Physical Therapy

Physical Therapy at Adirondack Health

EXERCISE IS MEDICINE

Physical therapists are licensed healthcare professionals with extensive education and clinical experience in helping patients address pain and improve or restore mobility. Often, treatment provided by a physical therapist is a less costly alternative to surgery and reduces the need for long-term prescription medication and associated side effects.

Physical therapists work with patients to prevent or manage their conditions in order to achieve long-term health benefits. They diagnose and treat individuals of all ages and develop plans, using therapeutic techniques that promote the ability to move, reduce pain, restore function, and prevent disability. In addition, physical therapists develop fitness and wellness programs to encourage health and prevent disability.

Physical therapist assistants (PTAs) work as part of a team to provide physical therapy services under the direction and supervision of a physical therapist. PTAs implement treatment, obtain data related to interventions, and make modifications in selected interventions to progress the patient/client as directed by the physical therapist.

Outpatient Rehabilitation:

Outpatient physical therapy is provided at our locations in Tupper Lake, Saranac Lake and Lake Placid, operating Monday through Friday. We provide evaluation and individualized treatment of functional impairments associated with orthopedic, neurological, vestibular and/or cardiopulmonary conditions.  Below are examples of the interventions provided. Click on each subject for additional information, or feel free to reach out with any questions regarding our services.

Amputee/Prosthetic Training

The loss of a limb is a life altering event. Adirondack Health’s team of physical and occupational therapists will work with you to provide a comprehensive plan for any stage of recovery following an amputation. Our team will work with your physician, prosthetist, and medical providers to assist you with the process of limb recovery, prosthetic fitting, and gait/activity training to help you regain independence, functional ability and greater activity levels. Interventions could include: compression, strength training, range of motion and flexibility training, education on positioning to avoid contractures, gait training, pain management, prosthetic fit and training, and functional mobility training.

For more information, please contact the site closest to you.  Our goal is to help you achieve your goals and obtain the highest level of function.

Aqua Therapy

Adirondack Health is now offering aquatic therapy in a state-of-the-art therapy pool heated from 88-93 degrees Fahrenheit at the new medical fitness center in Lake Placid. Aquatic therapy uses many properties of water to help individuals with a variety of acute and chronic musculoskeletal, neuromuscular, and cardiopulmonary medical conditions. These include but are not limited to:

· Joint pain and stiffness
· Joint replacements
· Muscle spasms
· Back pain
· Osteoarthritis
· Rheumatoid arthritis
· Fibromyalgia
· Lymphedema
· Peripheral neuropathy
· Cerebral palsy
· Parkinson's disease

Aquatic therapy uses the benefits of buoyancy, hydrostatic pressure, viscosity and thermal effects of water to assist in treatment. These effects can result in increased of range of motion, decreased pain, improved posture, balance, pulmonary and muscular strength. The water also allows for more comfortable walking in a partial weight-bearing environment.

To get started, obtain an aquatic therapy prescription from your physician. Then, schedule a land-based evaluation with a physical therapist at one of our locations to determine if you are a candidate for aquatic therapy.  

Arthritis Rehabilitation

Have you been told you have arthritis? Well you aren’t alone. Arthritis is a common inflammatory disease that usually happens over time and can affect one or more of your joints. Common symptoms include pain, swelling, redness around the joint, decreased movement and stiffness and can vary from mild to severe. Arthritis is used to describe more than 100 chronic diseases and conditions that affect the joints and the surrounding tissues. Some common types of arthritis are osteoarthritis, rheumatoid arthritis, post-traumatic arthritis and gout. Whether it is in your knees, hips, back or other joints a physical therapist can help!

Although there is no cure for arthritis, there are many treatment options available to manage your symptoms and physical therapy is one of them. A physical or occupational therapist will provide you with an individualized program to get you moving safely and effectively as well as provide education on the balance of rest and exercise. Some of the goals of physical therapy typically include:

- Improving mobility and restoring the use of affected joints
- Increased strength to support the joints
- Preserving the ability to perform daily activities
- Providing activity and lifestyle modifications
- Education on pain management strategies

If you are experiencing arthritis symptoms, don’t wait! Schedule your initial evaluation today with Adirondack Health Sports Medicine and Rehabilitation at one of our three locations!

Chronic Pain

Sensitization of the nervous system contributes to chronic pain. The nervous system detects changes, both in the environment and within your body, and then responds to those changes appropriately.  Five types of changes can trigger the nervous system to act: movement, blood flow, temperature or barometric pressure, illness, and stress. Various responses may include tingling, numbness, pain, swelling, sweating, feeling cold, changing positions, etc.  With chronic pain the nervous system becomes more sensitive to these changes; thus, pain is produced in response to small fluctuations. You might notice pain with weather changes, if you are touched lightly, or any time you move. The goal of physical therapy is to decrease the sensitivity of the nervous system. Interventions will target the type of stimulus that most often triggers the pain response. Elements of physical therapy care may include education, exercises, relaxation activities, and desensitization techniques. All treatments will be done in a gradual manner and catered to each person’s needs.

Fall Prevention

According to the Center for Disease Control each year 3 million older adults end up in the emergency room and 800,000individuals are hospitalized due to fall-related injury.  Falls can occur secondary to a variety of reasons.  Some common medical conditions and diagnoses that can lead to falls include orthostatic hypotension, diabetes, and stroke.  Other common causes of falls include environmental factors, safety hazards in your home, medication side effects, and impaired vision and hearing.

Physical therapists are trained to identify fall related risk factors, help prevent falls, and treat injuries from a fall.  If you are wondering if you would benefit from a physical therapy evaluation, ask yourself the following questions.

· Have I fallen in the last 12 months?
· Do I struggle getting out of bed or out of a chair?
· Do I feel unsteady when walking in my house or out in the community?  

If you answered yes to any of these questions, please talk to your physician to obtain a physical therapy referral.  

Although 1 in every 4 older adults falls each year, falling is not a part of normal aging. A physical therapist can help you assess your risk factors and develop a plan to address them:

· Designing an individualized plan for your fall-prevention needs.
· Helping you make your home as safe as possible.
· Educating you about the medical risk factors associated with falls.
· Providing you with appropriate exercises and balance training.
· Working with other health care professionals to address any underlying medical conditions that could increase your fall risk.
· Providing you with recommendations on appropriate community programs.

Physical therapists are movement experts who improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation.

Facts About Falls.(2017, February 10). Centers for Disease Control and Prevention. https://www.cdc.gov/falls/facts.html

LSVT BIG and LOUD Program for Parkinson's Disease

Parkinson disease (PD) is related to a loss of nerve cells in the brain that produce a chemical called dopamine. Dopamine and other brain chemicals are normally in balance and are important for the control of body movements, thought processes, decision making, moods, and other behaviors.

The exact cause of PD is not yet known. Family history, aging, or exposure to certain environmental toxins may contribute to the onset of PD. It is a chronic degenerative disease, which means that it gets worse over time; however, people usually do not die from it.

The severity and symptoms of PD can vary widely. Some people have the disease for 20 to 30 years and experience a slower decline in mobility and thinking over a longer period of time. Others may experience difficulty with physical movements and thought processes within 5 to10 years, as the disease progresses more rapidly.

Because PD affects each person differently, your physical therapist will partner with you to manage your specific situation—now and as your condition changes. You are not alone!

Following a diagnosis of PD, your physical therapist will conduct a comprehensive evaluation, including tests to examine your posture, strength, flexibility, walking, endurance, balance, coordination, and attention with movement. Based on your test results, your physical therapist will develop an individualized treatment plan to help you stay as active and as independent as possible. Your program will include exercises and techniques to combat the symptoms of PD.

Depending on the nature and severity of your condition, your treatment program may focus on activities and education to help you:

· Improve your fitness level, strength, and flexibility
· Develop more effective strategies to get in and out of bed, chairs, and cars
· Turn over in bed more easily
· Stand and turn to change directions more efficiently
· Improve the smoothness and coordination of your walking
· Improve your ability to perform hand movements
· Decrease your risk of falling
· Improve your ability to climb and descend stairs and curbs
· Perform more than 1 task at a time more efficiently
· Participate in activities that are important to you

Some of the medications designed to manage PD symptoms may have an immediate positive effect. For example, movement is typically much easier shortly after you begin taking certain PD medications. Your physical therapist will know how to time treatments, exercise, and activity based on both the schedule and the effects of your medications to get the best results.

Parkinson disease can make daily activities seem frustrating and time-consuming. Your physical therapist will become a partner with you and your family to help you combat and manage the symptoms of PD. As your condition changes, your treatment program will be adjusted to help you be as independent and as active as possible.

Some people with PD benefit from using a cane or a walker. Your physical therapist can work with you to determine if any of these devices may be helpful to you. If you need physical assistance to help you with moving in bed or getting out of a chair, your physical therapist can team with you and your family to develop strategies to make moving easier and help prevent injury. In addition, your physical therapist can make suggestions on changes to your home environment to optimize safe and efficient daily function at home.

LSVT programs are evidence-based speech, physical or occupational therapies. LSVT stands for Lee Silverman Voice Treatment. Named for Mrs. Lee Silverman, a woman living with Parkinson disease, it was developed by Dr. Lorraine Ramig and has been scientifically studied for over 25years with support from the National Institute for Deafness and other Communication Disorders within the National Institutes of Health (NIH) and other funding organizations.

Today there are two distinct LSVT therapy programs: LSVTLOUD speech therapy improves communication in daily living; and LSVTBIG physical or occupational therapy improves mobility and movement used in everyday function.

These are not general exercise programs. Instead, they are research-based treatment protocols designed specifically to address the motor, sensory and non-motor symptoms that many people with PD face. LSVTLOUD and LSVT BIG treatments can only be given by specially trained LSVTCertified Clinicians. With their guidance, people with PD will learn to translate skills built during treatment into better everyday communication, function and movement.

https://www.lsvtglobal.com/IdaIndexLSVT

Neurological Disorders

Neurological physical therapy encompasses specialized comprehensive evaluation and treatment of individuals with movement problems due to disease or injury of the nervous system. Advanced Physical Therapy provides individualized one on one treatment with primary focus on restoring function and improving overall quality of life.

Commonly Treated Conditions Include:

· Stroke
· Traumatic brain injury
· Spinal cord injury
· Parkinson Disease
· Multiple Sclerosis
· Guillain Barre Syndrome
· Ataxia
· Amyotrophic lateral sclerosis
· Polyneuropathies
· Progressive neurological conditions
· Spasticity/tone

Neurological physical therapy is extremely important for those patients who have had or who currently have neurological diseases or injuries. The brain, spinal cord and the peripheral nervous system control movement and sensation. Injuries to these areas, can cause death of the cells that control certain movements and sensations, and therefore people lose function. Without neurological physical therapy following a neurological injury, patients may lose many functions and not be able to perform certain activities. This can lead to many other health problems such as diabetes, heart problems, lung problems, decreased independence, and an overall poor quality of life.

Following the neurological disorder or injury, there is a certain amount of time when the nervous system can be trained to compensate for the impacted areas. Physical therapists are trained in expediting this process. This skilled assistance can help patients regain some to most of the impaired functions they lost because of the injury.

Manual Therapy Techniques

At Adirondack Health, one of the many ways that we can treat injuries, pain, swelling, and restrictions is through manual techniques. To assist with an individualized hands-on-approach we utilize tool assisted massage (SASTM), soft issue massage, joint mobilization, manipulation, stretching, traction, and various taping techniques of the spine, arms and legs.  See below for more detailed information.

- SASTM- instrument assisted soft tissue mobilization. This method enables clinicians to effectively locate and treat areas of soft tissue dysfunction using an instrument, allowing deeper pressure than a therapist’s hands. ​ Instruments effectively break down fascial restrictions while promoting increased blood flow to the area for healing.

- Mobilization includes moving joints of the body and stretching of soft tissues.

- Traction-Traction is a gentle decompression technique used for mobility, pain or relaxation. It can be applied with a therapist’s hands or by a machine.

- Manipulation - quick, little thrusts to joints to improve motion and reduce pain.

- Soft tissue massage- by therapist for various reasons including restrictions of muscles or tendons, swelling/edema, pain, spasm including trigger point release and positional release.

- Taping - Kinesiotape and Leukotape used in clinic to activate or inhibit muscles and support joints for either pain management or improved function.

Our licensed therapists will evaluate your condition and implement one or more of our manual therapies if appropriate to aide your healing process as part of a comprehensive plan.  Please contact our clinics with any further questions.

Orthotic Evaluation

Foot orthotics are a device that are inserted in the shoe to help with problems of the foot or other issues in the legs.  They can help with issues of pain in the feet, knees and hips or back.

Our physical therapy staff can help evaluate for the need of a “Custom” versus “Off the Shelf” type of device, including possible molding of a “slipper cast” of your foot to be sent away to a reputable lab for orthotic fabrication.

Orthotics are covered by many insurance companies and are reasonably priced for purchase if they are not covered.

Please contact us at any of our locations for more information.

Pelvic Rehabilitation

Did you know it is not normal to have pain during or after sex? Do you have urinary leakage (at all)? Have you been told that you have a pelvic organ prolapse? These are common, but not typical symptoms and pelvic PT can help! At Adirondack Health, we have a physical therapist who is specially trained in the examination and treatment of the pelvic floor.

Pelvic dysfunctions can be distressing and decrease quality of life. Exams can be performed both internally and externally, depending on comfort level. Exams and treatments are done in a private setting, making it more comfortable for you. Your treatment is tailored to your needs and goals. Kegels are not always the answer, and pelvic rehabilitation will work on pelvic floor strengthening, lengthening, coordination, and using the pelvic floor functionally.

We can help to return you to a normal level of function, including pain free penetration (including sex and annual female wellness exams), decreased or no urinary leakage, techniques to suppress urinary urge, and improvement in bulging or heaviness sensation in prolapse.

Diagnoses that can benefit from pelvic rehabilitation include: vaginismus, dyspareunia, endometriosis, vulvodynia, dysmenorrhea, stress incontinence, urge incontinence, mixed incontinence, cystocele, rectocele, uterine prolapse, post-partum, and more!

Post-Concussive Syndrome Treatment

Physical therapists can evaluate and treat many problems related to concussion. Because no two concussions are the same, a physical therapist will examine your neurological, orthopedic, and cardiovascular systems in order to best prescribe a routine to address your particular symptoms and your needs in all of your daily environments.

Treatment may include:

Rest and recovery. Your physical therapist will help you and your family understand why you should limit any kind of activity (daily tasks, work, school, sports, recreation, the use of electronics, etc.) after a concussion, until it is safe to return to these activities. A period of rest helps the brain heal and helps symptoms clear up as quickly as possible. Your physical therapist will prescribe the rest and recovery program most appropriate for your condition.

Restoring strength and endurance. The physical and mental rest required after a concussion can result in muscle weakness, and a decrease in physical endurance. Your physical therapist can help you regain your strength and endurance when the right time comes, without making your concussion symptoms worse. It is common for elite-level athletes and fit “weekend warriors” to experience exercise intolerance with concussion and brain injury. Your physical therapist will work with you to identify and treat your particular concussion symptoms.

Your physical therapist will design a therapeutic exercise program just for you, and closely monitor your symptoms as you participate in the program.

Stopping dizziness and improving balance. If you have dizziness or difficulty with your balance following a concussion, a type of physical therapy called vestibular physical therapy may help. The vestibular system, which includes the inner ear and its connections with the brain, helps you keep your balance and prevent dizziness. A qualified vestibular physical therapist may be able to help reduce or stop your dizziness or balance problems after a concussion by applying special treatments or teaching you specific exercises, some of which you may be able to do at home.

Reducing headaches. Your physical therapist will assess the different possible causes of your headaches, and use specific treatments and exercises to reduce and eliminate them. Treatment may include stretches, strength and motion exercises, eye exercises, hands-on techniques like specialized massage, and the use of technologies such as electrical stimulation.

Returning to normal activity or sport. As symptoms ease and you are able to regain your normal strength and endurance without symptoms returning, your physical therapist will help you gradually add normal activities back into your daily routine. Your physical therapist will help you avoid overloading the brain and nervous system as you increase your activity level. Overloading the brain during activity after a concussion interferes with the healing of the brain tissue, and can make your symptoms return. Your physical therapist will help you return to your normal life and sport activities in the quickest and safest way possible, while allowing your brain to properly heal.

Pre-Surgical and Post-Surgical

Whether you are having a joint replacement, ACL reconstruction or a spinal fusion it is essential to be prepared in knowing what to do next, as life immediately after surgery is not instant bliss. The success of your surgery depends on how you prepare and what you do during your post-surgical recovery period. Physical therapy is an integral component to optimize the healing process and help you learn the best way to care for yourself and return to daily activities.

Adirondack Health Sports Medicine and Rehabilitation is here to safely progress you through your recovery and prevent re-injury during your pre- and post-surgical rehabilitation.  Our Physical Therapists are knowledgeable in surgical procedures/protocols and will work with your healthcare team to tailor treatments to improve overall well-being and better ensure long-term success. Some reasons why you will benefit from physical therapy after surgery are:

- Enhanced mobility, balance and strength 
- Less pain and swelling
- Reduction of scar tissue formation
- Restoring range of motion
- Better muscle function
- Improved flexibility
- Reduction of developing secondary issues (inflection, blood-clots)
- Returning to activities of daily living

Physical therapy is typically recommended after an orthopedic surgery however many of us are not aware of the benefits of a structured pre-surgical rehabilitation program. This program designed by your physical therapist will prepare you prior to surgery with some of the goals as follows:

- Mentally prepare for surgery with what to expect
- Reduce pain and inflammation
- Improve range of motion
- Provide safe strengthening exercises
- Normalize movement patterns and muscular control
- Gain an understanding of the exercises you will be performing immediately after surgery

Adirondack Health Sports Medicine and Rehabilitation work as a team to return patients to their pre-surgical status as quickly as possible. To schedule an appointment with one of our outpatient rehabilitation locations please call.

Sports Related Injuries

One of the most frustrating and challenging things to endure as an athlete is a sport related injury.  Sport related injuries can be either acute(sudden onset) or chronic (progressive over time) and occur secondary to a variety of factors/reasons including:

- Too much activity too soon (volume and intensity)
- Faulty mechanics
- Strength and flexibility imbalance

Some of the most common sport related injuries treated by Adirondack Health’s Rehabilitation team include but are not limited to:

- Muscle strains (i.e: hamstring, groin, rotator cuff, lower back)
- Ligament sprains (i.e: knee, ankle)
- Tendonitis (i.e: tennis elbow, rotator cuff, Achilles)
- Fractures
- Dislocations and separations (i.e: shoulder subluxation, AC joint separation)

Our licensed physical and occupational therapists are trained in creating a comprehensive plan to help guide you through the healing process. We work closely with local clinicians and programs, including orthopedic physicians, athletic trainers, fitness coaches and schools to offer a multidisciplinary approach to care. This assists with a more efficient and timely return to activity with greater confidence and decreased risk of re-injury. Our clinicians utilize a vast array of interventions for a more individualized approach to your care, including sport-specific testing and training to get you back on the ice, track or field!

Spinal Cord Rehabilitation

A physical therapist is a key member of your spinal cord injury (SCI) rehab team. He or she will help you regain function, improve mobility, and prevent complications that may arise years after the initial traumatic injury.

A physical therapy (PT) program after SCI likely includes the following:

· Strength training
· Cardiovascular exercise
· Respiratory conditioning
· Mobility training
· Stretching

While PT can help people move better and easier after SCI, barriers such as ventilator dependence, neuropathic and somatic pain, and psychosocial challenges can limit gains in recovery. If you’re struggling to start or maintain a physical therapy program, talk to your physical therapist or another member of your health care team.

Regardless of the length of time since the injury, it is important to get intermittent evaluations by a physical therapist to optimize function, update exercise programs, and improve the efficiency of movement patterns. Staying active can vastly improve one’s quality of life and has been shown to improve cardiometabolic function in individuals with SCI, even those living with chronic injuries.

Stroke Rehabilitation

Physical therapists are part of the stroke rehabilitation team. Rehabilitation begins very soon after a stroke; your physical therapist’s main goal is to help you return to your activities at home, at work, and in your community.

After examining you and evaluating your condition, your physical therapist will develop an individualized plan to help you achieve the best possible quality of life. The plan will focus on your ability to move, any pain you might have, and ways to prevent problems that may occur after a stroke.

One of the first things your physical therapist will teach you is how to move safely from your bed to a chair, and to perform exercises in bed. As you become more mobile, your physical therapist will teach you strengthening exercises and functional activities.

Later, your physical therapist will:
· Help you improve your balance and walking.
· Fit you with a wheelchair, if needed.
· Provide training to your family and caregivers.
· Train you in how to use devices that can help you keep mobile when a stroke has affected your ability to move, walk, or keep your balance: orthoses, prostheses, canes, walkers, wheelchairs, and perhaps even robotics.

Treatment for stroke varies. Your specific treatment will depend on the results of your physical therapist's evaluation, and on how long it's been since you had your stroke. Recovery from a stroke depends on the size and location of the stroke, how quickly you received care, and your other health conditions. Your physical therapist will help you regain functional skills to allow you to participate in your specific life activities.

Vestibular Rehabilitation (Vertigo)

The vestibular system tells you where your head is in space; it tells you what direction your head is going and how fast it is moving. If there is an issue with this system you may feel unsteady or off balance, your vision may be blurry, the room may spin or you might feel like you are spinning. These symptoms may occur when you change position, move your head quickly, roll over in bed, lookup or down, walk in a busy environment, or move from sitting to standing. These symptoms may be associated with various conditions including benign paroxysmal positional vertigo (BPPV), unilateral vestibulopathy, cervicogenic dizziness, or side effects from a concussion or cerebrovascular accident. Physical therapists are trained to treat these conditions with exercises, positional maneuvers and/or manual therapy techniques.

If you feel that you would be a candidate for vestibular therapy, please contact one of our locations to make your appointment today.

Wheelchair Assessment

Our comprehensive wheelchair evaluation helps determine the right seating system for you. We work with you to find the best solution for regaining independence and mobility. We also provide therapy for balance problems.

What to Expect from a Wheelchair Evaluation

First, you visit your physician to address your mobility needs. Your doctor writes a referral for a seating and mobility evaluation. An occupational therapist (OT) or physical therapist (PT)provides your evaluation. The reason for the evaluation can be new equipment, replacement equipment or modifications to current equipment.

An OT or PT works with wheelchair vendors to determine your mobility needs. The team creates a wheelchair prescription based on:

· Your goals, abilities and physical assessment
· Skin safety
· Your home
· Your job
· How you perform your daily living activities with your current mobility device, if you have one

When you receive your wheelchair, our therapist checks the fit and how well you are able to use the chair.

Post-Rehabilitation Program at the Medical Fitness Center
Free Community Screens for Acute Injuries or Conditions

Have a new pain that you are unsure about? We can help…

If you are coping with an injury, pain or other physical ailment, our rehabilitation specialists provide free screenings for anyone who may benefit from physical therapy.

The free screening is a one-time consultation with a licensed physical therapist or athletic trainer. After gathering information about your condition, an assessment will be completed to help you decide the best course of treatment.

If this includes rehabilitation services, a member of our staff will help you get any referrals you need to ensure those services provided are covered by your health insurance.

Direct Access Physical Therapy:

Adirondack Health’s Rehabilitation and Sports Medicine Department is offering direct access physical therapy appointments, which can facilitate evaluation and treatment without a referral from your medical provider.

Patients will receive care from a licensed physical therapist who specializes in movement disorders and musculoskeletal injuries. Direct access physical therapy allows you to save time and money, including co-pays, by not having to see your primary care provider to get an order for physical therapy. Our team can treat you for 30 days or 10 visits, whichever comes first. If at that time more services are needed, you would need to see your primary medical provider.

If it is determined that physical therapy services are not appropriate, we will assist you in securing a referral for a more suitable course of treatment.

Many insurances can be billed for direct access. Our team will verify coverage with your insurance provider before your first visit.

Call any of our Rehabilitation and Sports Medicine locations to begin this service.

Acute Care Rehabilitation:  

Physical therapy (PT) plays an important role in the care of patients in the acute care/hospital setting. Some patients may experience a change or a decline in their physical ability due to the onset of a new medical condition, traumatic event or exacerbation of chronic disease for which they are seeking medical attention.

The acute care physical therapist will be asked to evaluate a patient’s current level of function in light of their current illness. Based on the results of this evaluation the physical therapist works with the patient on exercising and improving their mobility with the goal safely returning home to their previous level of function.

The physical therapist also makes recommendations to the patient, their family and to the multidisciplinary hospital team regarding need for assistance, assistive devices, and the safest discharge plan following their hospital stay. Sometimes, the patient may require assistance for functional mobility and be appropriate for further rehabilitation in a skilled setting prior to returning home. This is often referred to as “short term rehab.” Typically, the case manager assigned to the patient would make a referral to a facility based on physical and occupational therapy recommendations and patient preferences.