Your post-knee replacement rehab should include a downhill walking program

August 17, 2018 in News by Horizon Physical Therapy  |  Comments Off

As most of you know, we’ve had an Alter-G Anti-Gravity Treadmill for some time now. We’ve used this technology for years to help patients after lower body injury or surgery return to walking faster than they would while walking under the stress of their full body weight.

One of the functions of the Alter-G that we do not use all that frequently, however, is the treadmill’s ability to allow a patient to walk at a decline or downhill. Based on a recent case study in The Journal of Orthopedic and Sports Physical Therapy, we will likely be using this function much more frequently. The study, “A Novel Downhill Gait-Training Program Following a Total Knee Arthroplasty”, was featured in the Journal’s February 2018 issue and highlights the use of downhill walking as an integral part of rehabbing a patient after a knee replacement.

The simple fact is that most patients struggle with returning to their normal walking pattern after surgery. The study reports that most patients take upwards of 3 years to return to their normal walking pattern post-operatively. This “three-year limp” often creates a ton of secondary issues like arthritis in other areas. So we’re correcting one issue and, in turn, creating other issues in the process. The authors of the study suggest that 10-15 sessions of downhill gait training over a 5 week period will allow patients to return to their normal gait pattern in 5 weeks, not 3 years, thus preventing the secondary issues from ever developing.

I believe that most lower body surgical patients, not just those rehabbing a knee replacement, struggle to return to their normal walking pattern during rehab, and I believe that incorporating downhill walking into their rehab programs may be the missing link.

Blood Flow Restriction Training

August 1, 2018 in News by Horizon Physical Therapy  |  Comments Off

At Horizon Physical Therapy, we are always striving to keep up-to-date and educated on the most cutting edge and effective therapies. We were the first clinic to bring Functional Dry Needling to the Athens area and we utilize world class equipment, like the Alter G—anti-gravity treadmill. Treating and improving performance of endurance athletes, like runners and tri-athletes, has been an area of specialization for Horizon since opening our doors in 2005. Recently, our clinicians have taken continuing education courses from experienced leaders in the physical therapy treatment of fitness athletes to better serve the growing Crossfit communities in Athens and Oconee. Horizon continues to lead the way and expand our scope in bettering performance and treatment of competitive and recreational athletes alike. With that being said, we would like to introduce you to a treatment that will be a game-changer for athletes and patients of all ability levels—Blood Flow Restriction Training (BFR).

BFR training is utilized as both a performance tool and a physical therapy treatment. This application works similarly to a blood pressure cuff — where blood flow to the exercising muscle is narrowed by a cuff in order to optimize muscle strength and hypertrophy gains. The HUGE advantage of BFR training is that you can effectively gain strength, muscle mass, and endurance by only lifting 30% or less of your maximal available muscle strength! This type of training is beneficial for a wide range of patients, from those 1 week out of a surgical repair (like a meniscus, ACL, or rotator cuff repair) to the in-season athlete who wants to continue training but does not want to hinder performance due to the muscle soreness required to gain strength. A patient who recently had surgery typically cannot bear full weight or is not allowed to stress the affected area intensely until the site has had some time to heal. With BFR training, we can mitigate the amount of time where muscles would typically atrophy and strength would be lost—In fact, with BFR, we are able to improve strength during times when patients sometimes lose strength due to immobilization.

So how does exercising with 30% or less of a 1 rep max actually increase strength when typically you need to be lifting at least 70% of your muscles full potential in order to increase strength? Simply put, BFR training reduces the amount of oxygen that the exercising muscle is able to obtain via normal circulation. Your muscles have 2 types of fibers—oxidative fibers and non-oxidative fibers. The oxidative fibers are the first to work when you exercise and they are more for endurance. The non-oxidative fibers are used for strength and speed production. BFR training allows you to use and strengthen those type 2 fibers in order to build strength without the associated muscle damage and typical delayed onset muscle soreness (DOMS). These are the basic principles behind why BFR training works. To read a more in-depth explanation on the science behind BFR training, refer to the research articles cited at the end of this blog.

You might be wondering, “Who is BFR training appropriate for and how do I know if it is a tool that will help my athletic or rehabilitation needs?” First of all, patients and athletes must be screened by a medical professional who is knowledgeable on the topic before BFR training is applied in order to make sure it is a safe intervention, on an individual basis. There are certain cardiovascular, metabolic, and musculoskeletal conditions for which BFR training would not be recommended. The physical therapists at Horizon PT are up-to-date on the most current research regarding BFR training and can let you know if it is a treatment that will benefit you. Below is a bullet list of some, but not all, who would benefit from BFR training.

  • Post-surgical patients of the ankle, knee, hip, shoulder, elbow, and wrist
  • Non-surgical patients who have had muscle atrophy in the extremities or trunk
  • Patients or athletes who cannot tolerate high loads on their joints but need to continue to gain strength
  • In-season athletes who cannot comprise performance for in-season strength training
  • Endurance athletes who want to increase their VO2 max
  • Recreational athletes/fitness athletes looking to build muscle mass.

Horizon Physical Therapy is proud to be able to offer this new and innovative intervention to improve the rehabilitation and performance of our patients and athletes. BFR training is currently being used in a rehabilitation setting at HPT. For those interested in the performance and athletic benefits of BFR, keep your eyes on Horizon social media as we will begin offering sessions of BFR training for purchase – just as we do running clinics and Normatec recovery boots. We hope to rehabilitate and train you harder and smarter with the inclusion of Blood Flow Restriction training in our practice, while continuing to bring you the latest and greatest interventions.

VANWYE WR, WEATHERHOLT AM, MIKESKY AE. Blood Flow Restriction Training: Implementation into Clinical Practice. International Journal of Exercise Science. 2017;10(5):649-654.Kubota, Atsushi, Keishoku Sakuraba, Sadao Koh, Yuji Ogura, and Yoshifumi Tamura. “Blood Flow Restriction by Low Compressive Force Prevents Disuse Muscular Weakness.” Journal of Science and Medicine in Sport 14.2 (2011): 95-99. Web.

Loenneke, J. P., G. J. Wilson, and J. M. Wilson. “A Mechanistic Approach to Blood Flow Occlusion.” International Journal of Sports Medicine Int J Sports Med 31.01 (2009): 1-4. Web.
Loenneke, Jeremy P., Jacob M. Wilson, Pedro J. Marín, Michael C. Zourdos, and Michael G. Bemben. “Low Intensity Blood Flow Restriction Training: A Meta-analysis.” European Journal of Applied Physiology Eur J Appl Physiol 112.5 (2011): 1849-859. Web.

Neural mobilization. Did you know that nerves can become tight and immobile?

July 3, 2018 in News by Horizon Physical Therapy  |  Comments Off

We all know that muscle tension can lead to muscle pain and, in some cases, muscle strain. Did you know, however, that nerves can also become tight and immobile? Have you ever experienced unusual symptoms such as numbness or tingling in your arms or legs? Many musculoskeletal conditions are frequently accompanied by neurological symptoms including numbness, tingling, and weakness. Many people with musculoskeletal pain often begin addressing the issue with muscular mobilization and release techniques including stretching and foam rolling. These are helpful techniques to reduce muscular tightness and spasm that may contribute to musculoskeletal pain. However, additional neural mobilization techniques can and often should be performed to restore functional mobility of surrounding neural pathways.

What is neural mobilization? Neural mobilization facilitates movement between neural structures and their surroundings through manual techniques or exercise. Multiple research studies have been performed to determine the effectiveness of neural mobilization for musculoskeletal conditions. Research has shown significant improvements in nerve-related lower back, neck, and arm pain through incorporation of neural mobilization techniques. Neural mobilization can be performed for the upper and lower extremities, according to the area of pain and dysfunction. Neuromusculoskeletal assessment should be performed by your physical therapist to determine specific neural pathways that may be affected.

A commonly affected nerve that is often compromised in individuals with lower back and hip pain is the sciatic nerve. Sciatic nerve entrapment or irritation may often present as pain, numbness, tingling, and/or electric shock-like sensations down the back of the leg. These symptoms are often present in conditions such as lumbar disc bulge or herniation, sacroiliac joint dysfunction, and piriformis syndrome. The sciatic nerve can be mobilized to restore normal function and reduce neural compression or compromise. It is ideal, however, to perform sciatic nerve mobilization in conjunction with other manual therapy techniques including stretching, muscle release techniques, and joint mobilization. Evaluation and treatment of musculoskeletal and neuromuscular conditions involving nerve-related symptoms should be performed prior to initiating nerve mobilization techniques. For an example of sciatic nerve mobilization, see the link below:




Physical Therapy Can Save Thousands

June 5, 2018 in News by Horizon Physical Therapy  |  Comments Off

Most Americans are aware of the country’s poor ranking in healthcare quality, efficiency, and accessibility. Most of us have felt the increase in healthcare premiums and deductibles as well. The high cost of healthcare has sparked clinicians and researchers to look at healthcare utilization data in order to determine the best course of action for their patients. The research is starting to show the over utilization of prescription drugs, expensive imaging, and the merry-go-round of multiple providers to treat a single condition. This data is also suggesting that services such as physical therapy may be the key to improve the U.S. health system by saving patients thousands of dollars without sacrificing results.

Historically, having the ability to receive physical therapy services was at the mercy of a physician referral. Most people, however, are unaware that in the state of Georgia physical therapists have Direct Access, or the ability to treat patients without a physical referral. There are some restrictions to our direct access, but generally speaking, this means you can go directly to your physical therapists without burning a copay elsewhere.
Now, I’d agree, accessibility may not be the biggest issue. For instance, if you are suffering from terrible neck pain, you are ready to do whatever it takes to feel better in the quickest and most effective way possible. A study by the Journal of Orthopaedic & Sports Physical Therapy looked at Temple University employees and the use of direct access physical therapy in comparison to visiting the doctor. The study noted equivalent results and outcomes for musculoskeletal issues1. However; this study also noted 73% of the doctor visits ended with a referral to see the local physical therapist and there is even more research that supports this trend, as it relates to dollars in your pocket. Several published studies show the effectiveness of early physical therapy treatment on neck and back pain2,3. These studies highlight savings of $2,200 to $4800 depending on the type of injury and how soon the patient sought out physical therapy. Most of these savings come from avoiding unnecessary imaging, specialist visits, prescription drugs, and injections.

This isn’t a sales pitch; it’s a public service announcement. The therapists at Horizon Physical Therapy pay attention to research like this. We analyze our own outcomes by comparing them to large national data pool (FOTO)4. The U.S. health system isn’t performing well enough for us. Our goal is to flip the national ranking in quality, efficiency and accessibility.


1. Ojha et al. Direct-Access Physical Therapy Portal of Entry Compared with Physician Portal of Entry for Temple University Employees with Recent-Onset Musculoskeletal Conditions: A Blinded Randomized Controlled Trial. Journal of Orthopaedic & Sports Physical Therapy. 2008.
2. Horn M, Fritz J. Timing of Physical Therapy Consultation on 1-year Health Care Utilization and Costs in Patients Seeking Care for Neck Pain”. Journal of Orthopaedic & Sports Physical Therapy. 2008.
3. Fritz JM, Brennan GP, Hunter SJ. Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future Health Care Utilization and Charges. Health Services Research. 2015.

InFORM Your Squat Form:  The evidence behind the rules of the squat

December 21, 2017 in News by Horizon Physical Therapy  |  Comments Off

Whether you’re a gym rat with years of experience squatting under a barbell, or a novice who occasionally performs a workout in the comfort of your own home, you most likely share some of the same questions. Most of those questions are likely met with a different answer each time you’ve asked: “Should my knees ever pass my toes when I squat?” … “How wide should my stance be when I squat?”…“Is a front squat or back squat better for my knees?”  There is no better resource than evidence-based research articles to separate the anecdotal opinion from scientific outcome.  Our goal is to direct you to evidence-based answers to each of these questions.

Let’s start with understanding that the sum amount of force through your body during a squat – whether weighted or not – is going to be distributed throughout the joints of your body.  Squat form determines whether those forces will be shared evenly throughout the knees, hips and spine, or if one segment of the body will take the brunt of that force.

The cue that we have all heard and have even voiced to our clients and patients when squatting is “don’t ever let your knees pass your toes”.   Upon review of the article Effect of Knee Position on Hip and Knee Torques During the Barbell Squat; findings reveal that a restricted motion of the knees tracking beyond the athlete’s toe position does in fact decrease stress to the knee joints, but results in an increase of forward trunk lean causing increased lumbar and hip stress.  Understanding that decreasing the force from the knees causes a direct increase in force through the hips and lumbar spine gives us the advantage of choosing which is best for each individual athlete. In an athlete with a history of knee pain or surgery, we may want to restrict forward knee position. Whereas with an athlete with a history of hip or lumbar injury, we need to open up the travel of the knees over the toes. The final analysis of this evidence based study states, “To optimize the forces at all involved joints, it may be advantageous to permit the knees to move slightly past the toes when in a parallel squat position.”

When determining how wide our squat stance should be, the answer we all like to hear is actually acceptable this time – do what feels good.  Though, theoretically, we all have the same anatomy, each of us has a unique makeup of bone lengths and joint angle differences that ultimately lead to a tailored approach of stance width.  Since getting stronger is the goal for both the trained power lifter as well as the novice squatter under the barbell for the first time, the most important measure of stance position throughout the squat is the effectiveness of muscle activation.  The article The Effect of Stance Width on the Electromyographical Activity of Eight Superficial Thigh Muscles during Back Squat with Different Bar Loads, reveals the evidence of an increase in Gluteus Maximus activation with a wider stance, while all anterior thigh muscle activation remains the same with both narrow and wide stance width.  The variable of increased weight on the bar resulted in increased activation of all muscles of the thigh.

Last, but not least, is the debate of when and why to choose the front squat versus the back squat.  Again, we point to the evidence based research for the best answer here.  The article, A Biomechanical Comparison of Back and Front Squats in Healthy Trained Individuals gives us the breakdown of muscle recruitment, as well as the comparison of compression forces on the knee joints for both lifts.  The findings from this study reveal the front squat to be the best in show.  Why?  According to their research, during the front squat, electromyography of thigh muscle recruitment was equal to that of the back squat with significantly decreased compressive forces through the knee joint.  The study concludes by stating “The results suggest that front squats may be advantageous compared with back squats for individuals with knee problems such as meniscus tears, and for long-term joint health”.

In summary, the squat is an approachable, functional way to get stronger.  Now that we have the answers from evidence-based studies to know both how to squat and how to teach others to squat, we have no limits to seeing the best strength gains in our fitness journey.  Knowledge is power.  Here’s to using it to get stronger!

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