Physical Therapy Helps!

The Hidden Link Between Sleep and Pain

This is typically a time for new year resolutions. For most individuals, this involves exercising and healthy eating, but sleep is equally (if not more) important. One of the best things you can do for yourself this year is to try and get enough sleep. In fact, did you know that there is a correlation between sleep and pain?

Some people sleep longer because they are in pain, while others cannot sleep at all. P...ain affects the way a person sleeps and a lack of sleep can intensify pain. Individuals who suffer from chronic pain may experience sleep disorders. In fact, pain is one of the causes of insomnia.

Sleep disorder symptoms include difficulty falling asleep, waking up in the middle of the night, waking up early in the morning, restless sleep, and overall dissatisfaction with the quality of sleep. The consistent interruption of sleep triggers a vicious cycle of sleep deprivation and increased pain. The less sleep a person gets, the more intense the pain can become.

Strategies for Improved Sleep

If pain (or any other reason) is affecting the quality of your sleep, start by identifying the cause of the problem. The first step is an assessment of the sleeping environment and lifestyle habits. Here are some questions to answer:
•Is the bedroom a quiet place and are all lights switched off? Is there a television or laptop (and associated glare) in the bedroom?
•What are you sleeping on? How old is the mattress? Does your pillow provide enough support for your neck and head?
•What are you eating and drinking before you go to sleep? Are you consuming caffeinated beverages late in the day? Are you eating big meals close to bedtime?
•Are you sleeping at the same time every day? Are you avoiding stressful conversations or situations before going to bed?

By facilitating an environment that is quiet and comfortable, you will set the stage for sound sleep. A physical therapist can also help you sleep better by teaching you techniques such as autogenic relaxation, progressive muscle relaxation, and visualization.

Message From Your Physical Therapist
"Don't Lose Sleep Over It"

If pain is affecting your sleep patterns, physical therapy can play a big role in the recovery process. The combination of pain and lack of sleep creates a vicious cycle that can get progressively worse, if left untreated.

Fortunately, a physical therapist can identify the underlying cause of pain and create a plan for lasting pain relief. Using a combination of hands-on techniques (including joint mobilizations and massage), the therapist will help reduce muscle tension. This will help you sleep better. A therapist will also design a stretching and strengthening program to restore muscle balance and reduce pain; restoring normal sleep patterns.

If you have pain and are losing sleep over it, reach out to us, your physical therapy providers. We'll help you reduce pain and sleep better. We don't want you to lose any more sleep over this and it is time for you to start living a pain-free life.

Call us today.
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Car Accident? Physical Therapy Can Help

Each year, 2 million people suffer from whiplash related to car accidents in the United States alone. Studies using high-speed cameras and sophisticated crash dummies have revealed that rear impact car accidents result in a condition called ‘whiplash’. This forces the bones of the lower cervical spine (the neck) into hyper-extension (backward bending motion) while the bones of the upper neck are suddenly thrust into hyper-flexion (forward bending motion). In a split second, the normal curvature of the cervical spine is disrupted and the consequences can range from mild to serious. A sudden, abnormal motion to a sensitive region like the neck causes damage to the soft tissues (ligaments and muscles) of the cervical spine. This leads to inflammation and pain. Common symptoms: The most common symptoms related to whiplash include: Headaches Neck pain and stiffness Shoulder pain Dizziness Jaw pain Arm pain/weakness/ tingling Back pain

Physical Therapy Helps Recovery

Recent studies have shown that physical therapy may be the best choice to decrease pain, improve mobility, and minimize lost productivity as a direct result of whiplash-associated disorders. In a study in the Journal of Rheumatology (2007), a systematic review was performed of the existing literature on neck pain related to car accidents. The evidence strongly supported the use of stretching/strengthening exercises and mobilizations. Also, treatment with physical therapy was less expensive in the long run and reduced long-term disability compared to other treatment options. An article in the Emergency Medical Journal (2006) compared two groups of individuals recovering from car accidents. The first group received mobilization and exercise therapy (components of physical therapy) and the second group was treated with medication and a cervical collar. The group that received physical therapy had significantly less headaches and other symptoms related to whiplash compared to the second group. If you or someone you know has been injured in a car accident, the best thing you can do is to have them call our office today. The longer you wait to seek the expertise of one of our licensed physical therapists, the more prolonged the recovery process is likely to be. Don’t wait, pick up the phone and schedule an appointment right away.

An Active Approach To Be Pain-Free Again

In most cases, the potential for recover is high, especially with the right care as early as possible. A return to activity as soon as possible helps significantly. Although symptoms may be around for a while, the pain will improve within a few days or weeks. Be sure to continue with the medicines prescribed by your doctor to aid with early movement. Remember that prolonged inactivity does NOT help. Keep moving - it's important. Avoid staying in the same position for too long to avoid tightness and loss of flexibility. Exercise plays a big role in recovery. Simple neck and shoulder exercises are safe and effective. Stretching, strengthening and coordination exercises should be done regularly each day. Some soreness after exercise is to be expected. It is not a cause for concern. Physical therapy, in conjunction with standard medical care, has been shown to be the best choice to decrease pain, improve mobility and help you return to normal daily activities after a car accident. We can help you. Just contact us to see what we can do for you. If you have had a car accident, the first step toward recovery starts with us. Schedule your risk free appointment with your physical therapist. Let us help you return to a healthy, pain-free life once again.

Rehab For Rotator Cuff Injuries:

Acute Phase

Physical Therapy

Pain control and inflammation reduction are initially required to allow progression of healing and initiation of an active rehabilitation program in patients with a rotator cuff injury. This can be accomplished with a combination of relative rest, icing (20 min, 3-4 times per d), and acetaminophen or an NSAID. Have the patient sleep with a pillow between the trunk and arm to decrease tension on the supraspinatus tendon and to prevent blood flow compromise in its watershed region. Patients are instructed to continue the pain control techniques at home, work, or vacation as part of their exercise program. The home exercise program builds on itself through each phase of the rehabilitation process, and carry-over should be monitored.

Other Treatment

Corticosteroids delivered directly to the site via injection can be considered to allow further progression of the rehabilitation program. Place injections into the subacromial space, avoiding direct injection into the rotator cuff tendon. Advise the patient to limit activity that involves high-tensile loads (eg, maximal overhead throwing) for 2-3 weeks while the tendon is potentially at risk after injection, particularly if the patient exhibits rotator cuff muscle weakness. These injections need not be given to patients with complete rotator tears, especially if surgery is being considered.

Recovery Phase

Physical Therapy

The recovery phase from a rotator cuff injury must include several components to be successful. These include the following: (1) restoration of shoulder ROM, (2) normalization of strength and dynamic muscle control, and (3) proprioception and dynamic joint stabilization.

Restoration of shoulder ROM

After the pain has been managed, restoration of motion can be initiated. Codman pendulum exercises, wall walking, stick or towel exercises, and/or a physical therapy program are useful in attaining full pain-free ROM. Address any posterior capsular tightness because this can lead to anterior and superior humeral head migration, resulting in impingement. Posterior capsular tightness is common in athletes performing overhead motions (particularly throwers), because the posterior muscles and capsule are greatly stressed during the follow-through phase of the throwing motion. This activity places large eccentric loads on the posterior capsule and posterior rotator cuff musculature and can result in microtrauma and inflammation, followed by scarring and contracture.

Many overhead athletes have a great degree of external rotation with restriction of internal rotation. This was once thought to be a normal adaptation to the demands of the sport. The tight posterior capsule and the imbalance it causes forces the humeral head anterior, producing shearing of the anterior labrum and causing additional injury. Stretching of the posterior capsule is a difficult task to isolate. The horizontal adduction that is usually performed tends to stretch the scapular stabilizers and not the posterior capsule. If care is taken to fix and stabilize the scapula, which prevents stretching of the ST stabilizers, the objective of posterior capsule stretching is obtained. The focus of treatment in this early stage should be on improving range, flexibility of the posterior capsular postural biomechanics, and restoring normal scapular motion.

Initially, ultrasonography to the posterior capsule followed by gentle passive prolonged stretch may be needed. Closely monitor ultrasonography use to avoid heating an inflamed tendon, which worsens the situation. Instruct the patient about proper posterior shoulder stretches with the scapula fixed, which should be performed after a period of aerobic exercise. Such exercise results in increasing the core body temperature. The increase in core temperature makes the tissues more extensible and allows for greater benefit from stretch. Each stretch should be held for a minimum of 30 seconds, although stretching for 1 minute is encouraged. Postural biomechanics are important because poor posture (eg, excessive thoracic kyphosis and protracted shoulders) increases outlet narrowing, resulting in greater risk for rotator cuff impingement. Restoring normal scapular motion is also essential because the scapula is the platform upon which the GH joint rotates; thus, an unstable scapula can secondarily cause GH joint instability and resultant impingement. Scapular stabilization includes exercises such as wall push-ups and biofeedback (visual and tactile).

Strengthening

Perform strengthening in a pain-free range only. Begin with the ST stabilizers. The scapular stabilizers include the rhomboids, levator scapulae, trapezius, and serratus anterior. Shoulder shrugs, rowing, and push-ups isolate these muscles and help return smooth motion, allowing normal rhythm between the scapula and GH joint. Then, turn attention toward strengthening the rotator cuff muscles. Position the arm at 45° and 90° of abduction for exercises to prevent the wringing out phenomenon, in which hyperadduction can be caused, stressing the tenuous blood supply to the tendon of the exercising muscle. Avoid the thumbs-down position with the arm in greater than 90° of abduction and internal rotation to minimize subacromial impingement.

Many ways to strengthen muscles are available. The rehabilitation program usually starts with isometric and co-contractions, progresses to concentric contractions, and finally incorporates eccentric contractions as part of the preparation for return to sports. Using the baseball thrower example, the most important muscle conditioning is that of eccentric control. Eccentric forces are the most damaging to muscles, and if the patient is not fully rehabilitated and conditioned, injury occurs or reoccurs. Additional strengthening techniques that can be used are progressive resistive exercises (PREs), Thera-Band (Hygienic Corporation; Akron, Ohio), and plyometrics. Use of isokinetic exercises has been debated because they are not performed in a functional manner. Probably the best use for isokinetic exercise machines is for objective side-to-side comparison of strength and progress made in strength rehabilitation. Incorporate endurance training into the program as it advances. When strength is restored, continue a maintenance program for fitness and prevention of reinjury.
 

Proprioception

Proprioceptive training is important to retrain neurologic control of the strengthened muscles, providing improved dynamic interaction and coupled execution of tasks for harmonious movement of the shoulder and arm. Begin tasks with closed kinetic chain exercises to provide joint stabilizing forces. Then, as the muscles become reeducated, one can progress to open chain activities, which may be used in sports or tasks. Capsuloligamentous structures contain sensory afferents, which respond to motion and changes in joint position, whereas musculotendinous structures sense muscle length and tension. Injury can affect these afferents, which require retraining much like restrengthening the muscles. In addition, proprioceptive neuromuscular facilitation (PNF) is designed to stimulate muscle/tendon stretch receptors for reeducation. In a 1965 report, Kabat described shoulder PNF techniques in detail.^[26]

Surgical Intervention

Indications for operative treatment of rotator cuff disease include partial-thickness or full-thickness tears in an active individual who does not have improved pain and/or function within 3-6 months with a supervised rehabilitation program. An acromioplasty is usually performed in the presence of a type II (curved) or type III (hooked) acromion with an associated rotator cuff tear. Athletes with rotator cuff pathology secondary to GH instability also need to have this addressed. In surgical candidates, early repair is useful to avoid fatty degeneration and retraction of the remnant rotator cuff musculature. Functional recovery should be stressed, and, in a patient who can achieve pain-free activities of daily living in the setting of a rotator cuff tear, surgical repair may be avoided. Surgeries including muscle transfers and debridement are generally reserved for massive, irreparable rotator cuff tears. A latissimus dorsi tendon transfer is one type of treatment for irreparable rotator cuff tears that has demonstrated improvement in shoulder function, range of motion, strength, and pain relief.^[27]  Attempts to enhance healing in rotator cuff repair have included the use of platelet-rich fibrin matrix applied to the tendon-bone interface at the time of rotator cuff repair; this technique, however, has no demonstrable effect on tendon healing or vascularity, manual muscle strength, or clinical rating scales. Whether fibrin matrix is the ideal substrate to enhance tissue healing remains unknown, and perhaps other forms of growth factors may prove to be better at enhancing tissue healing following surgery.^[28]

Maintenance Phase

Physical Therapy

Return to task-specific or sport-specific activities is the last phase of rehabilitation. This phase is an advanced form of proprioceptive training for the muscles to relearn previous activities. It is an important phase of rehabilitation and should be supervised properly to minimize the possibility of reinjury. Rehabilitation begins at a cognitive level but must be practiced so that transition to unconscious motor programming occurs. All various phases of shoulder injury rehabilitation may overlap and can progress as rapidly as tolerated, but all should be performed to speed recovery and prevent reinjury.

At the conclusion of formal therapy sessions, patients should be independent in an ROM and strengthening program and should continue these exercises, initially under supervision and then completely on their own. A natural tendency exists for patients to abandon the home program once they feel better; however, patients must be encouraged to continue a maintenance exercise program to prevent symptom relapse. Athletes are often tempted to return to their overhead throwing sport too soon after recovery of the acute phase.

 

Sports Injury Rehabilitation 101

Injuries can occur in any sporting activity. Professional athletes in particular, are prone to injuries due to the excessive wear and tear associated with the demands of competitive sport. The right exercis...

e program to maintain strength, flexibility and stability can help athletes recover quickly after an injury, empowering them to resume athletic activities.

Sports injuries, by definition, include injuries involving the musculoskeletal system. The musculoskeletal system includes the bones, tissues, muscles, and cartilage. Every injury is different and every person heals differently. The purpose of rehabilitation is to help the injured tissues recover in a controlled and supervised manner. It takes time for an injury to heal, and it's best to seek the guidance of an experienced physical therapist during this time. The therapist can design a safe and effective recovery program specifically geared towards the individual's abilities. A physical therapist can identify the cause of the injury and create a treatment plan to prevent future injuries.

Some of the most common sports injuries include sprains, strains, shin splints and knee injuries. If you or someone you know is injured, schedule an evaluation with a physical therapist as soon as possible.

 Physical Therapy - The Right Choice

A physical therapist is a healthcare professional with extensive training in the musculoskeletal system. The therapist can work closely with athletes to assess muscle imbalance, range of motion and functional requirements of that particular sport. For example, a baseball pitcher may need a shoulder stabilization program and a basketball player may need a speed and plyometric (explosive strength) training program. The physical therapist can evaluate, identify, and plan a sport-specific injury prevention program.

As part of the treatment process, a therapist will prescribe an exercise program consisting of stretching (to improve mobility) and exercises (to improve strength). The goal of physical therapy is to reduce pain and improve function as quickly as possible. Along with exercise, rest is an important part of the recovery process. The physical therapist will help you to balance rest and exercise to recovery in an optimal manner.

Don't Wait For an Injury...

An injury is the last thing anyone wants. Without proper rehabilitation, the damage can get worse. In fact, did you know what physcial therapy helps not only with treatment, but also with prevention of athletic injuries? Also, it doesn't matter if you play professional sports or are a weekend warrior. Working with a physical therapist requires time and patience, but it's worth the effort. It's a great way to come back to the sport you love and enjoy, while minimizing the chances of re-injury.

If you or someone you know is an athlete, consider working with a physical therapist. In fact, you don't have to wait till you are injured, because a physical therapist can help an individual improve athletic performance and minimize injury. A preventive, proactive approach is important. After all, prevention is better than cure. Don't wait till someone gets injured because there is a lot that a physical therapist can do to save you from an injury. Schedule an evaluation with us, because we can design the right program and get you great results. It doesn't matter if you are a recreational athlete or participate in competitive sports, we can help you. We look forward to hearing from you.

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In our Hearts and Prayers

To those families and patients who are suffering with this tragic storm, our hearts and prayers go out. Please stay safe and we hope to see you soon. The governors of Florida, New York, and New Jersey should work together to move all that sand from their streets to our beaches

Joint Health:

It's well known that that nutrients in certain foods can boost immunity, improve heart health, and promote well being. However, did you know that nutrition can play a role in bone and joint health as well?

Joints serve an important function in the human body. Movement at the joints allows you to bend, reach, turn, and rotate.

As an individual gets older, more sedentary, and gains weight, arthritic changes can set in. Joints begin to degenerate, resulting in pain and discomfort in daily life.

The best way to build strength and stability of the joints and the surrounding ligaments, muscles, and bones is through a combination of exercise, healthy eating, and nutritional supplements.

Exercise is one of the best ways to keep your joints healthy and improve well being. On the other hand, sedentary individuals are at a higher risk for joint pain. The less you move, the more stiff your joints will be, so it’s important to move around.

"Getting up and moving" can be as simple as going for a brisk walk or using the vacuum. If you work in an office, you can increase your mobility by talking on the phone while standing up instead of sitting at your desk. You can also stand up and and stretch at regular intervals.

The weight of your body is supported by your lower back, knees, and hips. Loss of excess body weight will help ease the strain on your joints.

Adding resistance increases muscle strength around your joints and ligaments. It is very important to consult your physical therapist before beginning any resistance training program. You want to make sure you don't overdo anything and hurt yourself.

Nutrition plays an important role in joint health. Eating a diet rich in nutrients contributes to bone strength. The consumption of diary and foods such as broccoli and kale facilitate calcium intake. If you can't tolerate milk, ask your physician if calcium supplements are right for you.

Foods rich in Vitamin C and antioxidants may contribute to immunity and joint health. Eat plenty of colorful fruits like oranges, berries, and melons to take in an excellent supply of both nutrients. Salmon is an excellent source of calcium and omega-3 fatty acids. Omega-3 fats have several benefits, and may boost joint health, heart health and decrease pain and swelling. Please note that these are general guidelines, and are not meant to replace or constitute the advice of a registered dietician or nutritional consultant.

Email: flaglrcorf@aol.com
Phone:561 833 - 1747
Web: http://www.flagler-rehab.com

Prolonged sitting linked to increase kidney disease in women.

New research finds daily sitting for long stretches may raise the risk of chronic #kidney disease, especially in women. http://t.co/R22lIaDg

Here at The Flagler Institute for Rehab, Inc., we suggest getting up every hour and walking around office then doing some stretches for your legs and back. Sitting creates stagnant points in which the blood accumulates making it more difficult for your kidneys to filter your blood.

Wishing everyone a healthy and safe Halloween season.

Cancer News and rehab

New research comes out today in relation to breast cancer. Finding four classes of the disease as well as bringing new treatments to light should lead to some interesting and effective protocals in the future.

http://novato.patch.com/articles/buck-scientists-contribute-to-major-cancer-study

The Flagler Institute for Rehab, Inc. has been one of the only outpatient physical therapy clinics in south florida to offer comprehensive cancer rehabilitation tailored to fit your needs. Dr. Kevin Kunkel PhD, PT, MLD-CLD has developed a combination of Lymph drainage, exercise, education and pain managment (NO DRUGS) to help those recovering or currently going through cancer treatments. This program is designed to minimize side effects and helpmaintain your standard of life. If you or a oved one is fighting cancer please call and find out what we can do for you.

561-833-1747

 

Happy Rosh Hashanah! May all of our Jewis friends have a great and safe new year. Hopefully 5773 is better then 5772.

We will always remember!

We honor those who helped!

We look forward to our future!

And rest easier knowing we are safer.

Contact: Richard Rinehart Assistant Administrator Phone 561 833 - 1747 Fax 561 833 - 1394

311 Golf Road, Suite 1000 West Palm Beach, Florida 33407 Phone 561 833 - 1747 Fax 561 833 - 1394

The Flagler Institute For Rehabilitation

Press Release    

The Flagler Institute for Rehabilitation is inviting a select number of Physicians to join with Kevin Robert Kunkel, PhD, PT, MLD-CDT to be Co-Authors to our research department and have an active role in our projects and articles.

 

We will be looking for Doctors in the following specialties to review our research and provide Medical knowledge to our findings.

There are only a few spots in each area so please act quickly to add prestige and increased exposure to your practice.

§  Lymphedema: Research to measure proper treatments and combinations that yield the best results. Aided by perometer measurements for accurate data. See cancer rehab.

§  Cancer Rehabilitation: Measuring changes in outcomes from issues secondary to cancer and cancer treatments. Myofascial/soft tissue limitations, swelling issues, and nerve damage to name a few.

§  Bariatric Rehabilitation: Research to determine best practice and safety protocols, and Lifting systems and benefits to treatments.

§  Orthopedics: Gait analysis using Biodex treadmill to determine changes post surgery or injury, Neurocom Balance Master to determine balance issues and postural changes seen post surgery and others.

§  Neurological: Research for post TBI, Concussions, Stroke, Parkinsons, And others using the latest computerized analitics from Neurocom,and Biodex.

 

MD's please call 561-833-1747 for more information

 

Flagler is accepting new referrals, please contact numbers above for further information

Staying Well: Take Steps to Reduce Your Risk or Find Breast Cancer Early

http://acs.r.delivery.net/r?2.1.3LO.2iH.11hRe4.CPispW..P.EId0.g2s.bW89MSZoPTEtV1oxREMxCZSGQI00

Please, if you or a loved one is fighting cancer and need therapy call us. We will set up a customized rehab program for you. We offer Lymphedema therapy, Cranio-sacral and Myofascial release for scar tissue and fibrotic areas after radiation and surgery, as well as other services designed to reduce pain and increase your comfort levels.

Nothing beats prevention! But we offer help for those who need it.

The Flagler Institute for Rehabilitation, Inc.
311 Golf Rd. St 1000
West Palm Beach, Fl 33407
561-833-1747






http://www.flagler-rehab.com/

3 Basic Tips for Shoulder Pain:

1- Do no sleep on the same side every night, switch sides and change your hand positions.
2- Try to sit with your hands on arm rests and palms up, this opens the chest and un-pinches the tendons.
3- Pinch your shoulder back several times during day and focus on sitting up straighter and back in your chair.
www.flagler-rehab.com

The Will To Overcome!

The Flagler Institute for Rehabilitation would like to stand up and cheer for those few hard working American athletes competeing in the olympics and para-olympics. For those who go DO! when others say they can't. They are a shinning example of human will and the bodies ability to overcome.

If you or a loved one is battling to overcome a disability and need help getting started call us. If we cant help you we will direct you to those who can.

Richard Rinehart, BSHCA, PTA Assistant Administrator
The Flagler Institute for Rehabilitation, Inc.
311 Gold Rd. #1000 W.P.B. FL 33407
561-833-1747 phone
561-833-1394 fax
www.flagler-rehab.com

http://www.ptproductsonline.com/issues/articles/2011-01_04.asp

There is help for those patients suffering from foot drop. The Bioness L300 foot drop system allows those patients who have had strokes, spinal surgeries or LE injuries to walk by sending low electrical signals to muscles causing them to contract at the right time during your walking motion.

Hello everyone, just a reminder to keep hydrated when you are outside and get into the shade when possible. Limit small kids to an hour of direct play in sunlight to prevent heat exhaustion. Hope everyone is having a great summer.

Do you know someone who has a back like this?
Are you someone who is facing a spinal fusion or surgical procedure?
The Flagler Institute for Rehabilitation has been treating spinal patients from several of the leading hospitals in the eastern seaboard for the last 15 years.
Hospitals we service include: The Hospital for Special Surgery, New York,
                                                  Miami School of Medicine at Jackson Memorial, Miami
Let our comprehensive team of therapists progress you back to a fully functioning person and return your way of life.
Richard Rinehart, BSHCA, PTA
Assistant Administrator
www.flagler-rehab.com

The Flagler Institute for Rehabilitation

Flagler Institute for Rehabilitation was established in 1996 and has helped more than 5000 patients in the Palm Beach County area. Kevin Kunkel is the Chair of The Center for Cancer Rehabilitation and Lymphatic Disorders which is dedicated to education, research, development and treatment of these disorders.  Each year more than 1 million will be affected with lymphatic disorders associated with surgery, cancer and obesity.

Physical therapy.

When you’re injured or experiencing a change in your abilities, nothing seems right. You’re missing out on your favorite activities. You may be missing work, unable to earn a living or require assistance to take care of yourself. At the Flagler Institute for Rehabilitation, our physical therapists use gentle, hands-on methods to treat your condition and achieve improved function as fast as possible. This means fewer visits. It also means getting you back to your job, your family — your life — faster. Plus, we don’t just treat your symptoms — we show you how to keep them from coming back.

A facility so comprehensive, it’s certified.

The Flagler Institute for Rehabilitation is proud to be certified by Medicare as a Comprehensive Outpatient Rehabilitative Facility (CORF). A CORF is a highly specialized outpatient facility that provides diagnostic and therapeutic services to patients requiring complex rehabilitative care. At a minimum, a CORF must be able to provide physician services, physical therapy and social or psychological services. Here at the Flagler Institute for Rehabilitation, we offer all of these plus occupational therapy, medical nutrition and on-site nursing. Our team of specialists works under the medical supervision of a board-certified physician.