The case for Remote Physiotherapy — Problems and Possibilities

Hold up! Before you go any further, I am obliged to inform you that this is the second part in a three part series. You can find the background (first part) to this text here.

The longitudinal study of the world of musculoskeletal physiotherapy threw up a lot of interesting problems. There were many ways of approaching this field, one of which was to deep dive and focus all efforts towards one injury of one particular joint, and look at the various ways of allowing the patient to make use of ICT technologies to get them through this painful journey. While this method was extremely enticing to me as a designer with an inclination towards research, I had to keep in mind that I was, at the end of the day, in a country that spoke I language I barely could speak, let alone do research. With this constraint in place, I proceeded to look at the journey the user takes during the rehabilitation process.

Journey Mapping

After the interview with Dr.Schulz, a scenario was created from the various case studies and scenarios he had described.

The scenario chosen was that of a teenager who has broken his arm through a sport activity. This scenario was chosen as the physio ward at the University of Ulm Hospital was specialised in dealing with sport injuries.

The journey started with looking at what happens to a patient and other stakeholders right after a fracture, from the procedures that take place in the hospital to how family and friends are informed of the injury, to the process of getting started with the rehabilitation and the ongoings during and post the rehabilitation. Through this journey map, I was able to note down possible pain points and areas of intervention. From the pain points, insights were gathered which gave leads on possible design solutions.

Defining the Personas

The stakeholders in the scenario of an injury are the patient himself, Mike Kleiner; his parents/guardian; the doctor at the hospital where he undergoes the surgery for an elbow fracture; and the physiotherapist, James DuVall. A brief about the personas was drafted, with their frustrations, motivations, goal and needs listed down to bring depth to their personalities. These traits helped with defining the way each of the personas would react to the events that would take place.

The timeline below gives a brief outline of events that take place from the moment of the injury to the completion of rehabilitation.

Current Timeline

Pain Points

The scenario was divided into three stages; pre-therapy, during therapy, and post therapy. Pre-therapy is the stage when the patient is getting treated for the injury. In the scenario, it is the stage from the injury to the completion of the treatment of injury till the cast comes off. During therapy, as the name suggests is the stage where Mike is undergoing the physiotherapy to regain complete mobility in his arm. Post therapy is the follow-up Mike will have to do, which isn’t as intensive or measured as the therapy phase, but at the same time isn’t any less important for the holistic healing of the body.

The pain points observed were as follows:

Pre Therapy

• Patient info such as emergency contacts, blood type, etc. might not be available on persons not carrying electronic gadgets.
• Anxiety and pain of the treatment can cause forgetfulness in patients and caretakers. This might make remembering the prescriptions hard (especially with a doctors handwriting)
• Frequent visits to the doctor can confuse the patient’s daily routine.
• Missing school due to injuries makes catching up with the work harder.
• Not every physiotherapist has time. Many are booked out and patient might have to go to physiotherapists far from where they live.

During Therapy

• The patient is new to the entire setup, the physio has to understand how the patient reacts to the treatment, trust needs to be built between the patient and therapist.

• Patients, along with their caretaker, will have to carry a lot of files to the therapist’s clinic for the initial few visits.

• The patient is tired after school, when his physiotherapy is scheduled.

• Boredom and tiredness will lead to the patient missing out on information that might be important.

• The patient has a hard time following through all the exercises the physiotherapist has recommended.

• Unintentionally neglects the exercises until the patient gets to the therapist’s clinic.

• Being uninterested in doing the exercises might lead to wrongly doing the exercises. This can cause long term damage.

• The parent/guardian/caretakers are not actively involved in the patient’s rehabilitation.

• A lot of the parent/caretaker’s time is used up without being able to do much. This gives them lesser time to go about their regular day.

Post Therapy

• After therapy, most young adults “feel” fine and do not see value in following up with the exercises.
• Motivation is even lower as there is no metric to tell the patient if the exercise is helping or if there is no longer any benefit to continuing.
• There is still the possibility of doing the exercise wrongly and causing further damage to the muscles.

Given that the scenarios can vary wildly during the treatment phase before the therapy, it was decided that the scope of the project would be limited only to the events that take place during the physiotherapy and with the possibility of seeing how follow-up could fit into the scheme of things.

Key Insights

Insights derived from the analysis of the pain points are:

• It is important to reduce cognitive load on the users in times of stress.
• It is imperative that the everyday rhythm of the patient is not disturbed. Going everyday or every alternate day to the physiotherapist can disturb this rhythm.
• Having a means of connection between the physiotherapist and patient would be beneficial.
• A better transfer of information from the doctor to the physiotherapist would be necessary.
• Exercises should be taught child-friendly, so that they also have fun and actually focus towards getting better.
• The patient should be able to refer back and see how exercises they have forgotten are done.
• Physiotherapy works with long term gains, and not seeing gains in the short term demotivates patients.
• It is beneficial to the practitioner if he can see how the patient is doing the exercise at home so that he is better informed if something goes wrong.

The insights we gathered could be grouped under one of three categories:

1. Motivation
2. Connection
3. Correction

Motivating the user to do the exercises while at home was an important feedback from the therapists, but the reasons for the users not doing the exercises was not for lack of motivation, but rather due to lack of instructions on how to do them and possibility of doing them incorrectly.

Ensuring the users know how and what exercise to do and being able to correct the user if doing the exercise incorrectly became the more important task. And to reduce cognitive stress of the user, the possibility of always being connected to their physiotherapist seemed like the right direction to go in.

Ideation

Ideation followed the insights, with possible solutions for the various problems being thrown on paper. The ideation also was carried out for the three categories the insights fell under.

Connection

• Gain familiarity with the physiotherapist in order to build trust in the relationship through introductory sessions
• Chat interfaces / chatbots
• Video chat with realtime telemetries relayed to the physiotherapist for live corrections
• Appointment Scheduler for an in-person meeting
• Virtual Reality for physiotherapist’s virtual presence

Correction

• Real-time feedback via animation
• Wearables to track movements
• Skeleton Motion capture
• Video analysis
• Post exercise objective analysis
• Game scores and leaderboard for evaluation

Ideation for corrective measures

Motivation

Different ways to motivate people were considered, such as motivation by:

• Scheduling: Scheduling the exercise session in calendar so that it is not missed
• Understanding: Understanding how the exercise affects the body
• Enjoyment: Make it a game with a peer based leaderboard; Levels and badges as the therapy gets more advanced
• Peers: Group therapy: motivated by peers and family; using social media to stay connected and motivated, events for exercising in groups (WorkoutMondays)
• Results: Showing results, or how much they recovered by doing the exercise for that particular day or documented comparison of recovery, check-in after 10 Login days…
• Support: Video call or actual visit to the clinic of the physiotherapist where the patient can see improvement through reliable metrics

Re-imagined Journey Map

After the ideation, the journey map was re-imagined. This was to get an idea, a feel, of how the entire ecosystem would work.

The events thats lead up to Mike visiting the physiotherapist remain the same as before. But after Mike meets the physiotherapist, instead of scheduling appointments, he instead registers Mike onto the remote physiotherapy service.

The idea of using a band with a 6-axis gyroscope was taken ahead as that was the one that could be accessible for most people. After registering with the physiotherapy service, Mike is given a band by James DuVall, which works with the application using Bluetooth. This band will then help James DuVall keep track of how Mike is doing the exercises.

Re-imagined journey map

Through this new map, the number of interactions, back and forth, between physiotherapist and patient is drastically cut. This is beneficial to the patient, who saves time and is able to undergo rehabilitation in a safe space, and to the physiotherapist, who is now gets more time to tend to newer patients.

This map helped inform the areas that a virtual interface would be necessary to enable remote physiotherapy. Quite a few scribbles were made, transformed to wireframes, the user flow worked upon and reworked to filter out unnecessary features.

The final solution that came about as a result of this process is described in greater detail in another article, to prevent this one from being impossibly long. You can read about it here.