All right. Thank you very much, Brian, for the introduction. My name is Kevin Vincent. I am the Chair of the Department of Physical Medicine and Rehabilitation at the University of Florida. So I get the honor of introducing our speaker tonight for National Grand Rounds, which is going to be Dr. Heather Vincent. So currently, Dr. Heather is the Vice Chair of Research and the Director of the UF Health Support Performance Center at the University of Florida in our College of in our Physical Medicine Department. She did receive her PhD in exercise physiology from the University of Florida and completed a postdoc in complementary alternative medicine at the University of Virginia. Her area of research and much of her educational expertise is in the areas of exercise medicine and prevention of physical disability across an age spectrum from pediatric all the way through our older adults with musculoskeletal pain conditions. She works very directly with our clinicians, so she interfaces with them in a patient facing setting, helping to directly translate science into effective, innovative clinical practice and patient based outcomes. She does have over 400 published works and recently was named one of the top 1.9 percent of all rehabilitation risk researchers in the entire world. So with that level of citations and publications, we're very honored that Dr. Heather brings this area of expertise and translational approach to tonight's topic. So without further ado, it is my pleasure to introduce Dr. Heather Vincent. Dr. Heather, take it away. Thank you very much, everyone. I'm going to go ahead and see if we can get this to advance. First of all, I want to take a moment and thank each and every one of you for taking time out of your evening to spend with us. Tonight we're going to discuss a few things and I wish I had more time to discuss it with you because the field is changing so quickly. So what I'm hoping to be able to do with you tonight is talk about considerations for selecting technologies for assessment of biomechanics related markers in your clinic, talking about pros and cons of different technology types for use, and then share with you a couple of clinical scenarios in which we can apply these technologies to really enhance the patient care experience and improve outcomes. And I do want to make a point that the items that we've picked tonight really have relevance to all areas of physiatry and not just to specific subgroups. So we're going to be talking about technologies that cross disciplines from sports medicine to spine interventions and management, pediatrics, traumatic brain injury, and more. So I'm hoping to leave you tonight with a nice broad understanding of what we can do in the clinic to enhance experiences. And so as we think about what and how to use technology in the clinic, a couple of things to keep in mind. Always go back to the basics and remember what your clinic missions are. So if you stay true to what your original intent was and understand the patient population, you'll get a really good match of the technology that you need to accomplish your goals. Second, canvassing patients and families to understand their interests and needs with respect to technological outcomes is really important. And over the past year, I've spent some time canvassing patients in the UF system, and we discovered that gait and physical function metrics that we're going to talk about tonight are extremely important to both patients and families, just as important as understanding other metrics collected in the doctor's office. Also, think about the time that you have in your busy workflow to accomplish these measurements. Now, it might not be you directly as the attending physician, but if you have staff that work with you, consider in your clinic flow what can realistically be accomplished and how can you instill that into your day-to-day process. Resources will always be important. So getting an idea and keeping track of what you have for financial, human, and space resources is also going to dictate, in part, what technologies might work most effectively. And then finally, thinking about opportunities just outside the data collection standpoint, what are ways to maybe increase billing capability, whether it's through insurance, which is a little bit more challenging, but also cash-based services. So as you on the call are thinking about ways to maybe rejuvenate some of the services that you're working on, potentially cash-based services for some of these extras might be very enticing, but also provide that extra layer of concierge service for whatever location that you're in. So another question to think about, is your clinic academically affiliated or is it freestanding in a private situation? And so technology is also going to drive some of these decisions, whether or not your clinic involves research efforts, learners as part of your clinical care paradigm, or if it's strictly a business-driven model in which really it comes down to more funds flow and a private practice type of effort. And if I could leave you with a point today, is that technology is always changing, which is good and bad, because it means so are the developers. So as we think about some of this emerging technology, it's really exciting that on a daily basis, I'm constantly keeping my pulse on what's going on out there to see what is emerging. But the number of small companies and startups is growing by leaps and bounds, and it's always a little bit risky to consider investing a lot into a smaller company, even though the idea is great. So we caution you to think about looking at the technologies that you're interested in, but maybe it might be prudent to look at more established technological companies that have a track record of producing some really nice equipment, devices, software of interest, and then seeing if they're moving in that direction of the true technology you're interested in. Often they are in the backgrounds, and it's just not available on the internet to be able to see yet. So not that working with small companies is necessarily a negative, just understand that there are limitations that some of the companies that are brand new over the last year or two might not be in existence in another year or two, they might be folded in or bought up by another large company. And also just a thought that technology, just for the sake of technology, really doesn't improve care. What we want to share with you tonight is that technology should enhance the overall art of medicine and the services that you are providing. So strongly consider how technology can really enhance what you're doing and how patients are going to benefit. So as we think about the clinical needs with respect to the biomechanical features that we're going to talk about tonight, I picked specific groups that have direct relevance across the spectrum of physical medicine care. So we're going to talk a little bit about gait outcomes, balance, force measures, reaction times very briefly, and then functional tasks and activities of daily living. So as we look across the board, we would also encourage you to think about doing some homework and looking at the technologies that really might be able to suit multiple purposes really for the best cost. So getting the best deal and providing you with the advanced knowledge and capabilities that you're looking for. So starting first with gait outcomes, we know that gait is a fundamental underpinning of physiatry and is extremely important for disease management and treatment outcomes. So the trackable parameters that are extremely important for clinical care include understanding temporal spatial parameters, kinematic, and kinetic. So these would be things such as velocity, cadence, step lengths and widths, toe angles, and swing and stance times for the given parts of the gait cycle. Some technologies also offer information about joint positions and excursions, and others also provide information about how the human body is interacting with the ground, ground reaction forces, joint moments, and power. And so why measure these? Why is it an important consideration in your clinic? Maybe to think about this as a way to improve your care. Gait is extremely powerful prognostically, particularly based on patient type. So gait outcomes provide very strong and powerful insight on disease progression, areas to target, looking at efficacy of physical therapy or other interventions, a recovery post-surgery or readiness to return to activity or sports. And then also measuring this in clinic excites and engages patients and families. So if you're looking for something that really gets people into understanding their care, it's providing feedback on some measurables that are direct, relatively easy to understand, but also have very powerful prognostic value. You can measure gait outcomes across clinical settings depending on the technology that's used, whether it's in the therapy clinic, clinical testing labs, or directly in patient room areas or hallway spaces that are set between conjoining clinic rooms. So traditionally, and I would say over the last 10 to 20 years, most of what we have worked with are treadmill-based options, which include marker-based optical capture with infrared cameras. Now this is an excellent gold standard to work from, but these technologies are expensive. They require a lot of processing time, and most clinical conglomerations really don't necessarily have the ability to do this. This is not something that all clinics can do. In the meantime, over the last 10, 12 years, there's been a plethora of new software developments for iPads or phone video reviews that have worked to try and provide cursory overviews of gait measurements across a variety of settings, and that's wonderful. So we have our gold standard, we have cursory, but is there somewhere where we can go in between with advancing some of our metrics here? And the answer is yes. The future is going toward artificial intelligence-based markerless motion capture. So some companies now have stepped forward, and instead of using infrared cameras, are now using just simple video-based groupings of cameras together to create a 3D hull of a person in space. And so what I'm showing here for these pictures over here on the right-hand side, few companies have now gotten into the market on this, and these include companies such as Dari, Thea, among others. And the concept is to create a video hull from the person while they're moving through the camera space, and apply and snap onto the video hull a skeletonized version, which actually comes pretty darn close to what can be captured with our gold standard. So what I'm showing you is a picture of a demonstration that we were doing in our laboratory space that is directly connected to physical therapy and right underneath the clinics upstairs in physical medicine. So this person is on the treadmill with the blue skeleton that moves in real time over a moving person. This type of technology is continuing to improve every day that we speak. As more and more data captures occur, the processing and the deep learning and the thinking by these AI algorithms improves every day for greater precision. Now the only downside to this is that these are a little bit more costly than something like the iPad or the phone video review, so a typical cost outlay for something like the systems that you see here is roughly about 25k plus annual subscription costs or a one-time investment with doing your own processing. So there's a couple ways to embark on this trajectory depending on the company that you're working with. The setup for these type of video-based systems is really quite flexible and it can be placed into real-life scenarios. So whether you're in a private clinic space, an academic clinic practice, or you want to have the setup in an affiliated PT clinic, this just shows you over here on the left-hand side the variation of spaces that the system can accommodate. And here you can have a very small clinic footprint of an 8x8 space all the way up to a 50x50 foot space if you have the ability to use it. So we can accommodate a variety of options here depending on what your situation is. Now if these cameras are too much there's other technology that is rapidly developing and these are applications that can be available through iPads or phones and these are also AI based. Similar concepts but these are much easier to use and they're plug and play. So if you get the chance check out corporations such as Exer Labs Incorporated. Their software is called Exergate and really what they're doing is a similar concept as we just saw with the video-based systems here. And the series of pictures here along the bottom of this screenshot shows a person in a PT space simply walking through the front of an area where someone is holding an iPad. Using a single camera, AI algorithms are able to provide and develop estimated joint centers and tracking a human being while they're ambulating across the screen. What's remarkable about this is that you can get some basic kinematics and your temporal spatial features of gait for a relatively cheap cost. So you might find based on your needs or based on your resources right now starting with something like this is the way to go get an understanding of how it can help how it works in your clinic flow. If you like it then invest and save for something a little bit more sophisticated and keep growing. You can also take these apps and up the level of sophistication by combining them with wearable sensors. So the term wearable sensors is now the buzzword in human motion where the field is trying to rapidly develop and outcompete with each other which type of sensors are going to be most effective for capturing the human experience. And so here there are combinations of basic iPhone apps that can collect simple gait metrics for walking and these include things like the gait analyzer which we just took a step a look at, step lab which I'll show you in just a moment, and pocket gait which will come next. And the advantage a potential advantage of using AI-based applications with the use of what are called inertial measurement units or IMUs might give you a little bit more sophistication in understanding the phases of the gait cycle and what's going on. So what this image is showing over here on the right hand side is a young lady who's demonstrating putting these little pods or IMUs on the top of her shoes. She simply started up the iPad application and is now a plug and play able to track the movement that she's doing for walking gait. These systems are cloud-based or downloadable so depending on your location, institution, what your capabilities are you can pick and choose which technology type might work best for you and these are also subscription-based and on average you might see these run anywhere from about 800 to about 1200 a year. Some of these companies will also offer a few thousand for a lifetime of the device and so the reports that you might get in cases like this include step number, cadence, distance, and velocity, and important features about the gait cycle that might be important to you in clinic. So for those who work with individuals that might have more mobility limitations or cognitive issues or need to be concerned about balance and control, these type of situations can provide information about double stance times, stride, toe coherence, and also provide basics about the heel angle and the forefoot rocker angle to get a feel about how people are interacting with the ground. So it gives you a little bit of extra precision in what you're doing. This is a sample called Pocket Gait App and this was actually designed largely for the elderly. This is strictly for walking and the technology actually first emerged in 2020 but has rapidly developed to something that now people can purchase and use and could be useful for you in your clinic setting. So this person is demonstrating the placement of the phone on the back of the spine above the sacrum and she's actually going to walk up and down a clinic hallway. Very easy to use, plug and play, ready to operate very quickly. What's interesting about this option is that there are several conditions in which you can capture gait motion. Normal speed, fast walking speed, and then putting a cognitive challenge while walking. So this is asking the person to walk while doing math subtraction efforts. So doing a dual task can also be captured on this device. Here you get output such things like step frequency, variation around steps, step regularity, step time, symmetry, and variability. This information can be put into graph form, report form, and then you click a button and it can be sent also like an email or an attachment. So there's some benefits to these simple types of emerging technologies. They're quick, they're easy, and could potentially enhance your interpretation as part of your clinical care. Other options for gait include gait mat devices. Now the concept for this has been around for a little while but what has drastically changed is the technology with respect to the software. So over the last 10 years there has been a huge and dramatic improvement in how data are captured and processed with these devices. So what we're looking at here is simply a concept of creating a portable device that can be placed on the floor in just about any setting as long as it's stable. These devices range in lengths and also range in sampling rates depending on what your needs are. So three companies that are shown here are TechScan, GaitRite, and ProtoKinetics. TechScan on the top, ProtoKinetics on the left, and GaitRite over here on the right. The beauty of every single one of these options is all you have to do is plug into a USB port and it is ready to go. You create a patient profile and these devices will produce quite sophisticated information about time-related sequencing events with respect to gait cycle, stance times, double support times, temporal spatial, and now the greatest advancement here especially with the TechScan device is being able to estimate kinetics. So by making calculations based on a person's body weight, these devices now can provide you with force estimates and ground reaction forces. So this device might be able to give you a couple things in one product. GaitRite has a similar idea that they use pressures rather than forces, so a little bit different. All of these provide the opportunity to give you information that you can use to produce research with, teach with, but also provide printable reports for your patients. These are samples of what some of this output might look like. So the left half of the screen is the TechScan output and the right side refers to the GaitRite output, and you'll see in general concept is about the same. So the top bars on each of these show you a tracking of foot fall to foot fall to foot fall between colored blocks here, a left and a right to a left and a right, and the gait mat over here shows a purple foot and a green, purple green. So it's simply mapping out foot fall after foot fall and the line simply connecting each foot fall represents the movement of the center of gravity from foot to foot. So this gives you very visually appealing and very important metrics that you can use as part of your feedback to the patient, with the patient, and back and forth with therapists to see what the next target would be. The TechScan also provides for you the kinetics on the bottom to show ground reaction force curves, and the outputs also provide differences between right and left feet, which is also a really nice advancement in how the software is working. The gait mat also does very similar features as well. It just depends on user preference, what type of screen view you like to see and what you like to work with. These data can also be downloaded in raw form should you wish to pursue any of this further. So this has been a great tool for us in our clinics. We've used this for runners, walkers, people who have had severe pes planus. We've used it in amputees, people who have had mobility challenges using assistive devices. So these are technologies that are very, very flexible and usable directly in clinic. So the pros and cons for these style of instrument really are they're easy to lay out, set up, and begin using. They produce reports that are relevant and printable. They can be set up and taken down quickly and very easily put into part of clinical visits, especially if the device is kept up on the side as part of a walkway in a hallway area that can work very well, and can be used from pediatrics all the way to elderly. In addition, there is the potential to enhance filling and easily incorporate into research. At our institution, we also use this as a fee for service. So should people want to come in and use this to enhance what they're doing, we're very upfront that it may not be covered by insurance and they will pay out of pocket. So consider that as well that patients may be willing to provide a little bit for that extra service. The con, like anything else, there's always the cost associated with it. These devices are not cheap, but what you get over the long term, and they're very durable, they last a long time, I think you get your money's worth with these type of devices. So as an overview of what we can look at with respect to gait, apps, apps and sensor combinations, markerless capture, and mat devices, if we look at all of these together, you can see a range of costs, ease of setup, and then what's going to give you really the most sophisticated output is really going to be the markerless capture and the mat devices. And that's okay. Should you want something that's a little bit maybe less precise or less with all the fancy features such as kinetics and kinematics, and you're fine with temporal spatial, the gait apps and the apps and sensors together may work quite well, and very easily in clinic. So if we take this now a step further, and work a little bit with balance and postural sway, this is an area also very important in physiatry, as this gives us an idea of movement control, either in a quiet stance, or as part of dynamic movement. So here we look at motion of the body, the center of gravity or center of mass, over the foot base of support. So that's what we're referring to when we talk about sway. And what we're particularly interested in, in tracking, and what technology can help us assess, are the time-related responses to when the center of gravity is perturbed or shifted. How quickly can your body respond to that perturbation? How quickly can your feet adjust to the shifting? Which side is taking more of the brunt of the responsibility or not? And what is the speed of the shifting of that center of gravity? So how much control does your patient have with balance and postural sway maneuvers? This has also very important prognostic value, but also really is important with tracking progress after specific conditions, such as concussion, traumatic brain injury, and so on. These types of measures can be collected across the wide range of clinical settings, but you may need a designated place either in the corner of a clinic room, or often a specific area so the equipment isn't banged or damaged. And the newest technology includes portable mats, platform devices, and mobile apps to provide you with a spectrum of capabilities. I want to share a few of those with you today. So these balance mats you see here, they're a kind of a cluster of the same genre of instrument, all from different companies, TextScan, X-Sensor, and the Novell E-Med sensor pads. And what they are is simply a force or pressure sensing device that here has become so easy to use, they literally are USB connecting right into a laptop. So you can carry this with one hand, carry the laptop, move it from room to room should you need to do that, put it in your therapy space, or you can combine that into your clinical research area as well. You can see from each of these, they're all slightly different appearance, the software all looks a little bit different, but the thrust of what it's collecting is pretty much the same. So think about what features are important to you, and you can decide which one is most cost effective. Two of these devices can capture quiet stance and dynamic capability and balance and control. These can also be used for capturing gait steps, so a person can walk back and forth and step directly on the mat, and it can calculate out some gait variables for you as well. So again, here's another instrument that can do a couple of things at once. Some of the sample outputs that you might see here are looking at pressure distributions of the plantar surface of the foot relative to the center of pressure. So what these pictures are showing here is the first one on the left is giving you an idea that this is a person in quiet stance with both feet on the platform, simply standing quietly. The red ellipse in the middle right there with this red smear and the black diamond right there, that is the center of pressure. So this person is not balanced, they're shifted off to the right. And what's happening here is that there's not an equal loading on both feet. So if you're looking at the percentage of how weight is distributed across the platform, you can coach in real time and make adjustments to re-establish normalcy and balance. So these instruments are also great for clinical tracking, but can also be a wonderful addition in the therapy area to help a patient achieve better outcomes over time. Other types of report outputs that are also available on these devices already include the force distribution over given areas of the foot, looking at ground reaction forces and shifting, and then also, and we'll talk about this in just a few minutes, about the plantar pressure distribution. Other options for looking at movement control with respect to balance and posture includes force plates. So you don't need necessarily a special force pad. If you've got a force plate, some of the new technology is in the software. So check out Nuraxon Myoforce software. This person is actually demonstrating the technique on Kistler force plates. So you don't have to buy the devices from the same company. You can mix and match the emerging technology with other devices that may be available. You just may have to check just to look at compatibility of how that may work. So these force plates, in addition to balance, during the balance maneuver can provide you or the therapist with important information about where force vectors are being applied to the body, which is extremely important to us when we look to see loading, where those loads are being applied to specific joints, how it relates to pain, movement control, and what parts of the body are compensating post-injury. In addition, this instrument can also be used for jump motions and recovery with landing. So for those that are interested in treating ACL injuries or doing ACL-related research, this might be a great addition to add as part of the clinical care paradigm in people that you are treating for return to sport after ACL injury. This also can be used for post-concussion assessment, readiness to return to play, and some of these products, such as Nuraxone, offer plug-and-play reports. So you don't have to create anything. These are done for you. And samples include this. So some of the reporting metrics that might be particularly important to you, especially for re-injury risks, include kinetic asymmetry. How is one side loading or placing forces compared to the other? What is the contact time and flight time during different maneuvers? Time to stabilization after a perturbation, so that can be for sway, but also with jump-related maneuvers, what is the peak power and impulse getting off the plates? And then coming back down upon landing, what are the forces upon landing as well as stiffness? So these are some hallmarks of different types of injury risks to keep in mind. This is quick, easy to do, and could very easily be implemented as part of your model. For single balance reports, I thought this was an interesting one to share. So you've seen now what the, excuse me, the mats might look like. This is what the Nuraxone force parameters might look like. So what we're looking at here is this gentleman is demonstrating a single leg balance test. Normally, we can look at this eyeballing it or using video or other maybe imprecise ways of doing this, but using tracing and force plates with this particular software and technology I'm showing you this red ellipse right there embedded within that is a black squiggle. This black squiggle is the center of mass right here in this red dot, roughly where the navel is. And as it is swaying and moving around over the feet, it is recording the amount of movement and sway. So it can provide for you a very discrete ellipse size of what that sway is over a certain period of time. Again, this is a great and easy way to test how well people are doing during their recovery period and therapy. Other types of software advancements allow a person to put this directly in clinic. So this is an AMTI platform option with a clinic software using a similar concept for tracking center of pressure and mass motion, but also the same software offers another advancement to be able to use this software to be able to use it for training purposes. So using the same instrument, not only can you measure, but you can use this as part of your therapy program in teaching people how to reestablish control with posture and sway. So using targets that the device provides to the patient, the patient tries to carefully move and control muscles to achieve an approved level of balance. If all of those are too much, we can always keep it even simpler. And like always, there's an app for that. So I wanted to share one with you that is brand new, and this is called the New Sway Balance Mobile App. And in this case here, I wanted to show this picture of this young lady demonstrating what this looks like. This can be used with iPhones with basically a single licensed user, if you will, the licensed user being able to apply this to the care model that they're using. And so the young lady is holding the cell phone and holding it as still as she can and trying to stay as stable as possible. And so what this allows the clinician to do is perform mass scale sway tests. So for those of you who were on the call who engage with high school outreach, work with teams, if you work with inpatient groups that might have class settings together where you might track sway and balance together, this is a great way to do that. So patients can simply hold the phone up to the chest. You can collect measures very quickly and download the information. Now, these run on a subscription-based service. These aren't cheap either, but they're less expensive than some of the other devices that you may be considering. So somewhere between 12 and 15K per year, depending on what that might be. And these are really good for conditions involving balance issues, cognitive change, and other related fall risks. So this also extends into the inpatient setting and you might get some benefit from that. For sports settings, this is excellent for concussion tracking. And actually the tools that are on here can actually replace the IMPACT, the SCAT-5, C3Logix, as well as the King-Devitt tests. It's also very helpful for digital tracking of return to play because the data are stored in a cloud-based fashion. So some of the output looks like this. And if you look at the reaction times, as well as the balance error scores here, provides test summaries, baseline ranges, and percentile ranks that are very easy for the clinician to follow track and determine whether or not there needs to be additional intervention. If we take a little step further, no pun intended, we're gonna go with plantar pressures and take the concept of what the mouse can provide that we talked about a little earlier and talk just a little bit more in depth about plantar pressures. So as part of balance and control, we also are concerned about plantar pressures. And so these mats that we've talked about before, or the long gait mats, can provide this information for you. And what this does is provide trackable outcomes of static or striding foot pressures and potentially kinetics. And when you look at this colorized visualization of the plantar surface of the foot, very quickly you can get a feel for how a person is doing with respect to loading. Areas of high loading with the red represent areas that are going to be experiencing greater push-off, whereas areas that are in blue have less pressure here. So the development over the last couple of years has largely been in the precision with these instruments and the software to provide outcomes of interest. So for those who are working with patients that have orthotics or insoles, or you're looking at treatment impact over a period of time, post-surgical tracking, this can also be very effective. I just want to show examples of what these outputs might look like. Some are very sophisticated with all the information you could possibly need and more, sometimes overkill depending on what your time to review the data are, but also from the therapy point of view, one application through TxScan is called the Sports AT, which is allowing the patient and therapist to interface together, use this device to provide patients with feedback and signaling so they can establish a shifting imbalance from one foot to the other or establish normalcy when put into positions where there is imbalance. So there's a lot of benefits from these tools to be derived. Now you can consider if cost is a challenge for gait, balance, and plantar pressure. As I mentioned at the beginning, I want to tie the concept back, choose one device that first captures as many as you need, and then add technology over time. So as we summarize a few of these technologies, sway apps, of course, are going to be the cheapest, pressure mats are close, but maybe slightly higher, force plates are going to be slightly higher, and then the software added onto that. Depending on what your interests are, if you want tools for extra tasks, such as jump and single leg tasks and other balance metrics, you might consider the pressure mats or the force plates to give you that extra bit of information. I want to come full circle to wearable sensors. So I want to revisit this concept of IMUs. And my feeling, based on the evidence, where the science is moving toward, I believe IMUs is really going to be the next major advancement next to video-based motion analysis. Why? Because they're easy to use, and these little devices are packed full of useful information. So an IMU is simply an inertial measurement unit, which contains in it a triaxial accelerometer and a gyroscope, which gives you not just information about joint angles and positions and where you are in space, but it gives you additional insight to how well people are accelerating, what angular velocities are, so those who are at risk for high-velocity-related injuries, and how gravity is playing on the human body. These IMU sensors are tiny. They're only about three to four centimeters in length, or they're small. And they often come in packs together, and they are applied to the body either using Velcro straps, like this person who is running. You can see they're applied in several different places around the body, lower body, axial area, and upper body. They can also be applied to smaller areas, whether it's wrist motion, foot motion, or otherwise for very active type of movements, high speed, and then also for people with mobility impairments. So the beauty of IMUs is that these can be applied in any setting, no limitation with respect to age, movement speed, bodily position, or otherwise. Now, I mentioned that they're often sold in packages with a little charger, almost like a battery pack, and often these come with various software to produce some automated kinetic metrics for you or joint positions, or you can download the raw data for you. So where I think right now in emerging technology we have a little bit of a mismatch is that this is a tool with so much promise, but not enough automated reporting yet, but I think this is coming. And some of this is the direction where our laboratory is going, is picking some of these key pieces of information to provide automated reports for movements that are important to our clinicians. Cost range for these is also very affordable with respect to how much information you can actually get from them, anywhere between 3,000 to 8,000 per set of six sensors, what you're really paying for when you go into this purchase is really what the company is giving you for their automated software. So if they're giving you metrics you're not really interested in, it might be worth considering getting a set that's from a company that doesn't provide as much of the software, and you can build a little bit on your own if you have someone who can help you with that part. So the strengths and the limitations of IMUs are the following. Strengths, they are so easy to put on, they're not threatening to the wearer, kids, older adults, people with different mobility capabilities. They're really relatively easy for capture with very little downside. They don't tend to fall off and they don't really move too much as long as they're securely anchored to the body. And you can collect natural movement across environments. In addition, as soon as you put the sensor on the person's body and you activate the software up on the laptop, you can start to see the movement already being captured. So it's responsive, it's very quick, and you can really visualize fatigue effects during human motion, symmetry issues, motion limitations. So I'm very excited to see in the upcoming couple of years what other types of software is gonna start emerging to allow the clinical user to take advantage of these strengths. Limitations currently are the prepackaged outputs might not be relevant to all of you on the call. And so this is likely a time where you might need to phone a friend and find an engineering professional or someone who can take some of these data and help you create some of these customized outputs, even in Excel, and then convert that over to something else. So that may or may not require a little bit of money for that first step. And then beyond that, the IMUs last a really long time. They're very durable and you can get a long life from them. So I just wanted to take a moment and share with you kind of a really crazy idea that we're doing at the University of Florida that involves clinicians, therapists, innovative therapy, and research, and how we are building this to help patient care. So we are using IMU models in a couple of weeks to put on patients who are suffering from chronic back pain and receiving care in our Spine Intervention Clinic. The main clinicians are sending their patients over and they're part of this exercise to look at how horticultural therapy may benefit spine pain through activating motion about the spine. And so we're using these IMUs in real time to watch what patients are doing as they participate in their therapy. Using those data, we're going to find who improves their pain symptoms and we're readily able to engage. Taking those data a step further, we're going to develop protocols based on what produced the most spine motion so we can inspire movement through activities that are fun and integrated. So we involve the clinicians to build better therapies for patient care, and we're going to put this toward research efforts to continue developing that area. I want to mention one piece about reaction time. Although reaction time per se is one of the lesser discussed biomechanical measurements, it's important here for physiatry in general simply because brain processing speed is going to be very important for how a person functions. So this is a brand new software called BrainGage, clinic software through cortical metrics. And what this is, it's a combination of a little mouse device, and you can see the hand on the screen with these little buttons on it. All it is is a USB plugin to a laptop. And what the laptop program does is send back to the patient tactile stimuli to the hand. And what that does is it's asking the person to respond based onto the tactile information or information on the screen. And in so doing, this USB device gamifies and helps to assess responsiveness, the human response to the signals from this BrainGage software. And what you can do with this is now take this to published normal values for all kinds of conditions ranging from post-concussion, traumatic brain or stroke, or various treatment paradigms. So keep your eye on this and watch for other additions that are going to be created. And then functional measurements, this is the last point that I want to bring together as the sort of the last domain. Functional tasks and activities of daily living can best be captured at this present time by markerless motion, IMUs, and various phonemes. So going a little bit further, I just want you to know that these capabilities provide a variety of automated reports, and some of these look like this. It's an overall joint review, which identifies areas of the body that may or may not be functioning in the optimal range similar to that of healthy adults with no other sort of impairments or limitations. So this is a really quick way of incorporating a screen, which might take about 15, 20 minutes to do in the therapy area, but repeat measurements or specific areas of repeat measurements are very important for tracking. And this is the second stage that I wanted to mention where I said markerless motion is going to be the way to go, using phone apps and making this accessible to the lay person and to the clinician together to be able to share information is going to be very exciting. So AI-based algorithms for iPhones are going to be extremely important for people of all ages and activities. So although this may not necessarily be ready yet for clinic use, I wanted to tell you that this is going to be up and coming, and I guarantee this is going to be coming forward for some clinical tests. This is a company called NewStream AI Technologies that just simply shows you a combination of taking a video hull of the human being from one phone camera point of view, which is pretty spectacular. So this technology allows one point of view to create an estimate of this human skeleton scaffold to be able to estimate motion here. The screen output simply provides information about the motion, and should the therapist be interested, you can set targets of motion for the person in real time, so whether or not they're executing a specific movement, you can have the therapist coach them into the correct position and make real-time adjustments. So as we close, I wanted to mention a couple last things and then open the floor for questions. At the beginning, I wanted to share with you a couple cases of clinical scenarios where you might be able to put this technology into your clinical practice, and what might that look like, depending on your space, your budgetary capabilities, and so on. So the first one that I wanted to share is a very busy high-output musculoskeletal and sports medicine clinic with an affiliated PT area and a performance area downstairs. So this is the model that we are working with right now. It's an academic affiliate with some research and teaching in this. So the needs are going to be high. The demand is going to be high for the type of technology that we're going to need. Services, basically anywhere from five to 85 years, and there are some that even go beyond that range, serving the regional and sometimes national community, school coverage, as well as competitive athletes. And the patient treatment areas in the building are in very close proximity to each other with a moderate-sized budget. So moderate is all in the ear of the beholder, and here we're talking about moderate is anywhere between 50 and 150,000 to at least get some key outfitting done. So what can you do with that? A couple of options are in the clinic space where patient care is actually being delivered, if you had to go from room to room, what could you bring with you for a relatively controlled cost? You can bring a portable mat platform, which can provide you plantar pressures, simple gait, kinematics, and postural sway. You can also use an iPad with a gait app and pick that option instead, or you can also choose the sway balance app. So that way, you are able to accommodate people of all different ages with musculoskeletal issues very quickly. In the ancillary areas in the same building, there's a markerless motion system, force platforms, and IMUs for use. So in real time, we can provide important information to the clinicians and therapists as our patients go from upstairs to downstairs for assessment, and then over to therapy. So if you think about your clinic flow and what this might look like, you can mix and match different types of technologies to accommodate as many of the patients as possible and get them excited and engaged and interacting with their therapeutic process. A second example is completely in the opposite direction. This is a stroke follow-up clinic outpatient. So let's assume that this is a private practice, a small local facility that services people largely over 35 years of age for long-term stroke management. It's in a community setting and doesn't have as much budgetary opportunity as the first option. And so here, how might we take advantage of this? How can we enhance experience and potentially improve billing capability? Well, in the meet and greet area as patients come in, you could lay out a gait map walkway. So as patients come and go, they can sign in, potentially do a brain gauge program, even in the waiting room while they're waiting for their appointment, get an initial kind of cognitive and reaction time to see how they're doing. And as they're brought back to clinic, they can walk over the gait map, collect information about how their gait is doing, plantar pressures, sway, and even some kinetics should you need that. And or room to room, you can replace the gait map walkway with a sway balance or a pressure platform. So any of those options could work quite well and provide some of that advanced technology that could get your patients excited and give that extra level of concierge service that patients are looking for. So some final reports, but before I love to hear from all of you is study your clinic, your clinic flow, your patient needs and discover opportunities. And what I mean by that are quality of experience for you as the clinician. How can you have a better understanding of what your patients are going through and what's working and what's not? I get better patient experience for those who are in it and living it and potentially for billing. And then understand the strengths and limitations of each of the options that you might be thinking about. Start with what's most important to you and it's going to give you the most positive change in your workspace and that doesn't impede workflow, which is the tricky part. And then choosing the technology that's budget friendly, meets a lot of options first or a lot of the checkboxes and then build more over time. And if I could also ask, share your outcomes with the field. So no matter where you are, it's so important for these startup companies, big companies, give them feedback. Provide what's working, what works really well, what do patients like? They want that feedback so they can continue to make the technology better. Companies listen. If they're not producing a product that you like, you're not going to go back and buy it and you're not going to recommend it. So your feedback is going to be extremely important to getting the technology that you need for your clinical practice. I thank you so much again for hanging with me tonight and we open up the floor and I also welcome Dr. Kevin back as the discussant in case there's any thoughts on clinic issues that he can maybe help me answer. All right, thank you, Dr. Heather. If anybody has a question, they can raise their hand. There was one in the chat that I can help to answer. The question was, is to insurance companies pay for an office gate analysis as a separate billable item or is it done as an extended office visit? So essentially that's going to be up to your local area. There are CPT codes for gate analysis, computerized, three-dimensional, planter pressures. So they're in the 9600. So it's 000, 96001, two, three, and four. And four is the physician interpretation. The hard part is, is what they do it for because it's considered by some to be experimental, saying there isn't evidence to show that it works, which is actually kind of funny, but that's what the insurance company will say. Most of the time it's for something neuromuscular, cerebral palsy, traumatic brain, quadriplegics, spastic hemiplegia, diplegia, and they're looking for it to be pre and post the procedure. So if you're getting ready to do Achilles lengthening procedure, if you're going to go and do something procedure-wise surgically, you can bill for a gate analysis beforehand and you can deal for one afterwards. And you can also get it for some of the prosthetics and orthotics. It just depends on the payer in your area, if they're going to honor the codes. We don't really have much luck with that at UF or in our area. We're in the First Coast area. There are some states that do, and most of that's going to be around pediatrics, around what I was mentioning, from a diagnosis and pre-post surgery. So that's kind of the answer to that question, but you just have to ask, what are the rules in your local area and see if they're honoring those codes or not. That's it. I think I saw another question just come into the chat here. Yeah, it says, what devices are best to be able to provide real-time patient feedback that can be used therapeutically? Great question. So I tried to tap into that a little bit in the talk tonight. It depends what you mean by therapeutically and for what purpose. So what I can tell you is that the gait mat styles are fantastic for feedback. So for example, as soon as a person walks across the mat, the trial is done and they can come right around and look at the computer with you and see what's going on, where there are deficiencies in the movement. Other options, actually the marker list works actually quite well because you can replay the videos of the blue skeleton of what the person is doing. And in real time, they can make adjustments to their movement. So case in point, yesterday we actually had a young lady with spina bifida come into the clinic and we had one of our attendings come on in as well. We had the young lady watch herself on screen with the skeleton applied over her body and she could make movement corrections to that. So anywhere where there's a type of visual where in real time they can make those adjustments, those are good options. I hope I answered that for you. Any other questions? It looks like we're going once, twice. It looks like we're at 8.59. So it looks like we're gonna be finishing right on time. So I'd like to thank everybody for spending this time with us tonight. Hopefully you learned some ways that we can apply these new technologies to help our patients. I will say at our institution, we utilize these services a lot across the whole spectrum of populations, whether we're looking at spasticity with traumatic brain and patients who've had a stroke, cerebral palsy, as Dr. Heather mentioned, spina bifida, we do it a lot in our athletic populations as well and back pain. So pretty much if there's a population, we apply these techniques and it's been a great help to help them get as functional as they can. So if you have the ability to deploy it in your area, that would be great for your clinic, it's great for the patient. With that, I am gonna thank everybody and thank Dr. Heather, thank the Academy for hosting this event for us tonight. We had a lot of fun doing so and everybody have a great night. Thank you very much. Thank you so much.

exercise medicine

physical rehabilitation

technology

biomechanics

patient care

selecting technologies

gait apps

wearable sensors

clinical settings