Innovation in Musculoskeletal Health: The Technology-Augmented Physical Exam

In our last conversation you spoke about how digital technology was enabling patients to better understand their personal health, injuries and treatment options. It also offers them additional options, beyond the office visit to communicate progress or issues related to their recovery program. In your opinion, what gaps continue to be problematic in musculoskeletal care?

Medicine has always been a combination of “art” and “science”. In medical school we learn, and become experts in, the anatomy, physiology, and pathology of the human body as well as the conditions that affect patients. We must combine that knowledge with interpersonal skills to interview, assess, motivate and overall improve one’s health status.

With the acceleration of technology, there has been a de-emphasis and subsequent loss in the “art” of medicine related to the history and physical examination. I therefore see a need to develop technologies and tools that augment medical professionals' ability to communicate and receive important information from the patient’s perspective to maximize their ability to truly care for people in a shared decision-making model.?

New graduates are relying on technology to make a diagnosis and treatment plan. As a physician and surgeon, we should be able to make a diagnosis or differential diagnosis (i.e. alternatives) 90% of the time with the history and physical exam and use diagnostic studies to confirm and augment the specificity of that diagnosis. Unfortunately, it is frequently done the other way around. Therefore, an opportunity exists to leverage new technology in the clinical office to supplement the physical exam with highly accurate and reproducible data and provide better care for our patients.

What does a technology-augmented physical exam look like to you?

Some of the key information that we collect during the physical exam are measurements of range of motion, or how much a joint moves relative to a “normal” value, muscle strength, and special tests that are related to that specific injury or condition. This data allows a provider to determine what tissue or structure is involved, the severity of the injury, and its impact on function. We then use that initial information gleaned from the evaluation to monitor progress and the effectiveness of treatment over time.

For example, if you injure your knee and have reconstructive surgery, immediately post-op there will likely be a reduction in knee range of motion due to swelling and some trauma or inflammation to the surrounding tissues, like the ligaments, muscles, articular cartilage or bone. This, along with immobilization that may be required after surgery, can lead to atrophy of muscles and strength deficits that may impact one’s ability to stand, walk, climb stairs, return to work, or play a sport. Over time, rehabilitation will address and improve those deficits and when appropriate, determinations will be made regarding return to activity.

When I was working with the San Jose Earthquakes, the athletes and by extension the medical team were plagued by hamstring injuries. You might have heard that in sports the best “ability” is “availability”, and when a soccer player has a hamstring injury it is very difficult to play through it. So, there was pressure on the medical staff to get these athletes better quickly and get them back on the field.?

Our medical team introduced new care models, which included pre-season screening, warm-up stretching and strengthening exercises for injury prevention, and accelerated rehab protocols after injury. But, what we lacked was highly accurate and reproducible objective data that demonstrated the positive impact of our efforts and increased our knowledge of when the athlete was truly ready to return to play, while minimizing the risk of reinjury. This is primarily the case since most of these decisions to return to play related to soft tissue injuries currently relies on subjective information from the athlete, who wants to return ASAP, and findings on the physical exam like muscle strength testing that was developed over 100 years ago.

100 years?

Manual muscle testing, the most common way to evaluate strength in the clinical setting, was introduced into the physical exam somewhere around the turn of the 20th century by Dr. Robert Lovett, an orthopaedic surgeon in Boston.?

It was originally used to describe the degree of impairment in patients with polio and nerve related injuries using a scale from 0-5, where full strength is graded 5/5 (i.e. the patient can fully resist the examiner) and flaccid paralysis (i.e. the patient has no inherent ability to move or even initiate a twitch of the muscle) is graded 0/5. Others have since further subdivided the 5-point scale to add + and – to increase the granularity within each grade but it is still not highly accurate.?

In professional and collegiate athletes, we gradually reintroduce them back into their sport with a progressive program of kicking, running, jumping, short- and long-field drills, but even these activities may exacerbate a completely unhealed muscle or ligament injury. In the case of high school, recreational or youth sports, this almost never happens. They don’t have athletic trainers, therapists and doctors constantly available to access their return to play, so it’s either play or don’t play.?

And this is still what providers are using today to measure muscle function? Based on what you said it sounds like there is a lot of data that is not able to be captured by this.

We also frequently measure thigh circumference to check side to side differences in muscle girth, which is a crude method of determining muscle atrophy, but unless biometric testing is available and regularly performed, that’s it.?

It is the same with range of motion.?

In the clinic today, we generally measure and record the peak angle of a movement and perhaps annotate that with some qualitative and subjective measure of movement quality.

Advancements in technology have the potential to deliver metrics to providers that they use in their daily practice, like peak angles during movement or peak outputs of a muscle against a resistance, and then augment the evaluation of quality with highly accurate and reproducible data. This is what excites me about FIGUR8 and why I wanted to be a part of this team.

Technology can greatly expand our understanding of movement quality and the nuanced alterations in defined movement activities and gait in the presence of injury. This may include variability in the smoothness, hesitation, or compensation during movement that can be diagnostic or certainly track recovery or deterioration of a condition. The speed and duration of movement are important as well, and multiplane assessment of joint motion performing standard functional activities like gait, squatting, or lifting an object from the floor, can now be quantitatively documented over time. These are activities that musculoskeletal providers are currently evaluating subjectively and recording in written notes, later in the day, when their charting is completed. This technology drastically alters the documentation of objective movement analysis and standardizes it across different providers, reducing variability and improving the delivery of this critical information to the various stakeholders involved in that patient's care.

The addition of high resolution objective muscle data, collected simultaneously and across multiple body segments along with joint motion, helps providers evaluate dynamic function, make decisions about the effectiveness of a treatment plan, monitor progress, and ultimately determine when a patient is ready to return to activity and maximize outcomes. This kind of data would have been invaluable to me and my patients both in-clinic and on the field.

Thank you Dr. Oberlander for your time and sharing your story with us. If one thing was clear throughout our conversations it's that change in healthcare is constant. Whether it’s an improvement in a surgical technique, the advancement of digital health?to improve patient’s understanding of their injury/condition and recovery, or the value that objective highly detailed movement and muscle data can have on the clinical environment, stakeholders are constantly looking for new ways to improve patient?outcomes and create value.