If we can bring the technology to the patients and not the patients to the technology, we will all be much more successful care providers," says Gad Alon, PhD, PT, associate professor at the University of Maryland School of Medicine, Department of Physical Therapy & Rehabilitation Sciences, Baltimore.

Entering the 21st century, most political activists, physicians, therapists, and other care providers—and the public—have become acutely aware of the growing need to expand physical rehabilitation services to the entire spectrum of people in need. Moreover, everyone is equally aware of the diminishing human and financial resources that are available to extend rehabilitation services.

The most likely option to bridge the gap between rehabilitation needs and limited resources is to develop rehabilitation technologies that will enable and empower patients to practice outside the clinical environment. To maximize rehabilitation outcomes, most patients with various diagnoses including musculoskeletal trauma or disease, peripheral vascular and integument (skin) disease, chronic cardiopulmonary diseases, and damaged central nervous system (CNS) must continue to train for months and years. The only groups that are yet to adopt this evidence-based concept (and reality) are clinicians (physicians and therapists) and most academic institutions.

In contrast, this likely scenario has been already adopted by leading companies of rehabilitation technologies, most notably those who manufacture and distribute electrotherapy, exercise machines, robotics, and virtual reality technologies. New electrical stimulation devices, including neuromuscular stimulation (NMES) and functional electrical stimulation (FES), treadmills, FES-motorized bicycles, virtual reality systems, and robot systems, are now available for training in the community and in the patient's home.

One exciting feature in the latest technologies is the ability to conduct simultaneously state-of-the-art clinical and basic research, while treating the patients in their home environment. For example, at the Department of Physical Therapy & Rehabilitation Sciences, University of Maryland School of Medicine, Baltimore, we are studying the effect of multichannel FES-motorized bicycle on selected impairments and locomotion deficits of chronic stroke using the TRI-300s system™, by Restorative Therapy Inc, Baltimore. Some of the data can be collected via the Internet while the patient trains at home.

Another new product is the Bioness™ L300, a radio-frequency-controlled neuro-prosthesis. It is an FES system designed to improve locomotion of persons with foot drop. The system not only improves gait performance but simultaneously collects selected gait variable data and actual-use documentation that is likely to help secure reimbursement.

Our research effort and clinical practice also include wearable stimulation technology from Bioflex Electromedicine, Columbus, Ohio. The system includes conductive garments that enable children or adults with low back pain, fibromyalgia, poststroke, and post-spinal cord injury to "dress up" and manage their pain, muscle weakness, or motor control and functional deficits.

The Sys*Stim 294 by Mettler Electronics Corp, Anaheim, Calif.

The two most common reasons that clinicians and academic institutions have not adopted 21st-century clinical practices are the inadequate training in therapeutic technologies (that many clinicians acknowledge) and the notorious question, "Who is going to pay for unattended, self-administered treatment at home?"

To overcome these barriers, we must challenge academic institutions to follow the lead of the advanced professional DscPT program at the University of Maryland, Department of Physical Therapy & Rehabilitation Sciences School of Medicine, which already offers an advanced course in Therapeutic Technologies, and extend training to clinicians in tele-rehabilitation. Therapeutic Technology courses are designed to integrate the latest knowledge of principles of operation, interfacing, and communicating with the human body and mind, the physical and physiological mechanism(s) of action that each technology is likely to enhance, and the commonalities and difference among the technologies with respect to clinical outcomes and cost-effectiveness.

An equally important component of the teaching is how to learn to determine whether the technology truly (objectively) helps the individual patient to perform better and how to construct and deliver the most effective and efficient treatment program that is mostly self-administered by the patient with or without the help of a caregiver in the home environment.

Finally, the course should include a component that strengthens the confidence of the therapist in her or his ability to become the expert adviser to the patient, which technology to choose or not choose, how to maximize its benefit, and equally important, when to stop using it. Such advanced academic coursework is a major departure from the classical university teaching of "modalities," that is typically taught in the first year of physical therapy school before the student has had meaningful exposure to clinical knowledge or practice, and thus is usually forgotten within 2 weeks after the end of the semester. No wonder that so many clinicians feel very uncomfortable and thus resist changing their "legacy" practice habits.

To become 21st-century clinicians, we must also challenge the rehabilitation industry to collaborate by developing together (common interest rather than conflict of interest) patient-friendly technologies that empower and motivate the patient to adhere to the training. Lastly, but equally important, we must transform the ailing, inadequate, and deteriorating reimbursement system by shifting the power of decision to what constitutes clinical evidence and what is an adequate cost of service, from the insurance industry to the patients and their care providers.

The most likely way to remove the reimbursement barrier is to ask political activists, the American Physical Therapy Association, the public, and the rehabilitation industry to join forces and transform the system. Maximizing rehabilitation outcomes—and invariably, the respect of our patients—will depend on our actions as clinicians in the next few years.

Gad Alon, PhD, PT, is an associate professor, University of Maryland School of Medicine, Department of Physical Therapy & Rehabilitation Sciences, Baltimore. Alon's research focus has been to find new or improved therapeutic technologies that help to maximize clinical outcomes in patients with musculoskeletal, neurological, and peripheral vascular trauma or disease. He can be reached at .

Electrotherapy in Physical Therapy

Electrotherapy for treatment of pain and inflammation is widely used in physical therapy today. There are several types of electrotherapy, including those used strictly for pain control such as the commonly used transcutaneous electrical nerve stimulation (TENS); interferential current (IFC), which is essentially a deeper and often more effective, longer-lasting form of TENS; Russian stim for re-education and strengthening of atrophied muscles; and the newer and fast gaining microcurrent, which utilizes small-intensity current to stimulate a natural form of rebalancing in injured or compromised tissues.

Other forms of electrotherapy include galvanic stimulation and iontophoresis. Ultrasound, while strictly speaking is not electrotherapy, is often used in conjunction with electrotherapy for optimal healing results, and is offered along with various types of electrotherapy in "combination" delivery systems.

TENS, which was introduced into the healing professions in the 1970s and has since become a standard modality for the management of chronic and acute pain, works by overloading high-transmission-velocity nerve fibers on the skin, blocking the slower-transmission fibers that carry the pain signal from the brain to the affected area.

The Empi Select™ TENS unit.

One of the TENS products currently on the market is the Select™ TENS unit by Empi, St Paul, Minn, designed specifically for the relief of chronic, arthritic, and postsurgical pain. The Select TENS is a portable device that can be used at home or on the go, and integrates site-specific, preset treatment programs.

IFC, which modulates a penetrating high-frequency carrier waveform, has become widely used due to its deeper healing capabilities. Interferential units are more expensive, especially as they are commonly offered as an element in combination units.

A combination unit that features interferential as well as Russian stim is the Z-Stim IF250 by Amrex-Zetron, Carson, Calif. The IF250 is microprocessor controlled with solid-state circuitry; and it has quad-polar, bipolar, and Russian modalities. At a lower current (and cost) is the MS322 by Amrex-Zetron, which is a single-channel low-volt AC muscle stim that features variable pulsation mode and combination therapy capability.

Another combination model that provides a full range of currents—including interferential, premodulated, high volt, and microcurrent—is the Sys*Stim 294 by Mettler Electronics Corp, Anaheim, Calif.

The Intelect Legend® XT by Chattanooga Group, Hixson, Tenn, provides six clinical waveforms: interferential, premodulated, high volt, Russian, symmetrical byphasic, and microcurrent. It has two independent channels but allows for two additional channels with add-on modularity.

Chattanooga also offers a stand-alone portable ultrasound unit—the Intelect TranSport® ultrasound—that can be configured for desktop, wall-mount, or mobile use. It has fully functional 1- and 3.3-MHz frequencies, pulsed and continuous therapy operation, and 10 user-defined memory positions for user protocol. The Chattanooga Intelect Legend XT Four Channel Combo includes dual-frequency ultrasound along with all of the popular electrotherapy waveforms.

With such a variety in electrotherapy technology, PTs are not wanting for choice of treatments. And with the combination models now available, convenience is readily at hand.

—Alan Ruskin