Treatments

Orthopedic Physical Therapy

5 Important Questions To Ask Your Physical Therapist Before Starting Treatment

Physical Therapy Questions To Ask Before Starting Treatment

If you are starting physical therapy for the first time or someone returning for another round of treatment but trying a different clinic, ask these five crucial questions before you begin treatment. These questions will help you make more educated decisions about your health while avoiding setbacks, wasting time, and insurance benefits. Ask these questions over the phone before your first appointment or during the initial evaluation to ensure your treatment plan is clear and in line with your goals and expectations.

 

Best Physical Therapy

Question 1: What specialized training do you have to treat my particular condition?

Each physical therapy practice specializes in different types of rehabilitation, and each therapist that works at the practice also has their own specific education and certifications. Make sure to ask your therapist if they treat your condition or symptoms regularly and what credentials they have that will benefit you during recovery. 

The American Board of Physical Therapy Specialties list ten specialties, which is always great to identify to start:

  • Orthopedics
  • Cardiovascular and Pulmonary
  • Clinical Electrophysiology
  • Geriatrics
  • Neurology
  • Oncology
  • Pediatrics
  • Sports
  • Women’s Health
  • Wound Management

On top of that, there are individual certifications and continued education for therapists, such as:

  • DPT– Doctor of Physical Therapy
  • OCS- Orthopedic Certified Specialist
  • MLD- Manual Therapy Certified
  • ATC- Athletic Trainer Certified
  • PAS- Postural Alignment Specialist
  • COMT- Certified Orthopedic Manual Therapist
  • BRM- Barbell Rehab Method
  • BFR- Blood Flow Restriction Training
  • IASTM– Instrument Assisted Soft Tissue Manipulation

And many more.

Question 2: Who will I be working with for each visit? Will it be the same person each time?

Many people run into this problem in as little as a couple of appointments. They have an initial evaluation with a Doctor of Physical Therapy (DPT) and return to their second appointment to find out they will be working with a physical therapy assistant or a physical therapy technician.

Technically, this is ok as long as a licensed DPT is present in the clinic area, but it could lead to some problems with the quality of treatment moving forward. A PTA or PT Tech does not attend the same amount of schooling or have the same experience as a DPT.

If you or someone from your family is a fall risk, has new questions at each appointment, or requires special attention, it may be best to find who you will be working with each time. 

At Balanced Physical Therapy, all of our patients get treated by a licensed and certified Doctor of Physical Therapy. We believe this is the best way to provide the safest, most effective care for everyone. Patients experience different symptoms and feel better or worse daily. With Dr. Robert Litzenburg and Dr. Tori Gasperoni working individually with each patient for all appointments, they can adjust treatments quickly, provide timely and accurate education, and notify primary care doctors when necessary.

Mt. Clemens Physical Therapy

Question 3: How much time will I get with my physical therapist? How much time will I spend with an assistant, tech, or aid?

A great follow-up question to question number two is to find out the specific details of how much time you spend with each person. Confirm exactly what your treatment will look like if you are getting treatment from a physical therapy clinic that splits up your treatment time between a doctor, the assistant, and/or aid.

Sometimes certain therapy places will have the DPT or PTA perform manual skills at the beginning or end of treatment and exercises under the supervision of a tech/aid/or assistant.

Question 4: How long will each physical therapy appointment be? And how long will I be attending physical therapy?

These two questions for your physical therapist will give you a better idea of how long your recovery process will take. While an exact time may be difficult for any healthcare professional to provide for new patients, you can still gain valuable insight, even if it’s a general estimate.

Appointment times vary from clinic to clinic and typically range from 30 minutes to 45 minutes, up to an hour. At Balanced Physical Therapy, we always say time is valuable and something to consider seriously (which is why we treat every patient for 1 hour). From the surface, patients can flat out get more done in an hour than they can in 30 minutes, allowing them to progress better and/or more quickly. Other patients recover a little slower and can’t rush through an entire treatment program like others, which is another reason more time should be allowed.

Question 5: What will I do at each appointment with my therapist?

Each patient is different and requires specific treatments more than others. Knowing what you will be doing at a physical therapy session for the first week, month, and months after is crucial.

Pain management, strength, flexibility, mobility, biomechanics, and sports-specific exercises are a few possible things to work on during an appointment. Ask this question to make sure what you are doing is safe, will contribute to better outcomes, and help you achieve your long-term goals.

Mount Clemens Occupational Therapy

Occupational Therapy For Work Related Injuries

Occupational Therapy

A work injury is a common fear for many people across Michigan and the United States. Autoworkers, stockers/order fillers, construction workers, retail associates, and even nurses all have repetitive tasks that make them susceptible to injuries. Looking closer, every workplace has its dangers such as hazardous chemicals, unsafe tools, and poor ergonomics. If an injury occurs at work, it can be difficult for a person to adjust from a pain-free life where a person can make a living; to recovering and returning to a routine.

Occupational therapy is a great tool available for any employee injured on the job to help alleviate the confusion about what is wrong with the body and provide rehab expertise so you can return to work without risking another injury or more damage.

Occupational Therapy

What is Occupational Therapy?

Occupational therapy (OT) is an all-natural healthcare specialty focused on helping people of all ages with workplace-related injuries return to a pain-free, active life and improve how a person performs activities at work. The procedure involves diagnosing the injury type, the severity of the injury, what factors at work or throughout the body contributed to the damage, and creating a plan to return to work safely.

Specifically, occupational therapy includes therapeutic activities to improve mobility, body mechanics, coordination, stability, and employability. Patient education also provides workers with practical techniques for managing any symptoms caused by a work-related injury and putting preventive measures to ensure further damage doesn’t occur.

Common Work-Related Injuries

Cumulative Trauma Disorders (CTDs) are injuries caused by repetitive motions. CTD’s can be thought of as minor stress injuries that accumulate and worsen over time. A CTD can result from several things such as muscle imbalances, inefficient workstation setups, or just performing a task a thousand (or more) times a day for many years.

Injuries that fall under CTDs include:

  • Clinical syndromes (inflammations of the tendons such as tennis elbow)
  • Nerve compression disorder (for example, carpal tunnel syndrome)

carpal tunnel from working

Other common injuries that require Occupational Therapy include sudden injuries. These are injuries that happen quickly because of poor work safety standards or accidents such as:

  • Slips, Trips, or Falls
  • Overexertion and Muscle Strains
  • Bone Fractures and Dislocations
  • Neck Injuries (including whiplash)
  • Back Injuries ( such as herniated disc)

Why is Occupational Therapy Important?

Being injured in the workplace, either by an accident or repetitive stress, can severely limit or completely change someone’s life. Occupational therapy benefits injured workers by allowing them to regain function after an injury so they can return to work confidently and safely.

In the process, injured workers learn the specific triggers that put them at risk for re-injury, how to handle a flare-up, and ways to adjust to limitations when returning to work.

Occupational therapy can help workers return to normal after common work-related injuries. It allows them to work more confidently and strengthen/maintain their bodies for many years after discharge.

Occupational Therapy Benefits

Regain Strength and Prevent Further Injury

When a worker sprains, strains, or breaks a muscle, ligament, or bone, the body becomes weakened. Occupational therapy strengthens the injured body part and surrounding areas so that you have better protection from being hurt again in the future. In the case of a CTD, rehabilitation of a tendon or ligament can include implementing proper techniques for repetitive tasks that can cause that injury.

After a sudden injury such as a disc herniation, learning proper body mechanics for pushing, pulling, and lifting is one of the best ways to prevent future accidents. In the process, your therapist will also use natural methods to decrease pain so that you can work on more advanced exercises.

Mount Clemens Occupational Therapy

Avoid Surgery

With CTDs, if you and your doctor can catch an injury early enough, it is possible to reverse sufficient damage to avoid surgery. When a person takes advantage of the therapist’s expertise and comprehensive therapy plan, occupational therapy offers an opportunity to ease pain and regain function without going under the knife.

Eliminate Pain and Minimize Surgery Complications

After a workplace injury, occupational therapy can introduce methods for pain reduction, including splints, taping, and manual massage techniques.

After corrective surgery, occupational therapy will provide you with the best therapy treatments to return to full functionality quickly and safely. Communicating with your therapist, attending every appointment, and following a home exercise program can be critical in preventing setbacks, surgery complications, and re-injury.

Retain Independence

One of the most frightening parts of an injury from work is how it may change a life. No one wants to give up their hobbies or not have a source of income, so losing independence because of an injury is can be a scary thing. Occupational therapy offers ways to help heal your body and provides new methods for adapting the world to your body’s unique needs.

How Balanced Physical Therapy Helps With Worker’s Comp Injuries

After you’ve been hurt, you just want to feel better. We understand your concerns and fears, which is why we provide full 1-hour appointments with a licensed and certified therapist. With no double or triple bookings, we make sure injured workers are our number one priority. Our therapists are known for working with your doctors and worker’s comp case managers so that you get the care and documentation as quickly as possible.

Rest assured that when you work with Balanced Physical Therapy, your health and recovery will be cared for by most professional staff (we do not use techs or aids to provide our treatments for our patients. With flexible appointment times for early morning and late evenings, we are always ready to help anyone in Mount Clemens, St. Clair Shores, Clinton Township, Fraser, and other surrounding areas of Macomb County.

Our primary focus is getting back to living with the joy and confidence you had pre-injury. To find out more about our occupational therapy treatments, insurance coverage, or appointment availability, give us a call at (586) 741-5806.

 

 

Physical Therapy For Athletes

Benefits Of Physical Therapy For Athletes

Physical Therapy For Athletes

Physical therapy and sports medicine for athletes focus on the mechanics of your moving body. How an athlete’s body moves, what muscles and ligaments are used in each movement, and what are the strengths and weaknesses to work on in order to fully recover.

Working with a physical therapist will aid athletes in getting back on their feet (metaphorically and literally) quicker, safer, and more efficient.

Sports Injury Doctor

 

What is Physical Therapy?

Working with a Physical Therapist for athletes is like calling an auto mechanic for your car when you see a check engine light. Just like a mechanic will run the engine, listen for unusual noises, and watch the engine at work, your physical therapist will do the same after an athlete is injured.

In sports medicine, a physical therapist is a diagnostician. First, they assess the movements of your body to provide an accurate injury diagnosis, determine why the injury occurred, and consider other risk factors for future injuries. After your initial evaluation, your physical therapist will make a personalized treatment plan that includes a combination of hands-on orthopedic manual techniques, improving muscle strength, stability of the joints, optimizing mobility, and decreasing pain.

Orthopedic Manual Physical Therapy

For instance, if you’ve injured your Achilles tendon, they’ll examine it by checking the range of motion, level of pain, and how strong the associated muscles are. Then, a treatment plan to get you back on your feet is drawn up, including strengthening techniques, flexibility techniques, and other things designed to bring strength and mobility back.

Physical therapy is designed to bring function back after an injury holistically. What’s more, it’s also meant to prevent sports injuries by educating about proper moving techniques before the tendon ever ruptures.

Why is Physical Therapy Important for Athletes?

Relive Pain, Restore Function, and Prevent Future Injuries are the most important goals for athletes after suffering an injury.

Pain when moving is always unpleasant, but more so for athletes. Physical therapy has techniques for immediate pain relief (such as dry needling, Kinesio taping, or cupping therapy) to make all athletes more comfortable so they can progress to more advanced exercises in order to return to competition.

In addition, a physical therapist specializing in sports medicine has methods for bringing your body back from injury to get your body back into peak performance. Assessing what went wrong in your body allows them to formulate how to fix it and give tangible methods for strengthening the injury.

After an injury, strength, and mobility can be compromised. For instance, rolling your ankle on the field means it’s tender for a long time afterward and not supporting your weight as well. Maybe it won’t support your weight to run down the field anymore, or it supports your weight but hurts so much you can’t see the ball anymore. 

Physical therapy will help build the strength in that ankle back to where it was before the injury, eliminating the pain of that injury, as well as safeguarding against future damage. 

Sometimes an injury can take a long time to heal. In the meantime, strength is lost, and it can feel insurmountable to get it back. In physical therapy, we focus on regaining that strength safely and healthily to protect against re-injury. As a result, some people even feel stronger than before the injury.

Reducing Pain and Understanding Your Body

A physical therapist has specific training to understand your body and how sports injuries can happen. In physical therapy, we focus on fixing pain and reducing and preventing it. Physical therapists can suggest correct techniques and help you determine what works best for your body to keep it strong.

Sports Medicine Doctor

Then, we’ll work one-on-one with you to show you the proper procedures so that these sensitive areas of your body are taken care of so well you won’t have to worry about them. These strengthening techniques don’t only fix what’s broken but also help keep them from breaking.

The Value of Balanced Physical Therapy

When doing physical therapy, you want to choose professionals at the top of their field. Our doctors are movement specialists who understand how your body moves during your sport and all the stresses that come with training and competing at a high level.

With Balanced Physical Therapy, you are treated as individuals with unique needs. Our athletes work one-on-one with a certified Doctor of Physical Therapist and are not passed around between assistants, techs, or aids. Each treatment is 1 hour, allowing for the safest, most professional care.

Our doctors also have experience working with male and female athletes of all levels in a vast range of sports, including:

  • Track-and field
  • Football
  • Soccer
  • Basketball
  • Swimming
  • Gymnastics
  • Wrestling
  • Performance Arts
  • ..And more

Physical Therapy Prevents and Heals Sports Injuries

There are multiple disciplines in sports medicine. Depending on age, sports, and injury type, Balanced Physical Therapy has options that are proven to get you back to competing. Contact Us Today to speak with one of our licensed and certified Doctors of Physical Therapy or to get started with an initial evaluation.

 

Instrument-Assisted Soft Tissue Mobilization

IASTM: Manual Therapy For Movement Restrictions, Tension, and Pain

What is IASTM in Physical Therapy?

Instrument-Assisted Soft Tissue Mobilization (IASTM) is a type of manual massage therapy used by physical therapists. Commonly known as the Graston Technique, this type of treatment can be beneficial for many people with movement restrictions, tension, and pain.

The Taylor and Francis journal defines IASTM as “a skilled intervention that includes using specialized tools to manipulate the skin, myofascia, muscles, and tendons by using various direct compressive stroke techniques.”

Tightness, tension, and pain while sitting at office

What does IASTM Do?

Instrument-Assisted Soft Tissue Mobilization helps break down restrictions, reduce pain, and facilitate healing by addressing musculoskeletal problems at the cellular level.

At the musculoskeletal level, a facial restriction is often a combination of scar tissue and adhesions built up over time. Ortho Bethesda does a great job explaining that “Scar tissue and adhesions essentially act like superglue in your body. When scar tissue is created after injury, new cells are laid down excessively and in a disorganized manner. Scar tissue/ adhesions prevent the muscle or other tissues from lengthening appropriately.” 

IASTM is a way for physical therapists to use controlled microtrauma to stimulate a natural inflammatory response. When your body produces an inflammatory response, it triggers a series of events that include reabsorption of excess scar tissue and fibrosis that is causing restriction.

Additionally, IASTM also triggers a vascular response resulting in increased blood flow and improved healing. There is even a neural effect throughout pain receptors along the skin responsible for managing pain.

Who can benefit from IASTM?

IASTM treatment can be beneficial for a variety of impairments and conditions. It can be beneficial for many people undergoing orthopedic surgery, people that sit for long hours in an office, and athletes after intense training or injuries. Your physical therapist may provide you this manual therapy for impairments such as:

  • Limited mobility
  • Pain with motion
  • Loss of range of motion
  • Decreased muscle recruitments
  • Excessive scar tissue formation 

More specific conditions that benefit from the application of IASTM include:

  • Plantar Fasciitis
  • Carpal Tunnel Syndrome
  • Neck Pain
  • IT Band Syndrome
  • Heel Pain/ Achilles Tendinitis
  • Ankle Sprains and Strains
  • Back Pain
  • Shin Splints
  • Post Surgical Hip and Knee Replacements
  • Musculoskeletal Imbalances
  • Rotator Cuff Tendinitis
  • Myofascial Pain and Restrictions

Physical Therapy for Neck Pain

For certain conditions, instrument-assisted soft tissue mobilization may not be recommended. These can include having:

  • Unhealed Fracture
  • Hematoma
  • Hemophilia
  • Uncontrolled Hypertension
  • Open Wound
  • Patient Hypersensitivity 

What to expect during and after an IASTM Treatment

IASTM treatments during physical therapy sessions are often paired with a warm-up such as heat, stationary bike, elliptical machine, or light jogging to make the tissue more pliable. After a warm-up, your therapist can begin working with stainless steel, plastic, or titanium instruments that contour to your body in order to find the specific tissue and muscles that are restricted.

Tools used by Physical Therapist for IASTM

Instrument-Assisted Soft Tissue Mobilization starts with gentle pressure and steadily increases in order to effectively treat the areas causing pain and movement restrictions. At Balanced Physical Therapy, we encourage open communication and let our therapists know when the pressure becomes too uncomfortable to tolerate.

After the IASTM treatment, most patients follow up with more exercise to help restore better movement patterns. Some soreness after treatments is considered normal; patients should not panic because it does go away and gets less severe with multiple treatments. If you are attending physical therapy anywhere from 2-3 times per week, a noticeable result can be felt by the 3rd or 4th appointment (sometimes even on the first treatment). When IASTM is combined with exercise, stretching, and a focused effort on home exercises, patients can progress reasonably quickly through their recovery.

If you would like to learn more about IASTM or are experiencing pain, tension and movement restrictions give us a call to speak with a therapist. Our team is always ready to help you make the best decision with regard to your overall health and wellness.

Dry Needling Treatments

Dry Needling: Therapy for Pain and Movement Impairments

Balanced PT offers dry needling treatment to help with neuromusculoskeletal pain and movement impairment. Learn more about the dry needling process and some specific conditions that benefit from this treatment.

What is Dry Needling?

Dry needling is a safe and minimally invasive treatment used to help patients with neuromusculoskeletal pain and movement impairments(Mayo Clinic). Some benefits include decreased muscular pain, easing trigger points, and improved range of motion.

It is administered by certified and trained healthcare professionals such as physical therapists, medical doctors, and some chiropractors. Some other common names for dry needling therapy include trigger point dry needling (TDN) and Functional Dry Needling (FDN).

Difference Between Dry Needling and Acupuncture?

While dry needling stems from traditional Chinese medicine like acupuncture, dry needling is a treatment that has evolved into a modern western medicine treatment. Inserting needles into the skin is something both dry needling therapy and acupuncture share, but after that, the treatments are undoubtedly different (Denver Physical Medicine and Rehab).

Acupuncture treatments are more of traditional eastern medicine based on restoring the proper energy flow throughout the body by inserting needles along meridian lines. 

Dry needling therapy has been developing since the 1980s and focuses on relieving chronic and acute pain by inserting needles into trigger points to restore normal function.

Will Dry Needling Therapy Work For Me?

Patients that are experiencing chronic pain are typically great candidates to receive dry needling therapy. Patients can expect to see the most significant benefits when this dry needling is incorporated with exercise, manual therapy, stretching, and education. It is a low cost, low-risk treatment that can help with conditions such as (Virginia Sports Medicine Institute):

  • Acute and Chronic Tendonitis/ Tendinosis
  • Athletic Overuse Injuries
  • Carpal Tunnel Syndrome
  • Frozen Shoulder
  • Muscle Spasms
  • Whiplash from auto accidents
  • Ehlers Danlos Syndrome
  • Fibromyalgia
  • IT Band Syndrome
  • Sciatic pain
  • Tennis and Golfer’s Elbow
  • Neck and lower back pain

Whiplash from auto accident

While dry needling can be beneficial to various conditions, it is also essential to know when dry needling is not appropriate. Dry needling is not suitable and potentially harmful (Cleveland Clinic) for the following reasons:

  • A patient with a needle phobia
  • Pregnancy (first trimester)
  • Patient with an allergy to metals
  • Patients that have an infection present
  • Needling over cosmetic implants
  • Patients with a heart valve replacement (endocarditis)
  • Patients with epilepsy (or other seizure disorders)

Suppose you are looking for natural pain management treatment options, and dry needling is not an option. In that case, we always recommend scheduling an appointment with your primary care physician, orthopedic surgeon, or physical therapist. They will be able to diagnose your pain and provide you with a list of safe treatments available near you.

How Does Dry Needling Work?

Multiple clinical studies show that dry needling works by restoring muscles to a normal resting state. We know that patients suffering from chronic pain, a traumatic injury, or overused muscles often develop trigger points (also known as knots) that cause pain and discomfort. 

Looking further into why this causes you pain, research shows that the trigger points form due to prolonged or abnormal muscle contraction where your muscle is not receiving enough blood supply. The lack of blood supply (filled with oxygen and nutrients required for healing) to an injured area will cause the surrounding tissue and nerves to become more sensitive.

By stimulating the trigger point with a sterile needle, dry needling therapy can help drive more blood to an injured area, release muscular tension, and help the brain release endorphins that promote healing.

Step By Step Dry Needling Procedure

Before administering dry needling therapy to any patient, your physical therapist will perform an examination that includes your past medical history to ensure the treatment is appropriate and safe. Part of the evaluation will also consist of your therapist using palpation skills to identify trigger points causing pain and limited motion.

Phsyical Therapist finding trigger points for dry needling treatmetn

Once you and your therapist agree that dry needling will benefit your recovery, the therapist will go over each part of the treatment in more detail (Verywell Health). Specific details that help patients understand dry needling can include:

  • How long does dry needling take? Typically a single treatment can take anywhere from 15-30 minutes, which is most commonly a part of a total of 30-60 physical therapy sessions.
  • What to wear for a dry needling appointment: We recommend our patients wear the usual, comfortable physical therapy attire. Clothing that allows easy access for your therapist to administer the treatment is always a good idea. 
  • Insurance information and expected costs: Some insurances do cover dry needling, while others do not. It helps to know upfront what co-pay and out-of-pocket costs to expect.

Once an evaluation is complete, some patients can start dry needling therapy that same day( others may need to wait until the second appointment, this varies from clinician to clinician.)

Your physical therapist will always begin the dry needling procedure by sterilizing the treatment area and preparing the needles in a private setting. After preparing the treatment area, the therapist will start inserting thin, dry needles (needles that do not contain medications or fluids ) into problem-causing trigger points. 

The dry needles are inserted directly into the skin at varying depths (depending on the dry needling technique). Oftentimes, patients will feel the physical therapist gently move the needle around to stimulate a local twitch response. A local twitch is a good thing, as it signifies that a muscle is reacting to the treatment.

After 15-30 minutes, your therapist will carefully remove the dry needles. They will inspect the treatment area for bleeding and skin reactions before leaving for home.

What To Expect After a Dry Needling Treatment

After a dry needling treatment session, patients often report a decrease in pain and an increase in range of motion. In more severe cases, a patient will require more than one treatment to reach the desired results.

Muscle soreness and light bruising is a common side effect of dry needling, for which your therapist may recommend rest, heat, or ice. These symptoms typically resolve themselves over a couple of days to a week.

If you are experiencing more severe side effects (these are considered rare), such as difficulty breathing or significant bleeding, we recommend contacting emergency medical services immediately.

Schedule Dry Needling Treatment Today

Balanced Physical Therapy offers safe, effective, and certified dry needling treatments. Our patients enjoy working in one-on-one therapy settings with board-certified physical therapists. To schedule an appointment, call us at (586) 741-5806 or visit our Appointments page to schedule an evaluation.

 

 

 

Knee Replacement Surgery

13 Week Recovery Timeline For Knee Replacement

Find out how long it will take to recover from a knee replacement surgery. This general, 13 week timeline is an overview of common things to expect during your hospital stay, at home, and outpatient physical therapy.

How Long Does Recovering From Knee Replacement Surgery Take?

When patients and their orthopedic surgeons agree that knee replacement surgery is a good option, one of the first questions or concerns usually is “how long will the recovery process take?” The simple answer would be about 13 weeks to recover. This timeline is dependant on a lot of factors such as type of procedure, limiting complications, and being consistent with their doctor and physical therapy visits.

Patients typically have a good understanding of the benefits of having a knee replaced, but they also appreciate knowing what is required to reach those benefits. A knee replacement, otherwise known as knee arthroplasty, is one of the most successful surgeries performed throughout the world. If you want to be a part of the 90% of people with a well-functioning knee, 15 years post-surgery, understanding each part of the recovery process can help you with that goal. 

Balanced Physical Therapy has combined real-world experience with proven clinical research from around the internet to help you better understand each part of the recovery process, specific timelines for recovery, and why each element is essential. 

Knee Replacement Recovery Timeline

Generally, someone who undergoes a knee arthroplasty takes about 12-14 weeks to recover fully. With the help of the Wisconsin School of Orthopedics and Rehabilitation and Healthline, we have broken down the recovery process into 5 phases:

Phase 1: Hospital Stay to Discharge

Phase 2: Weeks 1-2, 

Phase 3: Weeks 3-6, 

Phase 4: Weeks 7-12

Phase 5: Weeks 13 and Beyond

Knee Replacement Recovery Phase 1: Hospital Stay and Discharge

A typical hospital stay after a knee arthroplasty ranges anywhere from 1-3 days. Some patients even leave the same day, which depends on the type of procedure that is performed.

Hospital Stay After Knee Replacement

The reason knee replacement surgeries are so successful is because of their relatively low risk of complications. A majority of your hospital stay will include surgeons and hospital staff working hard to prevent complications such as infection, blood clots, pain, hardware issues, and neurovascular injuries. 

While your healthcare team continues to monitor and prevent complications, patients can expect to start rehabilitation soon after the surgery. Within 24 hours, patients will work with a physical therapist to begin standing and walking again. Lack of confidence is very common during this time, so crutches and walkers help provide that extra support many patients require. 

Another standard device used amongst the knee replacement population is a continuous passive motion (CPM) machine. This machine helps provide your knee with a constant motion to prevent scar tissue buildup and stiffness from being immobile. You can expect your surgeon or physical therapist to help educate you about this device and how to use it at home.

Knee Replacement Recovery Phase 2: Weeks 1-3

The first week after undergoing knee arthroplasty, patients can expect to be back in the comfort of their own homes. One of the first and most important things to know during this period is your follow-up appointment with your surgeon. Typically the follow-up is scheduled about two weeks after the knee replacement and is something every patient should markdown as “must-attend.”

Phase 2 of knee replacement rehabilitation also includes patients becoming more active with therapy. Some patients start treatment at home, while others can attend an outpatient clinic. One is not necessarily better than the other; it just depends on a person’s health status.

Some goals and priorities to be aware of include:

  • Reduce pain and stiffness
  • Being able to transfer from lying to sitting to standing safely with the help of assistive devices
  • Being able to “heel strike” while ambulating
  • Increase knee range of motion
  • Ability to extend leg without lag
  • Being consistent with the home exercise program provided
  • Understanding the pain scale and the difference between “hurt and harm.”

Your physical therapist will design a rehab program to help you reach these goals without harming the new knee hardware or incision. Examples of exercises to expect for the weeks 1-3 after your surgery include:

  • Heel Slides
  • Quadriceps Sets
  • Straight Leg Raises
  • Sit To Stand Squats
  • Stationary bike with little to no resistance
  • Hamstring Curls

One of the best things about Phase 2 is that while you train your body to regain a proper gait and pain-free life, your therapist will also mix in modalities to help you progress more. Common knee replacement modalities include 

  • Electrical stimulation (E-stim) can help activate the quadriceps better
  • transcutaneous electrical stimulation (TENS) can be applied to help control pain symptoms
  • Soft tissue mobilization on elevated surfaces to help reduce edema (also known as swelling)

Note: These therapeutic modalities can and often are used throughout all phases of knee rehabilitation.

Knee Replacement Recovery Phase 3: Weeks 3-6

The third phase of recovering from a knee replacement is typically outside the home, in an outpatient physical therapy setting. A follow-up appointment around the six-week mark is also required, just like the one at the two-week mark. 

The main goals for patients that are 3-6 weeks post-surgery include:

  • Continue improving knee range of motion and quad strength
  • Progress strengthening towards bodyweight, functional ambulation
  • Normalization of gait (walking)
  • Reduce the need for assistive devices, such as walking with only one crutch a just using a cane
  • Walking short distances without using any assistive devices

During this part of the knee rehabilitation, patients are progressed with more moderate exercises such as:

  • Sit to stand squats
  • Leg Press
  • Stationary bike with resistance
  • Single leg balance
  • Gastrocnemius strengthening
  • Standing knee extension with therabands
  • Hip and core strengthening as needed
  • Neuromuscular reeducation
  • Pool therapy (must have authorization from a surgeon, never before four weeks, and must have a closed incision)

Knee Replacement Recovery Phase 4: Weeks 7-12

When recovering from knee arthroplasty, the fourth phase is when most patients see the most rapid improvement to mobility and range of motion. It is an exciting time where the hard work of attending physical 2-3 times a week and staying compliant with home exercise programs starts to pay off. 

Some common goals and milestones during this phase of rehab include:

  • No extensor lag (lack of full knee extension with full quadriceps contraction)
  • Normal gait without the use of an assistive device
  • Engaging in everyday activities such as driving, housekeeping, and shopping
  • Ability to ascend and descend 1-2 flight of stairs with a reciprocal gait

Knee Replacement Recovery Goals

Your physical therapist will continue to progress your rehab and increase difficulty in the 7-12 weeks following surgery. Patients can expect exercises such as:

  • Toe and heel raises while standing
  • Single leg balances
  • Step-ups in multiple directions
  • Continued lower extremity strengthening

Even if you do not see the best results, it is crucial to stay the course. Don’t give up, ask questions, and continue to follow the guidance of your healthcare team.

Knee Replacement Recovery Phase 5: Weeks 13 and Beyond

After 13 weeks since your surgery, most patients are happy to see the finish line. Some patients may still be attending physical therapy to reach the goals you set entirely, while others are safe for discharge. Both scenarios are expected, and it varies from person to person.

Providing you have not experienced any major setbacks or complications, pain should be almost nonexistent. It is a good idea to still check in with your healthcare team. If you have pain, swelling, stiffness, or unusual movement, it is always best to call your doctor immediately.

At Balanced Physical Therapy, we understand how important fully recovering from knee surgery is to our patients. From your first evaluation, we take the time to understand everything about you and your condition. Our treatments consist of one-on-one therapy with board-certified physical therapists who are always willing to help. Call us at (586) 741-5806 or visit our Appointments page to schedule an evaluation.

Uneven Hips and Abnormal Pelvic Tilt

5 Things To Know About Uneven Hips and Abnormal Pelvic Tilts

A guide for anyone who believes their hips are out of alignment. Learn about the signs and symptoms of misaligned hips. Find out how this condition relates to your pelvis, spine and posture. See the ways physical therapy can help you get realigned and get back to functional, pain free life

What Does It Mean When Your Hips Are Out Of Alignment?

When it comes to having uneven hips, it is essential to understand that your pelvis and spine are also affected. Having uneven hips is often associated with an anterior pelvic tilt. These two can drastically change a person’s back health, posture, and overall biomechanics. A slight misalignment can cause pain and discomfort in the hip and lower back regions. Over time this small problem can have compounding effects that reach up into the shoulders and neck. To help you avoid these type of complications, we will go over:
  1. How you can determine if your hips and pelvis are properly aligned
  2. Common symptoms and causes of uneven hips and abnormal pelvic tilts
  3. Physical Therapy Treatment for uneven hips and abnormal pelvic tilts

What Is A Normal Hip Alignment?

To determine whether or not you have proper hip and pelvis alignment, a physical therapist would need to observe and measure multiple factors around the hip, pelvis, and spine. As always, it is best to seek a professional opinion from your primary care physician, physical therapist, spine specialist, or chiropractor.  If you haven’t gone to see your doctor or physical therapist and would like to self-check your hip alignment, you should look out for three things:
  1. Your pelvis should be parallel to your shoulders and the ground
  2. Your hips should stay neutral and not be tilted forward or backward
  3. Your hips should be on the same level horizontally, not one higher and one lower
Uneven Hip and Pelvis Alignment
Hip and Pelvis Alignment Comparison via Runners World
An excellent way to check all three is to stand in front of a full-body mirror to observe your posture thoroughly.  First, take notice if your shoulders are even. A shoulder that sits higher than the other may present a lower, misaligned hip on the same side. A shoulder blade that sticks out can also help you determine the hip and pelvis’s misalignment on the same side.  Next, take a look at how your spine is aligned. A curved “C” or “S” shape of your spine can help you determine if the cause of your uneven hips is scoliosis-related.  It can also help to imagine a straight line from your nose to the belly button. If the line doesn’t touch, this would also indicate a spinal misalignment, possibly related to your hips or pelvis. Suppose you do not have access to a full-body mirror or have trouble visualizing the proper hip and pelvic alignment. In that case, it can help understand some common symptoms associated with misaligned hips and pelvis.

Signs And Symptoms Of Misaligned Hips or Pelvis

People with misaligned hips or abnormal pelvic tilts often experience symptoms that progress from minor and unnoticeable to significant and life-altering.  Minor symptoms that often go unnoticed for long periods include:
  • General low backache
  • Pain in the hip and buttocks area that increases during or after walking
  • Pain in the hip and low back after standing in place for long periods
  • Unbalanced walking or gait
  • Achy feeling in the lower back or hip while laying down
If these minor symptoms go untreated for too long, they can progress into more severe complications such as:
  • Pain that goes down into the thigh towards the knee
  • Pain in and around the groin
  • Inability to stand in place or walk
  • Poor spine alignment

What Causes Uneven Hips and Abnormal Pelvic Tilts?

To get back to a pain-free and active life, it is always best to understand why your hips and pelvis are misaligned. We recommend everyone see their primary care physician, spine doctor, or physical therapist as soon as symptoms begin to show. A medical professional can evaluate posture, gait, measure each leg’s length, prescribe an X-Ray or CT scan for the most accurate diagnosis.  Your health care professional can diagnose the cause of misaligned hips or abnormal pelvic tilts, which may include:
  1. A functional Leg Length Discrepancy: You can think of this as poor posture for prolonged amounts of time that result in muscular imbalance. When bad posture becomes a habit (in sitting or standing), the muscles surrounding the hip and can become tight and shorten, causing the hip to pull upwards. Also, on the other side of the body, muscles can become weaker and looser, causes the hip to sit lower.
  2. Structural Leg Length Discrepancy: You can think of this as one leg being shorter/longer than the other, outside the commonly accepted range. Most people have a slight difference in leg lengths, but significant differences (4cm or more) can cause hip and pelvic misalignment. These leg length discrepancies can be congenital (naturally from birth). Other causes include growth plate injuries (Salter-Harris fracture is common amongst children and adolescents), poor healing after bone breaks, joint conditions such as arthritis, or bone diseases such as neurofibromatosis.
  3. Scoliosis: This abnormal “S” or “C” curve in the spine is a prevalent cause of hip and pelvic misalignment. Scoliosis is more common amongst young females and can run in the family. 
Once a medical professional confirm a diagnosis, people with misaligned hips and pelvis can begin the recovery process. One of the best and most common ways to correct these issues is physical therapy.

Treating Uneven Hips and Misaligned Pelvis With Physical Therapy

Physical therapy is typically one of the best non-surgical treatment options for misaligned hips and abnormal pelvic tilts. Your physical therapist can help diagnose the cause of your pain and misalignment. They can also assist you with pain management, stretching, strengthening exercises, and biofeedback to prevent and eliminate symptoms. Some techniques and practices that are effective include:
  • Muscular release to tight hip flexors, quadriceps, hamstrings, and glutes.
  • Corrective exercises that address your specific diagnosis. Each type of pelvic tilt (Anterior, Posterior, and Lateral Pelvic Tilts) requires different treatment plans to realign.
  • Help fix bad habits related to posture when standing and sitting.
  • Assist and educate patients on the best way to sleep with as little pain as possible.
Early treatment can help speed up the recovery and prevent significant complications. If you believe your hips are misaligned, you have an abnormal pelvic tilt, or unsure about the cause of your back pain, please contact us at (586) 741-5806 today to make an appointment
Preventing Overtraining Syndrome

Prevent Overtraining Syndrome and Overuse Injuries in Youth Sports

Helping parents, coaches, and young athletes understand overtraining syndrome (OTS), the specific injuries associated with overuse, early signs of detection, and general guidelines for training.

Overtraining in Youth Sports

With over 30 million youth sports participants ages 6 to 18, it is important for parents and coaches to know about overtraining syndrome (OTS), the specific injuries associated with overuse, early signs of detection, and general guidelines for training.

Every year more children and adolescents are participating in organized and recreational sports. This is a great sign in the fight against childhood obesity as it builds lifelong physical activity habits, promotes healthy competition, and builds skills for future opportunities. Unfortunately one of the downsides with increased activity in youth sports is the increased risk of overtraining, overuse injuries, and burnout.

What is Overtraining Syndrome (OTS)?

Overtraining Syndrome (OTS) is more commonly referred to as “burnout”. OTS or “burnout” is caused by intensely working the body for long amounts of time without allowing the time for rest and recovery.

The American Academy of Pediatrics describes overtraining syndromes as a “series of psychological, physiologic, and hormonal changes that result in a decreased athletic performance. With so many options such as football, gymnastics, swimming, wrestling, and tennis at all levels; kids have naturally become more likely to suffer from injury.

What is an Overuse Injury?

Overtraining can directly cause an overuse injury. Overuse injuries often include damage to bone, muscle, and tendons. These injuries can be classified into 4 stages:

  1. Pain in the affected area after physical activity
  2. Pain during physical activity, but not restricting performance
  3. Pain during physical activity that also restricts performance
  4. Chronic, persistent pain, even at rest

Because young athletes’ bodies are still developing, they are more susceptible to overuse injuries. Their bones are still growing, therefore cannot handle as much stress as fully developed adults. Generally, the best way to prevent major overuse injuries is to understand and identify the young athlete who is at most at risk.

If your young athlete is showing signs of injury, it is always a good idea to get a professional assessment. A physical therapist can diagnose the injury and provide a treatment plan to safely return to competition.  Contact Balanced Physical Therapy to schedule a free injury screening or comprehensive evaluations here.

Common Overuse Injuries in Youth Sports

Some examples of overuse injuries and risks that may result from overtraining in youth sports include:

Little league and travel baseball players can be at risk for throwing injuries such as medial apophysitis or “little leaguer’s elbow”. Too much overhand throwing, especially with poor technique, can result in excess inflammation and irritation in the elbow. This can have long-lasting effects on the medial apophysis growth plate.

A child or adolescent gymnast can be at risk for developing spondylosis (pain in the spine due to deterioration) when doing repetitive hyperextension and rotation while participating.

Preventing Overtraining in Youth Athletes

Young swimmers are susceptible to shoulder injuries such a rotator cuff or bicep tendonitis, shoulder impingement, and neck pains.

Track and distance runners often develop shin splints and stress fractures as a result of overtraining.

These injuries are commonly caused over time, and not suddenly. This is good news, especially for parents and coaches who know the signs of overtraining and overuse.

Signs of Overtraining and Burnout

Parents and coaches concerned about the possibility of overtraining have multiple ways to tell when a young athlete needs more time to rest and recover. The Boston Children’s Hospital lists common signs of overtraining that include:

  • Slower times in distance sports
  • A decrease in athletic performance
  • Decreased ability to achieve training goals
  • Decreased motivation to practice
  • Young athlete getting tired easily
  • Irritability and unwillingness to work with teammates
  • Disturbance in sleep schedule
  • Weight loss or appetite changes

How To Prevent Overtraining Syndrome

General guidelines suggest that to promote fun, develop skills, and achieve individual goals; a young athlete requires good training and rest balance. Some ways to prevent overuse injuries and burnout include:

  • Encourage young athletes to take 1-2 rest days per week. This allows time to recover physically and psychologically between competition.
  • Advise young athletes that their weekly training time, repetitions, or total distance should not increase more than 10% per week.
  • Encourage athletes to take a seasonal rest from a single sport for 2-3 months a year. Taking breaks and developing other skills are essential for preventing injuries.
  • Focus on proper nutrition, hydration, and sleep.
  • Be mindful and cautious when entering multiple tournaments on consecutive weeks
  • Be consistent with yearly checkups with pediatricians and family physicians. 
  • Emphasize that the reason we participate in sports is to have fun, develop healthy lifestyle habits, and improve athletic skills.

Using these guidelines, parents, coaches, and healthcare professionals can help keep young athletes injury-free. Mixing in rest days and diversifying the activities kids participate in can help tremendously when developing skills and avoiding burnout.

Balance Training For Seniors and Older Adults

Balance Training: A Better Way To Prevent Falls

A balance training guide for seniors, older adults, and their family members. Learn what conditions affect balance and coordination, ways to identify a fall risk, and how physical therapy can improve everything from stability to sensory orientation.

Improve Balance and Coordination At Physical Therapy

 

Balance and coordination tend to decline as a person ages. Luckily there are things you can do to improve balance, reduce fall risks, and improve the overall quality of life. Being physically active is always a great first step when it comes to improving your overall health. It can also be necessary to seek specialized care for a custom balance training program as health declines.

Balanced Physical Therapy helps senior and older adult patients improve balance, control and coordination. Patients are less likely to fall and suffer from injuries when they have

  • Increased Overall Independence
  • Reduce Fear of Falling
  • Improved Coordination
  • Faster reaction Time
  • Stronger Bones
  • Increase Walking Speed
  • Improved Muscular Function
  • Improved Cognitive Function

Seniors and older adults often experience a decline in motor and cognitive functions. Balance is strongly affected and daily activities such as cleaning, exercising, and getting dressed can become more difficult in a short time.

Knee Stability Exercise

What conditions affect balance in seniors and older adults?

 

The American Family Physician attributes gait and balance disorders to seven different types of medical conditions including:

Affective Disorder and Psychiatric Conditions

    • Depression
    • Fear of Falling
    • Sleep Disorders
    • Substance Abuse

Cardiovascular Disease

    • Orthostatic Hypotension
    • Coronary Artery Disease
    • Congestive Heart Failure
    • Arrhythmias

Infectious and Metabolic Diseases

    • Diabetes Mellitus 
    • Obesity
    • Hyper and Hypothyroidism
    • HIV-associated neuropathy
    • Vitamin B12 deficiency

Musculoskeletal Disorders

    • Gout
    • Lumbar Spinal Stenosis
    • Osteoarthritis
    • Osteoporosis
    • Muscle Weakness and Atrophy
    • Podiatric Conditions
    • Cervical Spondylosis

Neurological Disorders

    • Dementia
    • Parkinson Disease
    • Stroke
    • Vestibular Disorders
    • Multiple Sclerosis 
    • Myelopathy

Sensory Abnormalities

    • Hearing Impairment
    • Peripheral Neuropathy 
    • Visual Impairment

Other

    • Other Acute Medical Conditions
    • Recent Hospitalization
    • Recent Surgery

How To Know If Someone Is a Fall Risk

 

A person who is a fall risk can often show signs and symptoms before having an accident. The best way to keep track of age-related balance issues is to be consistent and active when going for yearly checkups. It is extremely important to always report falls and near falls to your physician. Your primary care physician can help monitor your overall health and identify fall risks as they present themselves.

In addition to seeing your primary care physician on a regularly, it can be useful to know and watch out for some common signs of a balance deficit among friends and family. These include

  • A person having a difficult time getting up from a chair. This can indicate a weakness in the glutes, quadriceps, hamstrings, or hips.
  • A person who has a difficult time walking. Someone who tends to reach out for support on furniture or walls.
  • Near falls or someone who would have fallen if they had not caught themselves.
  • Someone taking pain medication or sleep aids. Some medications can cause dizziness, drowsiness, and balance issues.
  • Dizziness when standing up from a sitting or laying position.
  • Foot, knee, or hip pain that leads to an abnormal or shuffling type of walk.

Why Balance Training Is Important

 

People that fall once, have double the chance to fall again. Studies show that one out of five falls causes seniors injuries such as broken bones or head injuries. These falls can lead to long periods of pain, lower quality of life, disability, or even death. 

Balance training under the supervision of a physical therapist is a way to promote better overall health in a safe environment. A physical therapist can help improve balance and decrease your risk of falling by implementing a training program specific to your needs.
Patients can reverse the effects of physical inactivity and overcome the fear of falling. Patients can also benefit from additional education as well as emotional support from a healthcare professional.

Physical Therapy Program for Balance and Coordination

 

Patients who are unsure if they require specialized balance training should consult with their primary care physician. Your doctor can prescribe physical therapy to help improve balance and coordination. 

Once prescribed, your physical therapy program will always begin with an evaluation. A physical therapist will conduct a fall-risk assessment to better understand risk factors such as vision, mobility, transfers, daily activities, environment, and nutrition. Patients can also ask questions, discuss their goals, and express any concerns during the assessment.

Based on your current health your therapist will create a balance training program that is fit for your needs. Our therapists are experienced in modifying most therapy techniques to best suit your condition and to properly challenge you on a day-to-day basis.

Exercises For Balance Training

 

Physical Therapy exercises can be targeted to a specific physiological system or combine multiple systems to better simulate real-life activities. Certain parts of the balance training program will be geared towards motor function while other parts will focus more on cognitive improvements. Examples of these include

  • Increase stability limits
  • Improve anticipatory postural adjustments
  • Improve postural responses
  • Improve sensory orientation
  • Improve stability in gait

Yoga Ball Balance Exercise

Therapy sessions normally last about an hour and begin with a warm-up such as riding a bike, marching in place, or stretching. After warming up patients often train using therapy balls, uneven surfaces, body weight, and resistance training. A therapy session will conclude with stretching, massage, and a cool-down period. Not every appointment will be the same, in fact, they often differ to properly progress while keeping things interesting and fun.

At Balanced Physical Therapy, we pride ourselves on providing every patient with the expertise they deserve. Each patient is treated by a DPT for their entire session, avoiding any issues that may arise when working with assistants or techs. Your therapist will always be by your side and we encourage all our patients to ask questions and issue any concerns whenever at any point of your appointment.

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Improve Post-Op Recovery with Prehabilitation

What is Prehabilitation?

Prehabilitation, or “Pre-hab”, is a proactive measure for patients scheduled for orthopedic surgeries. A surgeon or primary care physician will often prescribe patients “prehab” to help prepare them for physical and lifestyle changes associated with surgeries.

Studies show that patients who move better, feel better, and feel stronger tend to do better. This article can be useful for patients considering or expecting orthopedic surgery. You can also find some specific tips at the end of each section about some common spine, knee, shoulder, and foot surgeries.

 

What are the benefits of prehabilitation?

‍Patients who attend physical therapy before surgery can improve physiological, mental, nutritional, and lifestyle health. Orthopedic surgery can be thought of as a marathon, meaning the preparation put before actually running the race will ultimately help your overall performance during and after it.

Physical Therapy Before Surgery

Tip #1: Timing, Type, Setting, and Costs

When considering a prehab program prior to surgery, important things to consider are timing, type, setting, and costs.  

The U.S Department of Health and Human Services published a study related to patient outcomes of major joint replacement surgeries (Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA). The evidence showed that when your rehabilitation occurs (timing), what the training consists of (type), where your rehab occurs (setting), and out-of-pocket or insurance costs are the most important things to consider for patients, surgeons, and therapists.

Physiological benefits of prehabilitation

If your surgeon has prescribed physical therapy prior to surgery, you can improve the function, strength, and conditioning of your body many weeks ahead.  A physical therapist can evaluate you and come up with a treatment plan that includes aerobic exercise, strengthening, and stretching, and pain management.

Improve Recovery After Knee Replacement

Studies show aerobic exercises such as low-impact cycling or walking as an effective nonpharmacological option for patients undergoing total joint replacements. Patients can often expect a decrease in pain symptoms, joint tenderness, and better overall function for daily activities.

Tip #2: Getting Prehab

The best way to get started with prehab is to work individually with a physical therapist.

If you are dealing with insurance issues and the number of appointments available, we recommend talking with your doctor, surgeon, or local physical therapy clinic. They may be able to direct you to some free prehab education classes or come up with a treatment plan that can be done at home.

Mental benefits of prehabilitation

‍Mental health is one of the most important and often overlooked aspects of orthopedic surgery. It is natural for patients to feel stressed and anxious before surgery. Attending physical therapy can be extremely useful to help get you prepared mentally and feel confident.

Tip #3: Make use of downtime

It is common for patients to wait multiple weeks before entering the operating room, this time can be used to get acquainted with your physical therapy clinic, your therapist, and surgical procedure. Learning how to modify daily activities, transferring positions, and using crutches or walkers can help reduce your hospital stay and home care costs.

Nutritional support from prehabilitation

Nutrition plays an important role when recovering from orthopedic surgery. Physical Therapists can assist you with fine-tuning your diet to improve blood circulation, manage glucose uptake and insulin resistance while reducing oxidative damage to blood vessels.

Daily Nutrition For Orthopedic Surgery

Tip #4: Avoid high-fat meals

Adults expecting an orthopedic surgery of any kind diets should limit fat intake to less than 35% of their daily calory intake. A high-fat meal close to surgery can increase the risk of blood clots and inflammation at the surgical site.

 

Lifestyle support from prehabilitation

Physical therapy can help patients adjust to various lifestyle changes associated with surgery recovery. Helping you prevent fall-related injuries, work from home tasks, and things like sleeping or showering.

Tip #5: Home Preparation For Knee and Hip Surgery

Move things you use frequently above waist level, prepare food ahead of time, and make sure your bed, armchair, car, and toilet seat are at safe levels before you leaving the hospital.

Question about Prehabilitation?

Balanced Physical Therapy is dedicated to providing everyone an equal opportunity for a full recovery. Contact us with any questions you have about insurance, treatments, and the rehabilitation process.