Nirtal Shah

Nirtal is a Physical Therapist at the University of Toronto with 17 years of experience. Nirtal has a Master and Doctorate of Physical Therapy and a Master of Public Health.

The world is mobile and so are physical therapists!

Mobile health technology is becoming a common way to access health care services all over the world. Physical therapists have embraced this change to help improve patient outcomes, improve access to physical therapy services and to reduce the administrate burden of providing quality patient care. The ultimate goal of physical therapy is functional independence and a return to your prior level of physical activity. With this in mind your physical therapist may recommend apps that help you along your rehabilitation journey.

More and more people are asking for health care delivered in a manner that suits their life and their needs. Mobile devices are ubiquitous with 4.92 billion users representing 66% of the world population and making mobile devices the most used form of technology in human history.1,2 Further, patients are starting to demand they have access to mobile health technology not as the alternative but as the normal form of care delivery. In 2015, 52% of all health care provider and patient interactions insured by Keiser Permanente, one of the largest health insurance providers in the United States, occurred virtually.3 The potential to access health information and health care visits through our mobile devices is an obvious extension of a technology that has become part of our daily lives. The physical therapy profession has echoed these same sentiments in the Trends and Drivers of Change in Physiotherapy in Ontario report by saying;

“We are seeing a dramatic increase in the use of technology for managing physiotherapy practices, performing marketing functions and delivering effective health care.”4

The same report also urged change for the profession of physical therapy to serve our patients better by stating;

“PTs (physical therapists) that go beyond the standard but archaic photocopied exercise handouts to offer web-based communication platforms can benefit from a more satisfied patient/consumer, and possibly facilitate higher levels of engagement between visits to the clinic to help people achieve their mobility goals.”4

It is with these drivers of change and calls from patients and the general public that we tackled the problem of access to physical therapy services after surgery. One of the most common orthopaedic surgeries for the knee is an anterior cruciate ligament (ACL) replacement. There are 250,000 people in the US who tear their ACL annually.5 The rehabilitation lasts 8-12 months, and poor compliance and long-term health consequences are major challenges following this surgery.6 The compliance rate for rehabilitation is estimated to be 20%.7 This means that 80% of people don’t do the necessary rehabilitation to fully recover! This low compliance rate can lead to poor patient outcomes, more pain and discomfort and future surgical interventions and additional time and money spent by the patient and the health care system.

With the widespread uptake of mobile technology, we have developed a mobile health (mHealth) tool to help improve compliance rates for post-operative rehabilitation.8,9 mHealth has the benefits of being remote, patient-centric, cost-effective, and has the ability to improve health outcomes.10,11 The app called Curovate, has been downloaded more than 1000 times and has had 500 active users in the past 30 days. We have already had patients using the app regularly along with their clinical care and we are seeing great results. Our next step is to conduct a qualitative study to learn more about the feasible, usable, and engagement of patients using mobile health technology for their rehabilitation.

We want to first learn about the lived experiences of the patients who are using our app for their ACL recovery. Our next step will be to conduct a study to evaluate the outcomes of those patients who have regularly used our app for their recovery. We plan to influence health care access, improve the patient experience and satisfaction and also improve patient outcomes after surgery. The app is available in the Google Play Store and can be downloaded here. To further achieve our goal of health care access we have also started this patient education blog that teaches patients about everything related to surgery, recovery and physical therapy. We hope this will be a resource for patients who are having surgery and those that are recovering from injury. The main page of this blog can be viewed here. Here is a brief demo video of our ACL app.

References

  1. We are social. Digital trends in 2017; January 24, 2017, cited 2017 Nov 10

  2. MIT technology review. Are smartphones spreading faster than any technology in human history?; May 9, 2012 cited 2017 Nov 10

  3. Fortune Magazine. More than half of Kaiser Permanente’s patient visits are done virtually; October 6, 2016 cited 2018 May 9

  4. Jones J, Norman K, Saunders S. The state of the union: Trends and drivers of change in Physiotherapy in Ontario in 2014; November 11, 2014, cited 2018 May 9

  5. Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ, Godges JJ. Knee stability and movement coordination impariments: knee ligament sprain. J Orthop Sports Phys Ther. 2010; 40(4): A1-A37.

  6. Adams, D, Logerstedt D, Hunter-Giordano A, Axe ML, Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. J Orthop Sports Phys Ther. 2012; 42(7): 601-6

  7. Campbell R, Evans M, Tucker M, et al. Why don’t patients do their exercise? Epidemiol Community Health 2001;55:132-138.

  8. eMarket. 2 billion consumers worldwide to get smart(phones) by 2016; December 11, 2014, cited May 9, 2018

  9. Islam R, Islam R, Mazumder T. Mobile application and its global impact. Int J Enj Technol(6) 2010 Dec;10(6): 72-78

  10. Labrique A, Vasudevan L, Chang LW, Mehl G. H_pe for mHealth: more "y" or "o" on the horizon? Int J Med Inform 2013 May;82(5):467-469

  11. Tomlinson M, Rotheram-Borus MJ, Swartz L, Tsai AC. Scaling up mHealth: where is the evidence? PLoS Med 2013;10(2):e1001382

More than ACL rehabilitation. Any questions?

Since I started this blog on December 11th, 2016 with my first blog about how to use crutches I have been focused on ACL rehabilitation. This made sense since I have helped to create an app for ACL injuries! For 3 reasons the blog will now include more than just ACL topics: 1. My patients and our blog users have been asking questions about things related to physical therapy and rehabilitation for other injuries, 2. I work with patients who have other injuries, 3. the excellent blog contributors I work with (Alenna, Nicole, Prateek, Tashkin) have expertise in a variety of areas besides ACL injuries.

This blog will still include information about ACL injuries but it will also include information about rehabilitation for other injuries.

I am now asking anyone who has a question related to physical therapy, rehabilitation or injury to email me (meetcura@gmail.com) with your question. If it is a really good questions that could help others we will answer the question in a future blog and publish your name! On the other hand if you are a physical therapist or an expert in the area of injury prevention or rehabilitation and you wish to contribute to our blog please email us (meetcura@gmail.com) and let us know what you wish to blog about.

Ice, compression, elevation and ankle pumps

After surgery or injury you will need to learn how to reduce swelling by using ice, applying compression using an elastic bandage, elevating and doing ankle pumps. All of these steps together will help reduce your pain and swelling.

Here are the basic steps:
1. Fill a sealable bag with ice cubes or use an ice pack
2. Place a plastic bag over the area and ice on top of the plastic bag
3. Wrap an elastic bandage over the ice. Learn how here
4. Use 5 pillows to create a wedge or ramp as shown in the video with your feet higher than your hips and your knees and hips straight
5. An ankle pump is moving your ankle all the way up and all the way down without holding either position. Do 50 of these every 5 minutes
6. Lie down with your head lower than your feet for 20 minutes

Our app, Curovate, has all of your daily exercises for ACL rehabilitation as well as built in reminders and timers for ice, compression, elevation and ankle pumps!

Here is a video (which can also be found in our app) of how to ice, compress, elevate and do ankle pumps.

ACL social support

After an ACL injury or surgery social support is very important to help you recover. The ACL Recovery Club is a social network of people who are going through the same challenges as you.

After I wake up from ACL surgery, what should I expect?

I have been through orthopaedic surgery myself (not ACL) and I can tell you the first day sucks! When you wake up you will feel very groggy and out of it. You likely won't have pain immediately since surgeons use medications to numb the operated area which will wear off in the first 24 to 48 hours.

When you do feel pain you are experiencing it from many different areas. You will feel pain where the surgeon made a cut or an incision to do the surgery. You will experience pain where the surgeon took the graft to replace your ACL. You will feel bone pain since this surgery involves some drilling into bone and you will feel the general pain and fullness due to swelling in your knee. You may also have pain in your throat as most people who undergo a general anesthetic have a tube put into their throat. This will make talking, swallowing and drinking hard for the first 1-2 days.

Hopefully before you leave the hospital you will be taught how to use crutches to walk. Make sure you know what your "weight bearing status" is. This is how much weight you are allowed to put on your operated leg. If you need a refreshed on how to use crutches you can refer to our previous blog here

It is very hard to remember instructions right after surgery so don't be surprised if you forget most of what you are told. This is why it is important to have a family member or friend with you right after surgery. Also, to drive you home since you will be in no shape to drive. Seriously, don't try to drive!

Once you get home remember to take your mediation as it was prescribed. You may feel super human because unlike everyone else you feel no pain. But this is likely just the anesthetic talking and as soon as it wears off you could be in considerable pain. If you have taken the medication as prescribed the pain will be manageable.

On the day of your surgery there are some simple things that you can start right away that are safe to do. If you are using our Android app for ACL rehabilitation this is Stage 0. As a physical therapist I can tell you that all of these things are great on the day of your surgery. However, I can honestly tell you as a patient I did NOTHING the day of surgery! If you manage to get some sleep, eat something and feel okay then you have done a great job! So get some sleep and worry about exercises the day after surgery.

When can I start jogging after ACL surgery? What is a walking jogging progression?

Usually 12 weeks after ACL surgery but there are some requirements before you start:

  1. You must have full knee bending and straightening when compared to your non-operated knee
  2. You must have minimal to no swelling in your knee
  3. You must be able to walk fast without a limp
  4. You must have minimal to no knee pain
  5. You must be able to walk 20 minutes without increasing pain and swelling
  6. You should have done squats and lunges before starting jogging
  7. You should have started some exercises to strengthen your non-operated leg

The details of how to get to this stage are specified in our ACL mobile app called Curovate that guides you through every day of your recovery! If you are not sure that you have met these requirements speak to your health care provider to make sure you are ready to start jogging.

I start my patients at week 12 with a walking jogging progression 3 times per week.
It looks like this:

5 minutes fast walk
1 minute jog
4 minutes walk
1 minute jog
4 minutes walk
1 minute jog
4 minutes walk
5 minutes walk slowing down
For a total of 25 minutes

Typically I increase the jogging time by 1 minute every week so that by week 13 it looks like this:

5 minutes fast walk
2 minutes jog
3 minutes walk
2 minutes jog
3 minutes walk
2 minutes jog
3 minutes walk
5 minutes walk slowing down
For a total of 25 minutes

Continue this progression 3 times per week until you are able to jog 25 minutes continuously. I also consider the patient's goals and if they have no desire to jog for 25 minutes then I modify what they have to do. If a patient wants to play a sport involving running then jogging for 25 minutes is a requirement after surgery and before returning to their sport. There are additional return to play guidelines provided in our ACL app here.

You can get the full 6 month ACL rehabilitation program which includes the walking jogging progression and all of the information about when you are allowed to do various physical activities after ACL injury at this Google Play Store link.