
three times to be more difficult and showing patient progress after
each modification or intervention; and
[0020] FIG. 15 is a representive set of multiple challenge levels
A, B, and C for protocol modification.
SUMMARY OF THE INVENTION
[0021] The present invention is a system for treating an orthopedic
injury. In a first embodiment, the system includes a definition of
a protocol for biological manipulation to be performed upon a
patient with an orthopedic injury to be treated according to a
coordinated, monitored recovery scheme; a monitoring device, which
might be a personal orthopedic restraining device appropriately
equipped with a transducer, portable and attachable to a patient
with an orthopedic injury to be treated, for monitoring patient
activity relative to the protocol or alternatively, a
non-restraining monitoring device such as a Therabelt; a portable
or more preferably a handheld computer or a palmtop computer; a
central processor or computer, segregated from the portable
computer, the central computer including a file server, a database,
memory, processing, display and communications and including means
to generate the protocol; a communication system allowing
communication between a pair of distinct computers, most
particularly the portable and the central computer; and an analysis
interaction algorithm, preferably available to or at the central
computer.
[0022] The system of the invention may also be understood, in one
embodiment, in terms of a process or in another embodiment, in
terms of an apparatus. Considered as a process, the invention
includes the steps of a.) biologically manipulating a patient for
coordinated monitored recovery (such monitoring may be either
biophysically or computer monitored); b.) providing a monitoring
means, such as a transducer equipped personal orthopedic
restraining device (PORD), or alternatively, a transduce equipped
belts, such as a Theraband type device to monitor patient
performance of protocol exercises; c.) providing a portable
computer, preferably a handheld computer, where the handheld
computer includes capabilities for memory, processing, display,
recording monitored information from the monitoring means (such as
a PORD), and data transmission and reception; d.) providing a
central processor (segregated from the portable computer), the
central computer including a file server, a database, memory,
processing, display and communications; e.) communicating between
the provided pair of distinct computers; and f.) analyzing
monitored data by an analysis interaction algorithm (preferably by
the central computer).
[0023] Considered as a device, the invention includes a.) means for
biologically manipulating a patient for coordinated monitored
recovery (such monitoring may be either biophysically or computer
monitored); b.) a monitoring means, such as a transducer equipped
personal orthopedic restraining device (PORD), or alternatively, a
transducer equipped belt, such as a Theraband type device to
monitor patient performance of protocol exercises; c.) a portable
computer, preferably a handheld computer, where the handheld
includes capabilities for memory, processing, display, recording
monitored information from the monitoring means (such as a PORD),
and data transmission and reception. The portable or handheld
computer is, at least at some time, in communication with the
monitoring means and preferably includes sufficient information
concerning the patient's biological manipulation protocol to
compare monitored information with the goal protocol information;
d.) a central processor or computer (segregated from the portable
computer), the central computer including a file server, a
database, memory, patient data outcome and compliance processing,
display and communications; e.) communication means between the
provided pair of distinct computers; and f.) analysis of monitored
data by an analysis interaction algorithm (preferably by the
central computer or alternatively another computer, distinct from
the handheld computer, and most preferably which is in
communication with the central computer).
[0024] In a preferred embodiment, the earlier mentioned process
embodiment further includes steps to generate information about a
prescribed protocol for treating the orthopedic injury of a
patient. Such generated information may be in the form of a script,
which will then be used in a handheld computer and orthosis device
combination to treat an orthopedic injury. The additional process
steps include: g.) presentation of a set of treatment protocols.
The set of protocols to be presented includes at least one
treatment protocol. The presentation might be on a display screen
or a paper printout or similar hardcopy or both. h.) approval of a
treatment protocol from among the presented set of treatment
protocols. This step is preferably undertaken by a treatment
professional employing professional judgement and, generally, the
approval is made in light of further information about the
treatment protocol which is being approved. i.) capturing
information identifying the approved treatment protocol from the
set of presented protocols; and j.) generating information from the
captured information into a form compatible with a handheld
computer adapted for connection to an orthopedic sensor system,
wherein the generated information includes parameters of the
identified approved treatment protocol. Additionally the method may
include e.) communication from the portable monitoring and
communication device of information concerning interactions,
communication exchange and/or patient exercise; and f.)
modification of the treatment protocol; and g.) monitoring the new
protocol.
[0025] The present invention includes a number of further
embodiments. One particularly notable embodiment involves a
database of historic information of earlier patients, their
injuries, their actual treatments protocols as performed, and
resulting outcomes and a communications and data method to connect
the two optimizing functions together. New information can be
accumulated in such a database while performing the process of
certain embodiments of the present invention and information from
the database is made available and utilized in other embodiments of
the present invention.
[0026] The present invention in another embodiment is a system for
treating an orthopedic injury. The system includes a handheld
computer adapted for connection to an orthopedic sensor system, a
central computer including a historic database of orthopedic
injuries, patient characteristics, treatment protocols and
outcomes. The system allows an inquiry of the database, i.e. the
central computer is queried to cause presentation of a set of
treatment protocols to a treatment professional. The treatment
professional approves a treatment protocol from the set and the
system generates formatted parameters corresponding to the approved
treatment protocol for installation in the handheld computer. Once
installed with such parameters, the handheld computer can mediate
the approved treatment protocol when it is connected to the
orthopedic sensor system. The system further includes monitoring
performance of the patient in response to the treatment protocol
and updating the historic database with the monitored performance
parameters. The system further includes the possibility for
treatment intervention in the form of modification of the formatted
treatment protocol parameters in real-time in response to updates
to the historic database or in response to patient data recently
sent to the computer. Data which is transmitted to the central
computer can be analyzed or compared against other databases and
sent on for other analysis. When the data is communicated, secure
communication schemes may be optionally employed.
DETAILED DISCLOSURE OF PREFERRED EMBODIMENTS
[0027] A background for better understanding of the present
invention may be gained by initially considering some earlier
innovations developed by one of the inventors. As shown in FIG. 1,
treatment of a patient 12 with an orthopedic injury, such as by way
of example, an injury at or adjacent the patient's knee, is
accomplished by fitting the patient with an orthosis, preferably, a
personal orthopedic restraining device (PORD) 14. The PORD 14
serves two important functions. First, it restrains or restricts
motion of the patient's leg at the knee to motions consistent with
a treatment protocol, and second, it measures a physical parameter
of the patient's exercise, such as stress when exercising and knee
angle when flexing or extending. The PORD 14 includes a transducer
to accomplish such measurement. The transducer of the PORD 14 is
connected to a handheld computer 16 which records transducer output
signals. The handheld computer 16 is adapted for connection to an
orthopedic sensor system. The handheld computer 16 also processes
the transducer signals and provides the processed information both
directly to an attending treatment professional 18 and to the
handheld computer memory for later retrieval. For example, the
processed information may be provided as a display on the handheld
computer 16. The treatment professional 18 may also install
sufficient information in the handheld computer 16 by way of a
desktop PC 18a to compare the patient's level of compliance with
the exercise treatment protocol. An exemplary handheld device such
as a SmartIDEA (tm) device is available from IZEX Technologies,
Inc., Golden Valley, Minn.
[0028] As shown in FIG. 2, the handheld computer 16 can also
communicate with another computer 20. This second computer 20 may
be a central computer 20 segregated from the handheld computer 16,
PORD 14 and patient 12 and can process the recorded, preferably
preprocessed, information. The communication may be via modem over
telephone lines or via cellular radio-telephone transmission. The
treatment professional 18 can review the processed results at the
central computer 20 location, for example, as a screen display or a
hardcopy printout.
[0029] As shown in FIG. 3, the treatment professional 18 may use a
personal computer (PC) 22 to communicate with the central computer
20 or directly to the handheld computer 16. The PC 22 may be
adjacent the central computer 20 and the communication take place
over a serial cable, or it may be remote and use modems over
telephone lines. In this system, the treatment professional 18
might send a signal to the handheld computer 16 to tell patient 12
to exercise.
[0030] In the present invention, as shown in FIG. 4, the same
treatment professional 18, using PC 22, may treat another patient
24 with another PORD 26 communicating with another handheld
computer 28 which in turn communicates with the central computer
20. The number of patients 12 and 24 being treated may be expanded
and is not limited to only two patients. The handheld computers 16
and 28 may, most preferably, include additional output capabilities
selected from the group consisting of RS-232 output, USB output,
parallel port output, light output, textual, graphical, audible
output, Ethernet input, RF communications output, IR communications
output and tactile output.
[0031] In another embodiment, as shown in FIG. 5, another treatment
professional 30, using PC 32, may treat the other patient 24 while
the original treatment professional 18 treats the original patient
12. Treatment of the patients 12 and 24 can also be shifted between
treatment professionals 18 and 30 as schedules and responsibilities
dictate. Alternatively, review, consultation, and related
communication between treatment professionals 18 and 30 is
possible, and may take place through central computer 20 or by
telephone or in face-to-face discussions. The number of patients
being treated and/or the number of treatment professionals may be
expanded and is not limited to only two.
[0032] In another embodiment, shown in FIG. 6, another central
computer 34 communicates with the original central computer 20 and
the treatment professional 18 uses original PC 22 to communicate
with the another central computer 34 rather than directly with the
original central computer 20. Communication between the central
computers 20 and 34 may be via modem connections over telephone
lines or more preferably over an Internet or intranet network. It
should be recognized that the central computer 34 can be one of
many central computers on a network, that the network is not
limited to only two central computers and that the communications
between the two central computers 20 and 34 may be passed through
other computers or devices rather than directly between the two
computers 20 and 34.
[0033] In another embodiment, shown in FIG. 7, the central computer
34 communicates with the original central computer 20 and the
treatment professionals 18 and 30 uses original PC 22 and
additional PC 32 respectively to communicate with the additional
central computer 34 rather than directly with central computer 20.
Communication between the central computers 20 and 34 may be via
modem connections over telephone lines or more preferably over an
Internet, either public or private, or intranet network. Patients
12 and 24 with another PORD 26 communicating with another handheld
computer 28 which in turn communicates with the central computer
20. The number of patients being treated may be expanded as may the
number of treatment professionals directing treatment.
Additionally, attending responsibility for patients may be rotated
amongst the treatment professionals. In a variation of this system,
any or all of handheld computers 16 and 28 and PCs 22 and 32 may
communicate with either central computer 20 or 34 or other like
computers on an intranet network or over the Internet. Similarly,
the PCs 22 and 32 may connect to other central computers
participating in and communicating with the central network. It
should also be recognized that either or both of the treating
professionals 18 and 30 might be using a networked PC or a
workstation of a network.
[0034] In a further embodiment of the system of the present
invention, a database 36 may be present, as shown schematically in
FIG. 8. The database 36 may be present on a central computer 20 or
34 or on another file server in communication with either one or
both of the central computers 20 or 34. The use and usefulness of
database 36 in the present invention may be further understood in
view of some particularly preferred embodiments.
[0035] In one such embodiment, treatment protocols can be generated
based upon information gleaned from database 36. The database 36
includes a plurality of historic treatment protocol records, the
records including fields populated by parameter data for patient
characteristics, orthopedic injury, actual treatment protocol
followed by the patient, and historic outcome. By "historic
treatment protocols" herein is meant actual, accomplished and
monitored treatment protocols; and by "historic outcomes" herein is
meant the actual, observed recovery or extent of recovery resulting
from such "historic treatment protocols." Additionally, in a most
particularly preferred embodiment, the database 36 further includes
parameter data selected from the group of characteristics
consisting of demographics, patient physical characteristics,
patient psychological characteristics, and the prescribed protocol
provided to the patient. In one variation of this aspect of the
present invention, treatment protocols are based upon statistical
analysis of data base records. In another variation, the treatment
protocols are presented to the treatment professional for review
before installing, either all or part, on the handheld computers.
That is, the treatment professional is presented with statistical
information, such as summaries, means, averages, medians or the
like. In a second variation, the treatment professional is
presented with at least one or more similar individual case
histories. Most preferably, the case history is a database record
of a patient or patients with similar characteristics and similar
injuries to the patient about be treated. The data from the
database 36 which is presented to a treatment professional for
approval, is presented either on screen or in printed form or both;
and the data may be presented graphically, textually or a
combination of both. The data communicated from the handheld
computers may also be used to update the historic database 36 with
the processed patient compliance information. Use of the data for
presentation in order to allow review by a treatment professional
or in updating a historic database are not mutually exclusive, and
in a most preferred embodiment, the data is used in both ways. It
should be understood, that the reviewing treatment professional and
the treatment professional involved in the earlier approval step
are not necessarily the same individual. Presented data and updated
data may additionally be communicated and employed for other uses,
such as for example, governmental compliance, insurance purposes,
and/or financial reimbursement or employment records. Methods of
limiting access to the data in the central computer for
confidentiality purposes or financial purposes are, of course, well
known, and might include passwords or, in the case of intranets and
private access networks, may also include call back modems as
security enhancements. Internet data communications may also be
made secure using a variety of means including secure socket layers
(SSL), encryption, passwords, keys or the like.
[0036] Consistent with capabilities of a handheld computer such as,
by way of example, the SMART IDEA.TM. device, the handheld computer
may also include patient signaling capabilities selected from the
group consisting of audible signaling, visual signaling, and
tactile signaling. Similarly, the handheld computer may include
input capabilities selected from the group consisting of RS-232
input, sensor signal input, USB input, modem input, keyboard input,
audible input, light input, RF input, IR input and Ethernet input.
Moreover, the handheld computer may include output capabilities
selected from the group consisting of RS-232 output, USB output,
parallel port output, light output, textual, graphical, audible
output, Ethernet input, tactile and vibrational output. In
addition, the handheld computer display may include any number of
languages including English, Spanish, and other foreign languages.
Also, the displayed graphics may be visual in nature such that
non-literate patients and children may readily understand and use
the device.
[0037] In one embodiment, the treatment professional 18 or 30 has
the initial opportunity to query the database 36 with at least some
parameters characteristic of the current patient 12 or 24 and the
current patient's orthopedic injury. A query computer program 40,
of FIG. 9, is present in the server computer system to query the
database 36. This allows the database 36 to be searched for similar
case histories in the form of historic records of treatment
protocols and outcomes. Alternatively, the query computer program
might be used to return statistical information relevant to the
patient 12 or 24.
[0038] In an extension of these treatment processes, the treatment
professional 18 or 30 may modify the initial query, to increase or
decrease the number of returned records. Additionally, the historic
database 36 may allow queries for predicting the likely outcome of
a treatment protocol for a patient 12 or 24 with a particular set
of characteristics and a particular orthopedic injury. Using this
approach, a treatment professional 18 or 30 can rapidly investigate
the efficacy of a range of possible treatment protocols which they
might envision for the patient 12 or 24 with a particular
orthopedic injury to be treated. Additionally, once at least one
treatment protocol is presented, to the treatment professional 18
or 30, they may either modify the presented protocol or the patient
characteristics and either re-query the database 36 for likely
outcomes or proceed to approve the protocol as indicated in FIG. 10
at 110. It is further provided that the treatment professional may
utilize the query program 40 and historical database 36 as part of
the treatment system of this invention to simulate an evaluation of
a treatment protocol under consideration for a particular patient,
then re-modify the treatment protocol based upon the simulation
outputs.
[0039] It is also part of the present invention that the treatment
professional may, in modifying the treatment protocol, select from
various pre-recorded sound files, one or more patient directed
voice comments, or record one or more individualized, i.e.
customized voice comments, for the patient. As mentioned
previously, the sound files may be played later for the patient as
part of the treatment protocol or conditionally played as part of
the treatment protocol. If the handheld computer 16 or 28 includes
the capability to play sound files, then the files are played via
the handheld computer 16 or 28. Alternatively, the handheld
computer 16 or 28 may signal the patient to play the recorded file,
for example, by displaying a message on an LCD screen for the
patient to do an added motivational or instructional task such as
"Listen side #2 cassette recording!" to cause the patient to play
an analog cassette recording of reproduced sound selected by or
custom recorded by the treatment professional, or alternatively,
the patient might be instructed by a displayed message to listen to
a sound which is transmitted to the patient over the Internet as a
sound file by a message such as "Listen to file PATIENT.WAV!" In
another variation of this aspect of the process, the sound files
may be provided to the patient as a set of sound files on a device
in communication with the handheld computer 16 or 28 such that the
device is instructed to play a particular sound file. By way of
example, this variation may involve a compact disc recording of one
or more sound track files of patient directed comments and a
communication link between the hand-held computer 16 or 28 and a
compact disc player device, with the ability to be controlled by a
handheld computer. Such control might be by a direct wire
communication connection or by an infrared signal originated by the
handheld computer 16 or 28. The compact disc may be recorded with
generic patient directed voice comments or customized comments,
such as the treatment professional's voice recording of custom
instructions and/or encouragement for the particular patient. In
the case of custom instructions, the treatment protocol
modification step further includes the treatment professional
recording the customized patient instructions, and the generation
step, described earlier, further includes the substep of recording
the track onto a recordable or rewritable compact disc.
[0040] In another embodiment, failure of the patient 12 or 24 to
comply with the treatment protocol indicated the necessity of a
centrally generated intervention or modification, either with or
without presentation to and review by the treatment professional 18
or 30. Failure to comply may include under or over exercise which
deviates from the treatment protocol. Alternatively, the monitoring
and alerting features (which identify accidents, harmful events, or
other incidents of significance in patient exercise) can be used to
alert the treatment professional.
[0041] In yet another embodiment, a script corresponding to the
treatment protocol may further include conditional logic. Most
preferably, the conditional logic incorporated within the script
serves to further treatment goals; that is, the goal-based
conditional logic facilitates a patient's overall treatment program
by incorporating the ability for intervention within the script
loaded onto the handheld computer. Goal-directed conditional logic,
incorporated within the script of the handheld computer might be
best understood as a third form of intervention, distinct from both
intervention by the treatment professional (which might be driven
by non-real time reports or by real time information (such as
video) and time-based intervention decisions which are made at a
central computer based upon pre-determined time periods. In such an
embodiment, the goal-based conditional logic may be used to
incorporate the criterion for recognition by the remotely located
handheld computer 16 or 26 of a failure of compliance by the
patient 12 or 24 and the ability to alter the treatment protocol.
For example, goal-based conditional logic could be used to monitor
a patient's attempts to meet a particular effort or angle objective
to be replicated a set number of times. Detecting that the effort
or angle is not being achieved, the goal-based conditional logic
might set a new, lower and easier to achieve level of effort or
angle and accordingly increase the desired replicate count to at
least partially compensate for the easier exercise. Alternatively,
the conditional logic may be used to provide criteria for
recognition by the remotely located handheld computer 16 or 28 of
meeting and satisfying, ahead of schedule, the treatment goal set
by the treatment professional as represented by the approved
treatment protocol. Those skilled in the art will likely recognize
the particular advantages of incorporating goal-based conditional
logic within a protocol script loaded on a handheld computer and
PORD combination. One such advantage is recognizing accelerated
progress toward a treatment goal and responding appropriately by
modifying the protocol. In many such cases, the treatment protocol
goals may be raised to more challenging levels to better capitalize
upon the patient's outstanding efforts. This approach holds the
potential to provide a psychological boost to the patient and
further allow the motivated patient to progress very rapidly
through orthopedic treatment. The alteration of the protocol need
not be immediately communicated back to the central computer 20 or
34 but might be saved for later communication. Alternatively, the
goal-based conditional logic analysis can be carried out at the
central computer, with one result being the production of a
modification or intervention in the protocol, followed by
transmission of the updated protocol from the central computer to
the handheld computer.
[0042] As shown in FIG. 9, the handling (i.e. the communication and
the processing) of information within the system of the present
invention can be very complete and yet very efficient in terms of
resource utilization. A treatment professional 18 or 30, uses a PC
22 or 32 to access the query program 40 to find protocols from the
historic database 36 on a central fileserver. The treatment
professional can either create 102 a fresh new protocol, select an
appropriate historic protocol or modify parameters of an existing
treatment protocol, made up of a group of exercise related
parameters. The creation 102 of a treatment protocol is most easily
accomplished by using the query program 40 for consultation of
database 36.
[0043] For example, the treatment professional 18 or 30 sits down
at PC 22 or 32 and selects a protocol from a list of historical
protocols obtained through query program 40 from historic database
36. Alternatively, a list of protocols may be resident locally at
the treatment professional's PC for the same reason. The treatment
professional 18 or 30 then optionally modifies parameters of the
protocol based upon particular injury details associated with the
patient. The resulting modified protocol 107 for the patient is
then downloaded 108 via hardwire or wireless communications 112 to
the SmartIDEA.TM. handheld device 16 or 28. The patient 12 or 24,
fitted with a PORD 14 or 26, takes the SmartIDEA.TM. device 16 or
26 home and periodically does exercises, generally according to
instructions from the treatment professional 18 or 30 to follow the
created protocol 107. As the patient 12 or 24 follows the presented
protocol 107, the patient's exercise activity and progress is
monitored. The patient is presented with reinforcement signals and
instructions based upon comparison of the patient's actual exercise
activity to the goals of the protocol 107. The reinforcement
signals to the patient may be in the form of visual signals,
audible signals, and/or tactile signals, and may include
qualitative or quantitative information about insufficient or
excessive patient exercise as well as more general motivational
signals. After partial completion of the prescribed exercise
protocol 107, the recorded data can be communicated (i.e.
transmitted) 112 to the central computer server 20 or 34 to
generate a progress report 114 for viewing by the treatment
professional 18 or 30. The reports can be generated and
subsequently presented by a variety of means 116. For example, the
presentation of the reports may be via fax, printer, graphic screen
display and/or pager display. Transmission 118 of the reports to
the treatment professional 18 or 30 may involve hardwire, wireless,
Internet or intranet communications. The treatment professional 18
or 30 may respond, after reviewing the reports and exercising
judgment about the patient progress, by intervening through
revising the protocol 107 to a revised protocol 109 in order to
increase the likelihood or rate of achievement of acceptable
outcome.
[0044] Such an activity pattern can be thought of as a manual
intervention. As will be discussed next, however, the system of
this invention can provide automatic revision of the protocol, and
such automatic intervention or modification may be performed in
real-time, if desired.
[0045] In another embodiment, this same process of reviewing report
compliance and outcome data and revising treatment protocols can be
automated through the use of an analysis interaction algorithm
which functions for the treatment professional.
[0046] More specifically, the analysis interaction algorithm
performs two functions (1) analyzing patient performance for
reporting or protocol adjustment, (2) automatically adjusting or
updating a patient protocol. These two activities are explained as
follows:
[0047] Patient Compliance to a Prescribed Exercise Schedule.
[0048] This portion of the analysis interaction algorithm performs
a tally of actual exercises completed, and the actual time of their
completion, in comparison to the exercises (goal) which were
prescribed and the prescribed schedule for those exercises (goal),
as prescribed by the caregiver.
[0049] For example, a patient is prescribed an exercise regimen
that calls for one exercise per day for 10 days. Upon completion of
the 10-day period, data from the handheld device is transferred to
the central computer. This portion of the analysis interaction
algorithm compares goal and actual schedules and concludes or
determines that the patient performed 90 percent of the prescribed
exercises. FIG. 11 illustrates one realization of a graphical
output of this algorithm.
[0050] Exercise Performance Compared to Prescribed Challenge Level
of Exercises.
[0051] This portion of the analysis interaction algorithm performs
a comparison of patient actual effort expended. This comparison
could be based upon measurements from the orthosis sensors in
units, such as limb joint angle of flexion/extension or muscle
strength measured in units of torque (for example, Ft-lbs). These
measured values are compared to the exercise regimen effort goals
prescribed by the treatment professional.
[0052] For example, a patient is prescribed an exercise regimen
that calls for the patient to strive to reach a strength goal of 20
Ft-lbs, as measured by the instrumented orthosis. The patient
attempts to reach this goal but can only meet 15 Ft-lbs. This
portion of the analysis interaction algorithm compares the goal and
actual recorded strength data and concludes or determines that the
patient reached 75% of the goal strength exercise regimen. FIG. 12
illustrates one realization of a graphical output of this
algorithm.
[0053] Exercise Performance Compared to Benchmark Exercise
Performance of the Unaffected, Contralateral Limb.
[0054] This portion of the analysis interaction algorithm performs
a comparison of patient actual effort expended with the injured
limb, as explained above, compared to the strength benchmark of the
contralateral (uninjured) limb.
[0055] For example, a patient prior to rehabilitation therapy has a
measurement made on the contralateral limb, and the MVC (Maximum
Voluntary Contraction) for that normal limb is found to be 60
Ft-lbs, as measured by an instrumented orthosis. The patient
progresses through several weeks of therapy and near the end, is
consistently attaining strength levels with the injured limb of 50
Ft-lbs. This portion of the analysis interaction algorithm compares
the benchmark and actual recorded strength data and concludes or
determines that the patient has regained 83.3% of the contralateral
limb MVC strength. FIG. 13 illustrates one realization of an output
of this algorithm.
[0056] Exercise Performance Compared to Statistical Historical
Summaries of Past Comparable Patients.
[0057] This portion of the analysis interaction algorithm performs
a comparison of patient actual effort and limb recovery levels
achieved, at various times in the recovery schedule and in general
over the entire duration of the prescribed exercise schedule, with
statistical summaries of historical patient data taken from
comparable patients with similar injuries and demographic
backgrounds.
[0058] For example, a patient's overall strength and range of
motion performance at weeks 1 through 8 are recorded during the
rehabilitation period. To arrive at conclusion or determination
about how this patient compares to past patients with the same
injuries and using the same (or nearly the same) recovery exercise
protocol, this portion of the analysis interaction algorithm
compares actual week 1 through week 8 performance of the patient,
against data from the historical database, and concludes or
determines that the patient has reached 82% overall of the expected
levels of strength and recovery, compared to the statistical,
historical performance of patients having the same (or nearly the
same) injury and demographic background. FIG. 13 illustrates one
realization of an output of this algorithm.
[0059] Additionally, the algorithm may output data for reports for
other use(s), such as insurance company reports to facilitate
efficiency of reimbursements and financial controls. No report is
shown but such would be customizable based upon the form desired at
an insurance organization or other non-medical entity.
[0060] Concepts on Protocol/Performance Data Analysis and
Feedback:
[0061] To further explain and discuss the concepts regarding the
closed-loop, goal-based, use of compliance data to make future
adjustments to a patient's protocol based upon past performance of
the patient, one might consider the following. This process can be
automated so that as patient performance and compliance data are
regularly collected, an algorithm can monitor the data
automatically and adjust and produce updated protocols to be sent
to the patient which will deliver optimally adjusted levels of
exercise challenge, consistent with a number of constraints,
including goal-based criteria and safety. Referring then to the
FIG. 14, three curves are shown:
[0062] 1. Patient Performance/Competence/Compliance is a measure of
how well the patient is complying with the prescribed exercises. A
high score (near 100%) indicates that the patient is doing well and
may no longer be significantly challenged at the current Challenge
Level.
[0063] 2. Protocol Challenge Level is a description of the protocol
difficulty level. This level should rise in conjunction with injury
recovery, but be moderated by safety considerations.
[0064] 3. Accumulated Exercise Units are the measured, actual
amount of work that the patient has achieved. This quantity can be
compared to the expected amount of work that the patient should
achieve, assuming a given (for example, 80%) level of average
compliance.
[0065] Discussion of Operation:
[0066] The patient starts out (point A, FIG. 14) just after
surgery/injury with an easy exercise protocol. At first, the
patient performance is low, but it steadily rises (B) as swelling
and pain reduce, and strength is regained. At some point (C) the
patient is mastering the current level of challenge (performance
levels near 100%) associated with the protocol.
[0067] Recognizing that this goal has been reached, the protocol
adjustment algorithm increases the challenge level (D) of the
protocol, possibly requiring as well that a minimum required number
of exercise units (D1) be logged by the patient. In response to
this change, patient performance falls below 100% (E) as the
patient now finds greater challenge, and a corresponding effort
increase required to meet goals. At the same time, the accumulated
work units are now rising at a faster rate (F) since for each
minute of exercise, the patient must now exert more work to meet
the protocol goals presented to him, than he had to with the
previous, easier challenge level.
[0068] This pattern repeats itself (G, H) as the protocol
adjustment algorithm continues to sense patient performance, and as
a result adapt (modify or adjust) the protocol to ever increasing
levels of difficulty so as to keep the patient challenged,
strengthening faster, and on the road to recovery sooner.
[0069] Challenge Level Rates Over Time
[0070] Referring to FIG. 15 for the following discussion, the
challenge levels used in progressive protocols will depend on a
number of factors including but not limited to:
[0071] Injury type & grade
[0072] Patient demographics (i.e. factors considered include:
Athlete, sedentary, etc)
[0073] Past performance of the patient during the current episode
(high compliance track record or low?)
[0074] Safety levels associated with the orthosis
[0075] In FIG. 15, Curve A illustrates a protocol challenge level
progression (rate) that is aggressive, associated with, for
example, an injury that has no biomechanical usage limitations,
(i.e. "indestructible" lesions such as an ACL reconstruction,
rodded femur, etc). In these cases the recovery protocol can be as
aggressive as is tolerable by the patient.
[0076] Curve B in contrast would be associated with a more gradual
progression in challenge level over time, as would be appropriate
with vulnerable lesions that cannot safely tolerate a rapid
increase in limb/joint re-use. Examples are a meniscus repair,
cartilage implant, or similar. A variation in rate (C) might be
associated with injuries which require low-level, early protocol
therapy, but that will tolerate, at some point, a switch to a more
aggressive protocol.
[0077] For the class of "indestructible" lesions where the exercise
protocol challenge level (Curve A) can be as aggressive as
possible, it may turn out the most effective protocols are the ones
in which patient motivation is highest. In this case, the protocols
which have the most interesting, attention-holding and compelling
game-theory elements will reveal themselves. These protocols will
have the effect of making the patient want to reach goals despite
pain and fatigue barriers (of course, always subject to safety
constraints) leading to a more rapid return to normal function.
[0078] The intervention, in the form of revised protocol 109, is
communicated back to the patient's handheld device 14 or 26
(similar to earlier communication (i.e. transmission) 108), which
in turn, presents or communicates to the patient 12 or 24 signals
about the revised protocol 109.
[0079] In another embodiment, the treatment professional 18 or 30
may employ real-time patient interaction 115 via video/audio
communications. Such real-time communications 115 include but are
not limited to video, audio, telephone, facsimile, wireless (radio,
cellular-telephone, television) communications. Alternatively, the
treatment professional 18 or 30 may employ other interaction means
117 to provide encouragement to the patient. The patient, thereby,
would be provided with guidance and motivational encouragement to
attempt, and hopefully complete, the exercise protocol. Such other
interaction means include but are not limited to TENS, muscle,
audible, visual, palpable, animation and video signals.
[0080] Upon completion 119 of the entire prescribed course of
treatment, the treatment professional 18 or 30 may view reports 120
and view a final report 122. As described earlier, the reports 120
and 122 may be presented in a variety of ways and communicated or
transmitted in a variety of ways 112 126. For example, report
presentations may be, but are not limited to fax, printer, graphic
screen display or pager display. Communication or transmission of
report data may involve hardwire, wireless, facsimile transmission,
Internet or intranet communications. The reports may be sent on
demand or may be sent automatically based upon a pre-determined
schedule.
[0081] Further detail of the portions of the protocol creation step
are shown in FIG. 10. A treatment professional 18 or 30 is
presented by the query program 40 with at least one and possibly a
plurality of historic protocols from the historic protocol database
36. The query program 40 uses prior patient parameters, such as
demographic information and previous outcomes, in the database 36
to select protocols most nearly similar to the query information
input by the treatment professional 18 or 30 about the patient to
be treated 12 or 24. Alternatively, the query program 40 may access
the historical database 36, both of which can reside on the
treatment professional's local PC rather than on a central
computer. The relevant patient injury characteristics from prior
patients are also present in the database 36 and in the treating
professional's query for the current patient.
[0082] A second source of highly relevant patient information is
available in many cases in the form of performance information,
particularly in the form of a measurement such as the maximum
voluntary contraction (MVC), as available from the patient's
uninjured contralateral limb. By way of further explanation, the
patient's opposite, uninjured limb is presumptively normal and
therefore has performance which can provide an approximate and
appropriate performance goal or target to be achieved by treatment
of the injured limb. In another embodiment of the present
invention, a treatment professional may measure the MVC of a
patient's uninjured contralateral limb by employing a personal
orthopedic restraining device in communication with a handheld
computer. This embodiment may be summarized as a process for
pre-assessing an orthopedic patient with a limb injury by employing
a personal orthopedic restraining device to measure the condition
of a presumptively normal contralateral limb. Preferably, the
personal orthopedic restraining device is in communication with a
handheld computer and most preferably both devices are the same
units that will be subsequently utilized in treatment of the
patient's orthopedic injury. One of ordinary skill will recognize
that a personal orthopedic restraining device is capable of
measuring other relevant parameters of the contralateral limb, for
example, angle of joint bending.
[0083] In another embodiment of the present invention, when the MVC
of the uninjured contralateral limb has been measured, the MVC, or
alternatively, an appropriate lower value, such as for example 95%
of the uninjured contralateral MVC, is set as a treatment goal for
the injured limb. More preferably, at least one of these values,
i.e. measured MVC of the contralateral limb or proposed MVC goal,
are compared to demographic MVC values in the historic database.
This comparison can be employed to avoid accepting measurement
errors and/or to assess the patient's condition relative to
demographic norms. In such a situation, communications are
appropriate and it is preferred to employ communications through
the Internet to a query program thereby obtaining information from
the historic protocol database.
[0084] As indicated in FIG. 10, the contralateral MVC and/or
proposed treatment MVC data 42 may be used in conjunction with
protocols provided from the historic database 36 to create an
exercise protocol 107. In the treatment exercise protocol creation
process step 102, the treatment professional 12 or 24 interacts
with the possible protocols from the historic database 36 and may
modify the protocols until an exercise protocol 107 is acceptable.
The treatment professional 12 or 24 then provides a final approval
by actively selecting an agreement portion 110 to allow the
exercise protocol 107 to become available for download to the
handheld computer 16 or 28. In addition, the treatment professional
may update a protocol 107 based upon recent patient performance
data 120 or direct patient feedback or comments 121 which is
obtained at anytime between the start of patient treatment and the
end of patient treatment.
[0085] In another embodiment, the present invention further
facilitates patient recovery outcomes by producing exercise
protocols which incorporate improved patient motivational aspects.
In particular, patient motivation can be improved by reducing
tedium and better holding the patient's attention. This can be
accomplished by making the exercise protocols appear as a game to
the patient. This is particularly suitable for patients who are
children and can also serve a readily learned interface for
patients who are illiterate. In this embodiment, the personal
orthopedic retraining device (PORD) functions as a "joystick" or
game control device which is in turn in communication with the
handheld computer (Smart IDEA). The handheld computer functions as
a pre-processor, modulator, or signal conditioner of game-like
information from the PORD. The conditioned or modulated information
is communicated to a central or base computer, preferably, via the
Internet or by modems over a telephone line or by other methods
described earlier. In order to better understand this embodiment,
it may be helpful to envision such well-known computerized
toys/games as those available from "SEGA" or "PlayStation" in which
a player/participant moves a joystick or presses buttons to
interact with the game and, in particular, the visual display of
the game which is typically represented as a interesting virtual
adventure. The handheld computer (for example, a Smart Idea) with
an LCD display can be set up to pass outputs into the base computer
via keyboard daisy chain, and the base computer (preferably via an
Internet web site) can be used to generate the sophisticated
graphics and present the data as an attractive, stimulating and
even fun display for the patient. Programming can be provided that
includes regimens that, instead of, by way of example, are
separately numbered exercises #1, #2, & #3, are innovative and
in particular integrate all of the actions in a more interesting
way.
[0086] For example, a indicia on a video screen visible to the
patient, such as the "Super Mario" figure or other character
representation with which a child patient may readily identify,
goes out into the world, he encounters a (virtual) dragon or
similar virtual hazard that he must (virtually) jump over, which
the child patient can only do by (actually) extending his leg to 5
degrees of flexion. Then the child patient has to push against a
(virtual) rock to get it out of the path, which requires an
(actual) isometric flexion/contraction at 45 degrees of 15 foot
pounds. Next, the child patient who is the game participant has to
ring a (virtual) gong by kicking a (virtual) ball, which is
accomplished by the child patient doing another (actual) isometric
in extension at 23 Foot pounds. Then the child patient who is a
game participant has to grab a (virtual) paddle and swat away the
angry (virtual) bumblebees, in a manner that can resemble a "pong"
proprioception game. In other words, the exercises of the protocol
do not have to be static, repetious, and/or boring for the patient,
since the computer can present the instructions for the protocol
exercises, as a game-like activity, and further can randomly alter
the order, mix, add entertaining visual and sound information to
the patient (i.e. flash, pow, and interesting graphics). Such
presentations would be similar to those are previously known and
available with the superior processing capability of the game base
stations.
[0087] In a further embodiment, multiple patients, particularly for
example two child patients undergoing orthopedic rehabilitation,
can play their protocol performances against each other over the
Internet. In such a system, each of the child patients must be
identified to the central computer to allow the computer to provide
"gaming" consistent with their individually prescribed treatment
protocols. The central computer can also handicap the players to
keep the game interesting to each of the multiple players. A "base
station" Internet site can have the capability to randomly create
these routines real-time, and even vary the routines for patients
to facilitate recovery from orthopedic injuries through innovative
treatment protocols.
[0088] Although the present invention has been described with
reference to preferred embodiments, workers skilled in the art will
recognize that changes may be made in form and detail without
departing from the spirit and scope of the invention.
* * * * *