Tough to Treat

Complex shoulder pain - how the narrative and red flags paint a different picture Nov 07, 2024

Clients self-refer for many reasons and we find ourselves on the front line of health care screening. Join Susan and Erica as they uncover key elements in a client's history and narrative around long-standing shoulder pain. Simplistic presentations usually mask true underlying considerations including the client's beliefs and red flags.

A glance at this episode:

[1:41] Client's Initial Presentation and History
[4:07] Exploring Past Injuries and Chronic Bike Riding
[6:56] Impact of Corporate Life and Breast Cancer on Health
[13:08] Concerns About Bone Health and DEXA Scan
[15:21] Addressing Left Shoulder Pain and Movement Dysfunction
[17:51] Implementing Modified Exercises and Pilates
[39:28] Discussing the Power of the Narrative and Patient Advocacy
[40:13] Connecting Patient Goals to Treatment Outcomes
[45:17] Final Thoughts and Episode Closing

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Shoulder Pain With Pull Ups or Push Ups? The Elbow Changes Everything Oct 24, 2024

In this episode, we explore the surprising journey of a boxer battling chronic shoulder pain that left him struggling to do even the most basic workout. Despite focusing on his shoulder, it turns out the root of his problem lay elsewhere—his elbow. Is that surprising? It was in his injury history. Do not discount the power of an old injury that could come back and haunt you. And think about the load on the elbow when you're doing a push or pull-up. Join us as we clinically reason through this interesting case from start to finish.

A glance at this episode:

[0:01] Introduction and Patient Background
[7:03] Initial Assessment and Observations
[11:56] Exploring the Root Causes
[14:12] Addressing the Pull-Up Challenge
[32:06] Implementing Exercise Program
[36:32] Final Thoughts and Key Takeaways

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Chronic Knee Pain - Where to Begin! Oct 10, 2024

Susan and Erica are back together for the Fall season! Chronic knee pain can be much more than a regional event. Susan presents a client with an extensive timeline and clinical reasoning as to why it is important to consider the entire system in this integrated approach. The key here is also maintaining relevance and sustainability for the client.

A glance at this episode:

[1:18] Explanation of Episode Structure and Content
[2:59] Introduction to the Client Case Study
[5:30] Client's Medical History and Injuries
[12:47] Initial Assessment and Observations
[13:33] Treatment Plan and Initial Intervention
[31:02] Follow-Up and Client Feedback
[31:17] Advanced Treatment and Future Plans
[31:31] Conclusion and Encouragement for Listeners

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Assessing Knee Health For Hip-Related Walking Pain Sep 26, 2024

In this episode, Erica explores the often-overlooked relationship between hip pain and knee function during walking when the patient does NOT have knee pain. Join in as she dives into the role of the knee in compensating for hip dysfunction, and how a thorough knee assessment can uncover hidden contributors to hip discomfort. Remember: old injuries have a way of sneaking up on us and becoming one of the drivers of our current problem. An old hamstring tear 5 years ago as a contributor to this patient's problem? Think again.

A glance at this episode:

[2:23] Patient Background and Injury History
[3:46] Assessment and Initial Findings
[6:33] Knee and Hip Mechanics
[10:11] Terminal Knee Extension and Treatment Approach
[20:43] Clinical Reasoning and Patient Outcome
[20:58] Conclusion and Call to Action

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When shoulder pain is dominant, but not the driver! Sep 12, 2024

Shoulder pain, like any other joint can present as primary pain and can be the #1 reason a client may be seeking help! In many cases, treating the obvious joint dysfunction (because it checks all of the boxes) may not result in optimal outcomes. Join the conversation as Susan and Erica explore the various reasons and important timelines in the client's history that has led to her shoulder pain. Most importantly follow the clinical reasoning that led to the real driver of this issue. Bonus - we also offer a great discussion of a good exercise progression!

A glance at this episode:

[1:39] Shoulder pain and internal rotation
[7:52] Which side of the table should you work from
[12:40] Learning to tape the wrist
[20:00] Opening the hands
[22:46] Using the blocks for yoga blocks
[27:58] Grip strength as a sign of health

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Beyond Tennis: Exploring Shoulder Compression Across Sports Sep 05, 2024

In this episode, Erica discusses the why behind shoulder problems, comparing the unique challenges faced by tennis players and non-tennis players alike. She explains why traditional shoulder treatment often fails these types of patients. A significant relationship between the shoulder and another region of the body is often missed. Erica also tells the story of one of her patients who does play tennis and the reason why he can do a full pushup but can't lift his arm over his head. For our physio listeners, oftentimes you can progress patients through a full range of CKC exercises but the OKC piece does not progress as quickly.

A glance at this episode:

[0:01] Erica's Summer Vacation and Introduction to the Episode
[2:30] Clinical Pearls for Tennis Players
[6:15] Assessing Upper Thorax and Glenohumeral Joint Compression
[12:53] Treatment Approach for Upper Thorax and Glenohumeral Joint Issues
[15:54] Progressing Patients with Glenohumeral Issues
[16:14] Clinical Pearls for Closed Chain Exercises
[20:37] Conclusion and Encouragement for Practitioners

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A Stiff 1st MTP Joint can Affect Everything! Aug 29, 2024

One of the most overlooked joints in the lower quarter is the first MTP joint unless that is the client's primary complaint. How does the stiffness of the MTP joint affect gait and lower quarter movement of all kinds? We spend some great time discussing differential diagnosis and practical interventions and sharing some new discoveries. Hint: the exam and intervention do not always center around the stiff 1st MTP - there is likely a primary driver elsewhere.

A glance at this episode:

[0:01] Introduction and Podcast Rebroadcast
[2:13] Overview of Stiff First MTP Joint
[4:21] Compensation and Adaptation
[6:30] Assessment and Treatment Approaches
[23:22] Exercise and Proprioception
[25:47] Shoe Recommendations and Adaptations
[34:17] Conclusion and Final Thoughts

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Fencer with Bilateral Calf Pain Aug 22, 2024

What is the cause of bilateral calf pain in this young fencer? From start to finish, it shows the power of a thorough evaluation, a specific exercise progression, and a return to the sport she loves. When it comes to exercise progression in persistent pain, think about context. How can you improve optimal movement patterning by changing the context? Think about this one. You can intervene via the visual system, eyes open, eyes closed. How about changing their base of support? Wide to narrow. And why not have them do their exercises to their favorite music? These are just some examples. Look at your patients through a different lens and then see positive change.

A glance at this episode:

[0:01] Introduction and Case Overview
[7:46] Initial Assessment and Clinical Reasoning
[10:27] Hypermobility and Initial Treatment
[20:14] Progression and Additional Techniques
[32:40] Advanced Techniques and Future Plans
[52:04] Conclusion and Reflection

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The Role of the Diaphragm in Chronic Low Back Pain and GI Dysfunction Aug 15, 2024

How similar are the neuromuscular responses to pain with Chronic low back pain and GI pain? Join Susan and Erica in a great discussion of the role of the diaphragm and how this changes with pain and inhibiition/over-recruitment in the system. In chronic low back pain and abdominal bloating/distention the diaphragm becomes a postural control muscle which greatly limits the respiratory ability and is an ineffectual model for spine stiffness and visceral organ pusher. This is an excellent discussion following the podcast episode 185.

1) Kolar P, Sulc J, Kyncl M, Sanda J, Cakrt O, Andel R, Kumagai K, Kobesova A. Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys Ther. 2012 Apr;42(4):352-62. doi: 10.2519/jospt.2012.3830. Epub 2011 Dec 21. PMID: 22236541. 2) Villoria A, Azpiroz F, Burri E, Cisternas D, Soldevilla A, Malagelada JR. Abdomino-phrenic dyssynergia in patients with abdominal bloating and distension. Am J Gastroenterol. 2011 May;106(5):815-9. doi: 10.1038/ajg.2010.408. Erratum in: Am J Gastroenterol. 2011 Jul;106(7):1405. PMID: 21540894. 3) Sicilia-Gomez C, Fernández-Carnero S, Martin-Perez A, Cuenca-Zaldívar N, Naranjo-Cinto F, Pecos-Martín D, Cervera-Cano M, Nunez-Nagy S. Abdominal and Pelvic Floor Activity Related to Respiratory Diaphragmatic Activity in Subjects with and without Non-Specific Low Back Pain. Diagnostics (Basel). 2022 Oct 18;12(10):2530. doi: 10.3390/diagnostics12102530. PMID: 36292219; PMCID: PMC9600311.

A glance at this episode:

[0:01] Diaphragm function, GI dysfunction, and postural control
[7:51] GI dysfunction and its impact on abdominal wall muscles and posture
[13:39] Abdominal dysfunction and diaphragm movement in relation to chronic low back pain
[20:36] Treating chronic low back pain through abdominal wall retraining
[25:09] Abdominal wall deficit and diaphragm dysfunction in chronic low back pain patients
[32:07] Treating gas and bloating through diaphragm therapy
36:32] Treating GI dysfunction through breathwork and positioning

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Hypermobility and Low Back Pain Aug 08, 2024

How do you rehab someone who is VERY hypermobile and suffers from persistent low back pain? Carefully and specifically! This episode highlights the beauty of a specific exercise progression tailored to the patient's meaningful movement. Listen as we go through the clinical reasoning process to determine what types of movement patterns will work and what ones won't. Doing the right thing at the right time is clinical expertise.

A glance at this episode:

[5:13] Hypermobility and pain management for a 24-year-old woman
[11:26] Hypermobility, muscle imbalances, and control issues in a patient with back pain
[19:00] Shoulder subluxation and its relation to past injuries and yoga practice
[23:57] Diaphragm recruitment in back pain patients
[27:47] Addressing short girl syndrome in a dancer
[32:03] Using tape and Pilates equipment to improve abdominal strength and stability for a hypermobile patient
[35:51] Improving posture and flexibility through exercises on a reformer machine
[39:23] Exercises for a spin instructor with tight hip flexors
[43:34] Exercises for hypermobile individuals to improve motor control and recruitment

Related links:

Low Back Pain - Regional vs. Movement System Considerations Aug 01, 2024

If it walks like a duck and quacks like a duck - it must be a duck, right? Low back pain is a descriptive term at best, indicating where symptoms present. Join Susan and Erica as they explore this Tough to Treat client with low back pain and mild stress urinary incontinence. Discover the history and the movement system examination and interventions that led to the successful reduction of symptoms. *Hint: this really isn't a duck!

Visit our website: toughtotreat.com

A glance at this episode:

[0:01] Low back pain and pelvic health issues, client with gradual onset of stress urinary incontinence
[2:16] Pelvic health and trauma history after a recent fall
[7:21] Patient's foot and leg issues, including supination and knee pain
[13:08] Addressing knee issues through breathing and positioning
[15:50] Knee and back pain treatment using bridging and lunge exercises
[22:01] Treating knee pain and low back pain through exercises and manual therapy
[27:45] Treating patients with movement system changes to address low back pain and pelvic health issues

Related links:

What To Do When You Are Their Last Resort Jul 25, 2024

Now, this is a CHALLENGING one! Ever have those patients who have been everywhere, had everything done to them (injections, surgeries, acupuncture) and nothing helped? Well, this is your lucky day because this episode really takes us down the chain from head to toe with someone who had low back pain. Pretty standard, right? But this was FAR from standard. Hint: her low back was not the source of her problem. Why do you think that is? Remember, we bring all of our compensations to our life events. And our movement and injury history sets us up and our dominant patterning keeps us there.

Visit our website: toughtotreat.com

A glance at this episode:

[0:01] Complex medical history and treatment options
[7:06] Chronic pain and potential causes
[12:14] Pelvic issues and postural compensations
[18:41] Pelvic and foot issues, possible nervous system impairment
[23:21] Decompression techniques for a patient with nervous system issues
[26:31] Yoga and physical therapy for a patient with neck pain
[29:13] Treating a patient with chronic pain using movement patterns and cranial work
[35:07] Standing and carrying issues, loading exercises suggested
[40:07] Exercises for back pain relief, including cycling, Nordic walking, and rock climbing
[42:28] Using yoga and rock climbing to improve standing tolerance for a client with chronic pain
[47:30] Treating patient with chronic pelvic pain

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Nociplastic Pain and a Visceral Driver Jul 18, 2024

What do you do when a client presents with a myriad of LQ symptoms without a clear regional driver? Look to the history and keep asking questions even further back than the recent onset or episodic flare. Join us as we discuss complex neurology of a visceral driver that has signs of dysfunction and a somatic pain presentation. Once again, the history is so important!

A glance at this episode:

[0:01] Left lower quadrant pain, nociceptive input from visceral driver
[2:23] Pelvic pain and potential visceral driver
[8:05] Bladder issues and pelvic floor tension
[10:49] Bladder irritants and pelvic health with a patient
[16:49] Lower back pain and posture with a physical therapist
[20:04] Pelvic floor exercises and visceral manipulation for pelvic pain relief
[24:34] Pelvic floor exercises and core strength for bladder control
[26:45] Improving driving skills and addressing bladder issues
[32:49] Visceral mobilization and pelvic floor issues

Related links:

Junior Golfer With Persistent Unsolved Knee Pain Jul 11, 2024

Golf is a sport of weight shifts and a narrow base of support. What happens when your knee can't adapt to an altered base of support? This is what exactly happened here with this case. This young golfer, in standing (and standing is VERY relevant for the golf swing) had an 80/20 load, R/L in this position. And it stayed that way throughout the golf swing. This begs the question: Did you know that right knee pain can be caused by an imbalance in your center of mass? If you continuously load your painful side, that has some serious implications for loading. Erica and Susan discuss in this episode how treating the left hip as well as the left side of the low back, got rid of this young golfer’s knee pain. He needed options for movement to his left side. A functional and interactive evaluation really hones in on where the true source of his knee pain lies. Remember: for persistent, unsolved problems, correlate the patient's history with your objective assessment. Hint: this patient had a history of concussion. You think that would alter his BOS?

A glance at this episode:

[0:01] Chronic knee pain in a junior golfer, analyzing the cause and treatment options
[4:48] Golf injury treatment and diagnosis
[12:19] Golf swing mechanics and potential issues with a young golfer
[17:03] Assessing a 12-year-old golf player with knee pain using a thorough history and clinical reasoning
[23:49] Using visual aids and manual therapy to help a golfer improve his swing by shifting weight to the left leg
[31:33] Using mirror therapy for knee rehabilitation
[39:25] Rehabilitating knee injuries via changing the center of mass
[43:34] Rehabilitation program for golfers with variance in exercises to improve adaptability
[47:36] Physical therapy for a young golfer with a focus on listening and meeting clients where they are

Related links:

What's Stopping this Former Fighter from Doing Push-Ups and Pull-Ups? Jun 27, 2024

In this episode, Erica dives into the intriguing story of a former fighter who faced unexpected challenges with basic exercises like push-ups and pull-ups. She sheds light on how years of specialized training led to muscle imbalances and problems outside the ring.

The "push" and "pull" are different movement patterns. What region(s) of the body are challenged with these movements? Remember the "push" is a 4-point closed chain movement and the "pull" is not.

What do fighters do on a routine basis to their wrists before a fight? Why is the "negative" on a pull-up more important than the push on a push-up?

Listen in as Erica discusses how to make this type of assessment more efficient by really listening to the story, connecting the dots, and ultimately going back to basics to treat another region of the body that was a secondary driver to the "pull". If you want the visual, here is a link to our YouTube channel.

A glance at this episode:

[0:01] A patient's medical history and symptoms related to military service and boxing
[5:00] Assessing push-ups and shoulder mobility in different positions related to COM
[8:18] Identifying different movement patterns with the push and pull and how to clinically reason and find the true driver
[12:31] How a dysfunctional elbow can limit the pull up but not the push-up

Related links:

Chronic Constipation: Interventions Beyond Pelvic Floor Dyssynergia Part 2 Jun 13, 2024

This episode is part 2 of episode 213. Utilizing evidence-based research and the latest clinical guidelines, the presentation will examine the multifactorial nature of chronic constipation, including non-pelvic interventions that can complement existing treatments. One key aspect will be the practical application of the balloon catheter, demonstrating its effective use for both assessment and therapeutic interventions.

A glance at this episode:

[0:01] Chronic constipation interventions and assessment, including muscle tightness and behavioral factors
[3:27] Using balloon catheter for rectal biofeedback to treat constipation
[8:37] Constipation, abdominal distension, and neural tension, with exercises to improve GI function and reduce discomfort
[14:54] Stress, sleep, and nervous system regulation for chronic problems
[20:16] GI health, manometry for constipation in infants, and mindfulness techniques

Related links:

Chronic Constipation: Interventions Beyond Pelvic Floor Dyssynergia Part 1 Jun 06, 2024

Utilizing evidence-based research and the latest clinical guidelines, the presentation will examine the multifactorial nature of chronic constipation, including non-pelvic interventions that can complement existing treatments.

One key aspect will be the practical application of the balloon catheter, demonstrating its effective use for both assessment and therapeutic interventions.

A glance at this episode:

[0:01] Chronic constipation and its impact on pelvic floor health
[4:24] Constipation and irritable bowel syndrome (IBS) causes, symptoms, and diagnosis
[12:18] Bloating and distension in chronic constipation, including causes and treatments
[17:07] Diaphragm function in chronic low back pain

Related links:

Postpartum Pelvic Pain and Urgency May 23, 2024

There are many ways to approach pelvic pain and symptoms of urinary urge incontinence, but did you know that how the MSK system moves can affect these symptoms as well?

On this podcast, we dive into the movement system, past/present autoimmune history, and post-partum process while changing this client's symptoms as well as her urinary incontinence. In turn, she regains control over her pelvic pain!

A glance at this episode:

[0:01] Postpartum pelvic pain and urinary incontinence in a 34-year-old woman
[2:07] Pregnancy, autoimmune disorders, and migraines
[5:36] Postpartum health, nutrition, and urinary incontinence
[11:18] Postpartum care and pain management
[14:40] Back pain and mobility issues
[17:56] Postpartum pelvic floor dysfunction and urgency issues
[24:09] Managing urinary incontinence through diet and exercise changes
[27:42] Urgency and pain during sex, pelvic exam, and internal rotation
[30:22] Pelvic pain and cranial flexion
[36:17] Evaluating and treating a patient's urgent symptoms through neural tension and movement
[38:54] Breathing techniques for managing urinary urgency and stress

Related links:

How To Assess The Knee Differently May 16, 2024

In this episode, Erica explores new and novel ways to evaluate and treat the knee.

She discusses different approaches aimed at providing a more accurate assessment of the knee.

Join her as she emphasizes the importance of training your vision.

What does "optimal" movement look like for that particular patient?

Does what you see match what you feel?

Are you assessing the knee in a movement that is relevant to the patient?

If someone's right knee is sore when they are walking with that leg behind, then assessing the knee in dorsiflexion and knee flexion is not efficient or effective here.

Train your vision to see what optimal movement looks like. And then put your hands on the femoral condyles and the joint lines to train your own brain to feel what is optimal. That's how you increase your clinical expertise.

Erica also discusses a movement you can evaluate if the patient has a hard time squatting or lunging. Finally, do not discount the patient's prior history. An old untreated hamstring tear from years ago could absolutely be relevant to someone's increased knee pain. Makes sense, right? But we often forget that - do not ignore prior history and its importance to current symptoms.

A glance at this episode:

[4:03] Knee pain and its compensatory patterning
[8:14] Using vision and palpation to assess knee joint movement and patterning for optimal assessment and treatment
[12:09] Assessing the knee through a body twist

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Addressing the Gaps in a Patient's Exercise Program May 09, 2024

This episode zeroes in on a scenario many physical therapists face: patients diligently following their exercise routines but not seeing the expected progress or recovery.

We discuss thorax, foot, and knee drivers as examples and why there can be holes in someone's program even after they've been doing advanced exercises. Being able to identify the patient's impairments is a good start.

We discuss common strength holes along with typical overactivity patterns in these patients. Susan and Erica also discuss a patient who is a high-level athlete with a fear-based movement that is a big hole in her program.

A glance at this episode:

[4:00] Exercise program for patients with knee and foot issues, focusing on strengthening key muscles
[7:30] Lunges and split squats for a runner with a thoracic driver
[13:56] Proper lunge technique and addressing knee pain through strengthening exercises
[20:24] Improving lunges with a stick and target practice
[23:43] Lunges and squats for runners with a focus on proper form and progression
[29:30] Exercise safety and program development for patients with knee pain

Related links:

Food Allergies vs. Intolerance May 02, 2024

What is the difference between food allergies and food sensitivities?

Join Susan as she discusses the importance of following the science and taking the guess work out of the food allergy vs. sensitivity issue and why this is important for systemic inflammation.

A glance at this episode:

[3:19] Dietary elimination for gut health and food intolerances
[9:18] Gluten sensitivity and its impact on IBS symptoms
[13:14] Gut microbiome's role in digestion, immunity, and weight gain

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Back Pain/Leg Pain - Making the Right Call For Our Clients Apr 25, 2024

This episode presents what should be a straightforward case of a significant nerve root irritation. Unfortunately for this client, her situation was not addressed adequately and has left her in a lot of pain for over 3 months.

Join us as Susan presents this client case, what went wrong, and the assessment and intervention with a rich discussion of the path forward.

Here is a Hint: center of mass and chronic loading play a strong part in this story!

A glance at this episode:

[2:21] Back and glute pain, stretches, and fatigue
[7:37] Back pain and re-curring mobility issues
[12:16] Chronic pain and it's relationship to mobility
[17:02] Proper standing and walking techniques for comfort and mobility
[22:00] Standing balance and stretching exercises for improved mobility
[26:51] Chronic back pain and neuroinflammation
[31:26] Back pain treatment options and the importance of proper imaging
[36:01] Proper treatment approaches for a patient with persistent low back pain

Related links:

Clinical Pearls For Effective Exercise Progression Apr 18, 2024

In this episode, Erica speaks about prescribing specific exercises based on the difficulty level relative to the region of the body driving the patient's symptoms.

NOT the pain generator.

NOT the area of symptoms.

If someone has knee pain, and their driver is their foot, then the exercise program is geared towards the foot, NOT the knee. SLR's and quad sets won't work here.

She also explores the significance of personalized exercise prescriptions in optimizing recovery outcomes. There are many clinical pearls in this episode, one of which is, "Why would a side-to-side deep squat be harder for the foot than the thorax?" Both are lateral movement patterns.

She also discusses the clinical reasoning behind a well-thought-out exercise plan. Remember: we are trying to give our patients options for movement and variability across many activities. Building volume of exercise at low levels is key to this outcome as is challenging the driver across many planes.

A glance at this episode:

[3:38] Prescribing specific exercises based on the patient's main driver, not the symptom
[8:02] Identifying the level of difficulty for a specific exercise using regional analysis
[14:02] How to dose exercise based on what is meaningful for the patient
[17:58] Exercises for improving lower body control and center of mass

Related links:

When The Driver Is Not The Pelvis Apr 11, 2024

In this episode, we discuss the case of a very active woman grappling with SI (sacroiliac) joint pain. These symptoms manifest while walking and with hip external rotation.

Furthermore, the episode unravels the complexities surrounding assessments, especially when individuals seek consultation for a single visit. We also delve into why and when using a pelvic belt is helpful.

Also, for the non-pelvic health therapists out there, we discuss how you can palpate relevant muscles externally to further confirm or negate your hypothesis as to whether the pelvis is a driver. This patient had an extensive medical and surgical history.

We also discuss certain aspects of her history that are very relevant for treatment. When someone has had 3 C-sections, an abdominoplasty, breast reconstruction, and more, do you think that the pelvis is the main driver?

Think again if you do.

Remember, we are a product of our compensations and adaptations to prior injuries and surgeries.

A glance at this episode:

[4:04] Pelvic girdle pain and nerve damage
[7:55] Patient's medical history and treatment options
[12:17] Pelvic girdle dysfunction and its impact on gait
[18:48] Pelvic health issues and scoliosis
[22:15] Patient's medical history and potential causes of pain
[26:23] Treating chronic pain and imbalance in a patient with a history of abdominal surgeries and scoliosis
[32:22] Pelvic floor assessment and treatment
[36:43] Treating chronic pain in a patient with complex history
[41:26] Pelvic health and its impact on overall body function

Related links:

Physical Therapy Examination and Intervention of GI Dysfunction Apr 04, 2024

In this short episode, Susan presents a good algorithm for the examination and interventions in clients with GI dysfunction.

Follow along as she discusses different nuances and considerations in the presence of pelvic and abdominal aspects of GI dysfunction.

A glance at this episode:

[0:01] Interventions for GI dysfunction and abdominal pain
[2:03] Manual therapy for abdominal and pelvic issues
[6:19] Abdominal massage for constipation and pain relief
[9:59] Breathing, abdominal muscles, and pelvic floor function
[14:35] Abdominal surgery effects on musculoskeletal and visceral support

Related links:

Overactive Bladder and Hip Dysfunction Mar 28, 2024

This episode presents a client with a seemingly straightforward diagnosis in pelvic health of overactive bladder (OAB). The history and physical presentation tell a different story.

Join Susan and Erica as they explore why often a regional approach will not help the client progress to their highest levels of function without symptoms. We discuss the various drivers viscerally and MSK regionally and why tendon function and the client's stage of life require the utmost consideration.

Join us in the conversation and discover the multi-system approach in consideration of the examination and interventions for this client

A glance at this episode:

[2:22] Urinary incontinence and hip injury
[6:50] Pelvic floor dysfunction and its connection to urgency frequency
[11:49] Pelvic floor exam and overactive bladder symptoms
[16:30] Abdominal and musculoskeletal issues
[22:12] Exercise modifications for lower back pain
[28:23] Exercises for pelvic health and bladder control
[32:59] Pelvic health and muscle imbalances
[39:00] Mental health cases and patient mentoring

Related links:

Exploring Open Chain vs Closed Chain Exercise in Upper Extremity Dysfunction Mar 21, 2024

In the episode, Erica explores the strategic use of open and closed-chain exercises for upper extremity dysfunction. She discusses the distinct benefits and applications of each type of movement, shedding light on how these exercises can be tailored to meet specific needs to enhance performance.

She uses an example of a tennis player who suffered from right shoulder pain with radiculopathy. She also tackles the critical question of when to load open-chain versus closed-chain exercises, offering practical guidelines based on the stage of recovery and individual progress.

OKC can be very difficult for someone who has a true shoulder driver. Based on her experience with these patients, most people who play an overhead sport, display a lot of compression in their upper rib cage and shoulder joint. This can masquerade as "thoracic outlet syndrome" or "rotator cuff strain" when it's a movement pattern created by their sport carried over to all life events.

By understanding the principles of load management and exercise progression for open and closed-chain exercises, listeners will gain valuable insights into prioritizing certain movements during the rehab process.

A glance at this episode:

[2:28] Physical therapy for tennis player with shoulder and rib compression
[5:58] Manual therapy techniques for shoulder issues
[11:15] Progressing patients through closed-chain exercises
[15:38] Rehabilitation techniques for chronic pain

Related links:

The Push Up: 2 Individuals, 2 Different Drivers and 2 Distinct Treatments Mar 14, 2024

In our latest episode, we explore the fascinating stories of two individuals navigating the challenges of mastering the push-up despite their unique injury history. Both individuals had different pain experiences with this movement.

Remember-What set them up?

What kept them there?

We explore why the push-up experience varied greatly between these 2 people and why it was so unique in these 2 individuals.

"Push" is a part of daily life whether we realize it or not from pushing open an umbrella to pushing a door open to a full push-up on the floor of a declined bench. The "What set them up?" is a significant factor in how they were assessed and treated.

One individual was a former boxer and the other held a desk job but had an extensive exercise and injury history.

Join us as we unravel the complex interplay of factors shaping each individual's journey toward mastering this seemingly simple yet profound exercise.

A glance at this episode:

[4:57] Two men's push-up techniques and their impact on their bodies
[10:04] Elbow injuries in boxers and their impact on grip strength
[18:44] Rehabilitation exercises for shoulder and elbow issues
[24:03] Exercise progression for two patients-they are very different
[29:53] Shoulder pain and movement analysis
[35:32] Rehabilitation strategies specific to the push up
[40:38] Relevant exercises for lower body and upper body strength

Related links:

Outcome Measures and Pain in GI Dysfunction Mar 07, 2024

This episode is a short compilation of an algorithm in looking at basic outcome measures and pain in GI Dysfunction. Susan explores the basics of the history which can give great insight into the addition of more sophisticated outcome measures and pain exploration. Start with the basics and then expand!

A glance at this episode:

[0:01] Evaluating and managing pain in people with GI dysfunction
[1:18] Abdominal pain and its relationship to GI dysfunction
[4:47] Visceral pain and myofascial pain syndromes
[9:14] Pelvic health and bowel dysfunction assessment tools
[13:12] Bowel habits and GI health assessment

Related links:

The Balance System As A Driver Feb 29, 2024

Join us in episode #200 where Susan and Erica explore the potentiality of the balance system as a primary or secondary driver. With a client's history of injury or illness, there is an event that sets up their system for adaptation. Oftentimes, in regional-specific rehab, the balance system is not considered as a driver. What keeps the client in this adapted pattern may be the primary driver; however, the balance system adapts to keep the entire body and physiology upright against gravity. This system can change, and the need for activity to accomplish this becomes a primary consideration in the assessment and the intervention. Listen in to the conversation and find easy clues to discover in your client assessment for effective interventions.

A glance at this episode:

[5:27] Balance system adaptation and rehabilitation
[12:43] Balance, vestibular system, and eye movements
[21:04] The importance of challenging the balance system and multitasking while keeping balance intact
[25:28] Balance challenges and treatment options for various populations
[29:53] Improving balance and rotation through exercises
[35:30] Pelvic health, balance, and movement patterns
[43:47] Balance system importance in exercise and rehabilitation

Related links:

The Body's Story: Finding Out Why You Hurt Through Your Story and Movement Patterns Feb 22, 2024

In this episode, we explore the profound connections between personal narratives and the origins of someone's injury. Join Erica as she delves into the stories of individuals who've experienced persistent injuries, and learn how to find clues in their narrative to help you prioritize the movement assessment and eventually find their driver(s). You will learn how to make the connections between the story and their movement patterning. Through the lens of their injury and movement history, we can uncover the reason why someone can't move the way they want. This leads to precise diagnosis and effective treatment. You don't treat the symptomatic region unless it's the driver. There is a video companion piece with slides on our "Tough To Treat" YouTube channel for this episode.

A glance at this episode:

[0:55] Finding the patient's primary driver from clues in their narrative
[4:30] Post-partum tennis player with neck pain during a push-up, what her story tells you
[9:11] How her injury and movement history will lead you to the driver(s)
[13:06] What movement(s) to assess and how to make this much more efficient

Related links:

Chronic Low Back Pain and an Underlying Pathophysiological Change: We Adapt Until We Can't Feb 08, 2024

How important are past events to present movement patterns and restrictions? What about past events of herniated lateral discs or hypermobility on the current presentation of the movement system? Clients can heal with faulty movement systems that can show up as new and different presentations in the future. This podcast is from a presentation that links the neuromuscular systems together and provides insight for evaluation and interventions.

A glance at this episode:

[0:01] Lumbopelvic pain causes and treatment
[5:02] Hip extension and lumbar spine rotation for efficient walking
[8:48] Back pain and nerve root impingement
[12:17] Hypermobile spine and neural patterning
[16:20] Lumbar spine mobility and exercises for pain relief

Related links:

Overcoming Fear-Based Movement Patterns Feb 01, 2024

In this empowering episode, we dive deep into the realm of fear-based movement and explore strategies to help patients conquer their anxieties, helping them move towards a more confident and pain-free existence.

Anxiety and fear of movement are real things and can prevail even when we are termed "fit to play", "fit to move" or "pain-free". Just because someone is pain-free, it doesn't mean that they can move well or move without fear.

We discuss the implications of movement anxiety and explore the roots of fear and how it manifests in the body. Our discussion involves 2 specific case studies where fear of a certain movement was stalling their recovery and includes specific techniques and exercises for a positive outcome.

By the end of this episode, you'll be equipped with valuable tools and insights to help your patients move better, even when fear holds them back.

A glance at this episode:

[5:37] Interoception, beliefs, and structural integrity in physical therapy
[10:12] Fear based pain with lumbar extension
[14:40] Graded exposure to movement
[18:29] Movement re-patterning with specificity
[26:11] An equestrian who is afraid to sit
[30:15] Integrating variance into exercise
[34:29] Using props to help patients overcome fear and improve movement patterns

Related links:

How To Find The Driver Through Patient-Centered Listening Jan 25, 2024

Discover the art of being an active listener who can pick up clues in your patient's narrative to help you find their driver quicker. This will save you lots of time in your movement assessment. Listen in as Erica discusses how to reframe your patient's story to help you maximize your time with them in the clinic. She discusses clues in their "subjective" that can aid you in prioritizing regions of the body to assess in your movement analysis. This is done with 3 case studies from her practice where she discusses each patient's story (injury and movement history) and what clues she honed in on to effectively make a clinical hypothesis about their driver(s).

A glance at this episode:

[4:13] Analyzing movement and injury history and why a timeline matters
[9:44] The importance of the narrative in assessing a patient's movement patterns. How to ask the right questions.
[15:17] Why the first injury sets them up and why their movement history keeps them there
[20:20] Case study-tennis player who was unable to do a push up.
[23:43] Case study-neural tension restricting UE closed chain activities.
[27:09] Case study- runner with pelvic girdle pain whose driver was her foot

Related links:

Take Back your Mental Fitness - Part 2 Jan 18, 2024

Welcome to the New Year and one of the topics always discussed by Healthcare providers is burnout and imposter syndrome. Join Susan in this short podcast - Part 2 Taking back your mental fitness. Learn how to identify the voices of your inner Judge and Saboteurs, how to limit their voices, and find a pathway to your Sage Brain!

A glance at this episode:

[3:21] Mindfulness techniques for neural plasticity
[6:48] Mindfulness and neural pathways for busy people
[10:33] Cultivating self-empathy and overcoming judgment
[14:09] Positive Intelligence and Self-Improvement

Related links:

Take Back Your Mental Fitness - Part 1 Jan 12, 2024

Welcome to the New Year and one of the topics always discussed by healthcare providers is burnout and imposter syndrome. Join Susan in this short podcast episode - Part 1 Taking back your mental fitness. Learn how to identify the voices of your inner Judge and Saboteurs, how to limit their voices, and find a pathway to your Sage Brain!

A glance at this episode:

[4:38] Saboteurs in the brain and their impact on decision-making
[9:11] Personality types and their impact on work performance
[13:30] The disruptive role of saboteurs in decision-Making
[18:27] Mental fitness in healthcare with a focus on saboteurs and sage powers

Related links:

A Case of Lateral Hip Pain Jan 04, 2024

Hip pain can be brutal. And more often than not-it's chronic. Not like an acute ankle sprain or even acute low back pain. People who suffer from hip pain, for whatever reason, sink into the chronic side of musculoskeletal pain. Let's face it-consideration of lateral hip pain requires a thoughtful clinical reasoning process to discover the physiology/movement patterns as well as neural contributions required to make a diagnosis and successfully build an intervention that lasts.

One size does not fit all - join us as we discuss the findings in this "not so unique" case and the discovery of the underlying movement patterns, impairments, and why lateral rotator strengthening is not always the answer.

A glance at this episode:

[2:15] Hip and knee pain case intro
[5:08] Chronic hip pain and potential causes
[9:35] Loss of mobility and symptoms
[12:51] Hip movement and range of motion influences
[19:04] Hip mobility and exercise prescription
[22:31] Motor planning and motor control
[25:45] Hip rotation and postural ramifications
[31:12] Pelvic floor muscles and hip rotator imbalance
[34:54] Physical therapy exercises for improving balance and reducing neurological symptoms
[41:48] Treating hip pain through physical therapy
[44:58] Manual therapy techniques for pain management

Related links:

Thoracic Mobility Beyond The Breath Dec 21, 2023

In this episode, Susan and Erica discuss the many ways the thorax can be the driver for a multitude of upper and lower extremity issues.

This important region of the body tends to cause a lot of movement dysfunction we often see.

As an example, the thorax is an important component in driving foot pain as well as issues in the pelvic girdle.

Suppose you can get the thorax to move differently. In that case, this can help people down-train old movement patterns that do not serve them and ultimately restore global movement patterning across many tasks.

Key point: The thorax can be a key driver, in how someone transfers load after an injury (no matter when that injury took place). It is a region of the body that compensates for pain and dysfunction elsewhere and then ends up being the driver years later. Don't miss it.

A glance at this episode:

[3:26] Thoracic mobility and breath control for pain relief
[11:19] Breathing and muscle release techniques for thoracic spine mobility
[14:26] Using sensory input with a theraband for thoracic mobility
[19:19] Using closed kinetic chain exercises for thoracic mobility and abdominal strength
[23:49] Assessing and treating shoulder injuries
[29:23] Thoracic mobility and its impact on movement patterns
[34:20] Thoracic rotation and breathing exercises for runners
[43:05] Reintegrating movement patterns for whole-body wellness
[47:42] Exercise and posture for older adults
[52:12] Posture and movement for homeschooling and virtual work

Related links:

Stress, Exercise and Sleep as it Relates to the GI System Dec 14, 2023

Many times, clinicians find that people with correlative GI system dysfunction are very overwhelming. The complexity makes it difficult to know where to begin to intervene.

Join us as Susan discusses some very simple mediations to help improve the GI system with stress, exercise, and sleep. Complex clinical pictures can often change when we address the foundations of health with simple interventions.

A glance at this episode:

[1:38] Stress, its effects on the body, and exercise as a remedy
[6:38] Exercise and stress management techniques
[10:56] Sleep's impact on digestion and overall health
[14:16] Improving sleep quality with expert tips

Related links:

A Complex Client With Medical Red Flags Dec 07, 2023

Susan and Erica welcome Kelly McClain to the podcast to discuss a very complex client with pelvic health, orthopedic, and neurological issues.

Follow along as the client case is presented and we pursue a rich discussion of tying together the systems involved as well as the red flags. Digging deeper into the client's story is key here to help with obvious referrals and also to recognize other systems and issues deeper into the client's history to gain insight.

A glance at this episode:

[3:05] Pelvic health issues and treatment
[12:28] Patient's symptoms and medical history
[20:20] Current medical issues and imaging recommendations
[26:14] Clinical reasoning and potential diagnoses
[31:08] Manual therapy for perineal pain
[33:24] Rectal pain and paraesthesia during squatting
[38:44] Treating patients with complex symptoms

Related links:

How To Diagnose A Young Soccer Player's Groin Pain Nov 30, 2023

Why doesn't my groin pain go away?

When someone is an athlete, you must understand what regions of the body are challenged with their sport. With soccer, you think of the thorax, foot, hip, and pelvis from the get-go.

Listen in as Erica discusses the movement she and her patient chose to assess and what they discovered.

Short-term treatment of someone's symptomatic region may help in the short term, but getting them back in the game is another matter entirely. When a person has an issue with a long lever movement like kicking a soccer ball, recognize and respect the length-tension relationships of the muscles involved in the movement, like how someone's lack of adductor power can stem from an overactive posterior tibialis muscle.

A glance at this episode:

[4:05] Prioritizing physical therapy treatment based on specific sport and movement patterns
[7:19] How to choose an appropriate movement pattern that is relevant to the patient yet specific to their sport
[11:07] Where is the non-optimal patterning? In the set up to the shot or in the kick?
[15:21] Improving athletic performance through training optimal movement patterns

Related links:

Why Does My Foot Hurt? What's Going On? Nov 23, 2023

Why would someone who is 3 months post-fibular fracture get worse after a basic theraband ankle exercise?

Not everyone needs inversion and eversion theraband exercises.

Right?

This is an in-depth clinical discussion on understanding the "why" hidden in the patient narrative.

And a specific process for assessing the whole foot, not just the ankle.

We also discuss why this patient's center of mass is biased toward her involved side and what implications this has for treatment.

A glance at this episode:

[5:28] Patient's ankle injury and physical therapy
[10:58] Assessing a patient's foot after a prolonged boot immobilization
[15:14] Menopause and tendon issues after a fibula fracture
[19:17] Rehabilitation strategies for a patient with a booted leg
[23:53] Foot and ankle assessment and treatment
[29:38] Assessing and treating a patient with lower extremity pain

Related links:

The GI System - Food intolerances vs. Allergies Nov 16, 2023

We continue with our GI dysfunction theme in this podcast about food intolerances/sensitivities vs. allergies.

Join Susan as she takes you through the algorithm to understand how to recognize what is the underlying information behind why certain food bothers us and when we should eliminate food.

A glance at this episode:

[3:49] Elimination diets for digestive health
[7:42] Gluten sensitivity and its effects on the body
[11:56] Gut microbiome's role in IBS symptoms and behavioral changes
[15:20] Gut microbiome and its impact on health

Related links:

The Role of the Diaphragm in Chronic Low Back Pain and GI Dysfunction Nov 09, 2023

How similar are the neuromuscular responses to pain with chronic low back pain and GI pain?

Join Susan and Erica in a great discussion of the role of the diaphragm and how this changes with pain and inhibition/over-recruitment in the system.

In chronic low back pain and abdominal bloating/distention the diaphragm becomes a postural control muscle which greatly limits the respiratory ability along with an ineffectual model for spine stiffness and visceral organ pusher.

This is an excellent discussion following the podcast episode 185.

A glance at this episode:

[3:13] How lying on your back affects breathing and posture
[7:42] Abdominal wall dysfunction and its impact on GI function and low back pain
[12:05] Abdominal diaphragm dysfunction in chronic low back pain
[19:43] Treatment for diaphragm and abdominal wall dysfunction in chronic low back pain
[25:24] Abdominal wall deficits and breathwork for chronic low back pain
[31:43] Treating gas and bloating through pelvic health therapy
[38:24] Treating GI dysfunction and Cushing's syndrome

Articles mentioned in the episode:

Postural function of the diaphragm in persons with and without chronic low back pain.

Abdomino-phrenic dyssynergia in patients with abdominal bloating and distension.

Abdominal and Pelvic Floor Activity Related to Respiratory Diaphragmatic Activity in Subjects with and without Non-Specific Low Back Pain.

Related links:

When Do You Treat The Viscera? Nov 02, 2023

When do you treat the viscera?

And why?

This episode discusses a bit about the abdominal viscera. It is certainly not all-encompassing by any means. We just want our audience to be aware of the possibilities.

Erica relays some clues in the patient's history as to why you would screen for GI dysfunction. She uses 2 case examples of when the abdominal viscera was the secondary driver in one case and when it was a significant impairment in a patient with a dural driver in the other.

Once again, it all comes down to listening to your patient and connecting the dots.

A glance at this episode:

[2:24] GI dysfunction and its relationship to manual therapy
[7:10] Abdominal palpation and soft tissue work for low back pain
[9:46] Identifying visceral dysfunction in patients with low back pain
[14:26] Abdominal viscera and soft tissue restrictions

Related links:

Back Pain, Thoracic Outlet, Post Cancer Recovery - Where do I go from here? Oct 26, 2023

In this episode, Susan and Erica welcome Darcie Pervier to the mic!

Darcie is a pelvic health and orthopedic PT who practices a fully integrative approach to complex client care. Susan, Erica, and Darcie really delve into "brainstorming" various aspects of examination and intervention in connecting some dots on this complex canvas.

Dural issues, fracture healing, bone health red flags, thoracic stiffness, neural tension, and GI visceral systems are tied together to help guide more meaningful interventions for this client.

Hint: How to get a client to do some nervous system regulation when they don't want to!

A glance at this episode:

[1:36] Patient's chronic pain and health history
[9:47] Patient's medical history and physical exam findings
[13:40] Patient's lower back pain and potential neural tension testing
[21:24] Cancer survivor's pelvic floor issues and potential treatments
[25:50] Patient's strengths and weaknesses in physical therapy exercises
[27:59] Treating pelvic floor dysfunction and GI issues through manual therapy
[35:37] Abdominal breathwork and body mechanics
[41:19] Managing a complex patient with back pain

Related links:

Colorectal Sensory Motor Integration Oct 19, 2023

This episode captures a critical aspect of integrating sensory and motor aspects of colorectal rehab from constipation and IBS to fecal incontinence.

The information is categorized under the hyposensitive vs. the hypersensitive quality of symptoms and the motor control from decreased muscle capacity, tissue quality, and motoric coordination.

A glance at this episode:

[3:27] Rectal balloon therapy for bowel dysfunction
[7:58] Rectal muscle exercises for constipation management
[12:46] Rectal sensitivity in IBS patients
[17:01] Treating anal inertia through physical therapy

Related links:

Post Partum: Urinary Incontinence, Abdominal Bloating and a Return to High Intensity Exercise Oct 12, 2023

In this episode, Erica and Susan welcome Julia Rosenthal to the mic.

Julia is a physical therapist in NYC. She brings a complex case of a postpartum patient of hers who has symptoms of urinary incontinence as well as other bowel and bladder issues that were made worse after giving birth.

The patient is a personal trainer and used to high-load exercise, so the need to get back to this is strong. She also has complaints of abdominal bloating along with occasional musculoskeletal pain with CKC lower extremity work.

This discussion is rich in treatment interventions for Julia's patient- from nutritional strategies to hormonal interventions to specific exercises the patient can do while feeling like she is loading her system in the necessary ways. Erica and Susan also discuss the importance of the thorax and its relationship to the pelvis and how best to balance these 2 regions of the body.

A glance at this episode:

[2:13] Pelvic floor and orthopedic physical therapy for a postpartum woman with GI issues and fecal smearing
[9:50] Postpartum bladder issues and musculoskeletal complaints
[17:33] Thyroid issues and autoimmune disorders
[21:36] Assessment and intervention for a patient with chronic constipation and pelvic floor dysfunction
[27:36] Patient's pelvic floor mobility and lifestyle changes
[33:06] Abdominal issues and breathing patterns
[38:01] Managing IBS symptoms through breathing exercises and mindful eating
[44:02] Using Nerva app for mental health
[47:31] Exercises for a pregnant woman with thoracic issues
[53:27] Addressing a personal trainer's physical and mental health issues
[1:00:01] Patient care and therapy approaches.

Related links:

Julia Rosenthal IG

How To Increase Patient Adherence To Exercise Oct 05, 2023

How do you increase patient compliance with their exercise program?

This can be very frustrating for both the therapist and the patient.

In this shortie episode, Erica discusses how she helps keep her patients on track with their movement program.

She often says, "If it's not trialed, then the chances of your patient doing the exercise are reduced at least 10-fold."

What is the goal of exercise?

Ultimately, it's about training the brain and optimizing movement.

You need to get the patient to "buy in". What will they buy into? Results. Plan and simple.

Some of the best results come from a team effort. Establishing a collaboration with your patient and increasing self-efficacy will get them where they need to go.

A glance at this episode:

[1:16] Patient compliance and adherence in therapy
[4:28] Exercises for persistent pain patients
[8:16] Patient adherence to home exercises and individualized treatment approaches
[10:56] Active involvement in exercise programs for better patient outcomes

Related links:

Unraveling the Web of Neuralgia: Navigating the Cervical Spine Sep 28, 2023

In this episode Susan and Erica welcome a Tough To Treat listener, Megan Barclay.

Megan brings a case of a patient who continues to suffer neuralgia after a bout of shingles, along with persistent neck pain.

Listen to the client's history, significant findings, and differentials as we navigate this client's journey and discuss relevant findings.

There is also a rich discussion on possible interventions targeting many points of the trigeminal system and cranial region.

A glance at this episode:

[1:25] Neck pain and potential causes and drivers
[8:39] Post-shingles symptoms and treatment
[16:32] Patient’s neck and shoulder pain, possible causes and treatments
[24:38] Treating a patient with neck and head issues
[28:55] Pain perception and treatment for cervical and lumbar issues
[30:16] Improving balance and reducing trigeminal symptoms through exercises
[33:31] Treating neck and back issues with physical therapy and nutrition
[41:09] Treating a patient with shingles
[43:28] Shingles treatment and empowerment
[46:12] Exercise and posture for chronic pain management

Related links:

Breath, Voice and HRV as Predictors and Interventions in Pelvic Health - Part 2 Sep 21, 2023

Look beyond the traditional regional approach of the pelvic and pelvic floor and understand how discovering and addressing dysfunctions of the trigeminal and respiratory system including the voice and heart rate variability can have an impact on pelvic health.

HRV is a well-researched indicator of the balance between the Sympathetic and the Parasympathetic nervous systems.

The balance has a large impact on the performance of the GI system and can influence pain, motility, and inflammation.

Working with Breath, Voice, and HRV can not only predict dysfunction but is an excellent metric to guide interventions in different domains.

This 2 part replay of a webinar is designed to expand your current practice through evidence-based and biologically plausible methods of examination and intervention into the thoracic, and cervical systems harnessing the breath and the voice can optimize respiratory mechanics and heart rate variability.

A glance at this episode:

[1:22] Why the vascular system is important
[2:55] What happens when we get into chronic stressors
[5:33] Nerves that fire together
[7:30] The trigeminal system and stress response
[10:35] The trigeminal system is the entire sensory system
[12:45] What is referred nociception central sensitization
[14:57] Cervical nerves and the brain
[17:31] Connections to the vagal system
[19:04] Breathing postures and sleep

Related links:

Breath, Voice and HRV as Predictors and Interventions in Pelvic Health - Part 1 Sep 14, 2023

Look beyond the traditional regional approach of the pelvis and pelvic floor and understand how discovering and addressing dysfunctions of the trigeminal and respiratory system including the voice and heart rate variability can have an impact on pelvic health.

HRV is a well-researched indicator of the balance between the Sympathetic and the Parasympathetic nervous systems.

The balance has a large impact on the performance of the GI system and can influence pain, motility, and inflammation.

Working with Breath, Voice, and HRV can not only predict dysfunction but is an excellent metric to guide interventions in different domains.

This 2 part replay of a webinar is designed to expand your current practice through evidence-based and biologically plausible methods of examination and intervention into the thoracic, and cervical systems harnessing the breath and the voice can optimize respiratory mechanics and heart rate variability.

A glance at this episode:

[1:41] Pelvic floor and breathing patterns
[4:12] What is GI dysfunction and why is it so prevalent
[5:41] The diaphragm and coughing and sneezing
8:22] The diaphragm needs to match the demands of the activity
[10:26] The diaphragm position
[12:25] The diaphragm and the chest wall
[15:09] How the diaphragm is connected to the regional nerves and inflammation
[17:21] Psoas as a trunk muscle vs. hip flexor

Related links:

The Mystery of This Man's Struggle With Pelvic Girdle Pain and the Breath Sep 07, 2023

In this episode, we dive into the often overlooked and misunderstood world of male health, exploring the complexities of groin pain, the challenges of taking deep breaths, and the impact on his pelvic girdle pain.

The history will give you the answer.

This is a complex case with many parts but listening to his story helps you to prioritize which regions of the body you need to rule out.

Visceral connections are key to this presentation.

Join Susan and Erica as they unravel the potential causes, shed light on some of his drivers, and offer insights to help those facing similar issues.

Don't miss this great conversation that aims to bring awareness to a topic that affects both men and women.

A glance at this episode:

[0:01] Intro to episode and patient
[8:41] Why the patient is experiencing paresthesias along with itching
[11:15] Breathwork and the visceral driver
[15:27] Pelvic floor and the breath
[18:12] Assessing hip pain
[23:53] A head lift and why it brings on his symptoms
[29:52] The effects of decompression on head rotation
[32:28] Yoga and the thorax
[37:08] Down dog and child’s pose
[43:11] Finding the driver and the root cause of his problem

Related links:

Shoulder Pain- A Motor Control Problem? Aug 31, 2023

When does motor control come into play when someone has persistent shoulder pain?

Is it soft tissue related, a joint problem, or a neuromuscular repatterning issue?

Or something else?

How does our nervous system adjust?

In this episode, we talk about the multiple sources of this person’s shoulder pain and how retraining his arm lift was the key to his recovery.

And we mean retraining, the right way.

A glance at this episode:

[7:27] Assessing symptoms associated with cycling
[8:47] The brachial plexus and its connection to hip pain
[12:57] Manual therapy for the shoulder?
[16:25] Drivers of this dominant postural pattern
[18:49] Mechanics of the shoulder joint
[23:52] Recovering the superior glide, why it's necessary
[28:49] Repatterning optimal shoulder movement

Related links:

SI Joint Pain - An Updated Approach Aug 24, 2023

Here is the clinical story of a client that is presenting with pain/sensitivity in the area of the (R) posterior pelvis.

A common area of symptoms for many patients. But there are many potential drivers and the need to differentially diagnose is crucial. Why? Because you won't want to miss the hidden connections that are so often present in patients, that when missed, can make the difference between a successful outcome and a patient who walks away unhappy.

In this episode, we discuss what has been unhelpful for her with regard to past interventions and why the biopsychosocial approach and creating the therapeutic alliance are so important to give her the ability to improve her movement system.

Meaningful activities, violating expectations, and movement system changes were key to her healing journey.

A glance at this episode:

[1:35] History of the patient
[5:30] Digging deeper to find the driver
[9:19] Lifestyle changes that work
[15:00] Establishing an alliance to explore fears
[25:30] Making the evaluation meaningful to the patient
[33:23] The reset exercise
[37:33] The problem with a sagittal plane squat

Related links:

Finding Hidden Connections In Functional Movements- Why They Matter Aug 17, 2023

In this episode, Erica explores the intersection of functional movement and persistent pain, offering a comprehensive blueprint for understanding and addressing movement dysfunctions that may contribute to ongoing discomfort.

Join her as she discusses her insights and tips with examples from her patient caseload.

Erica also speaks to functional movements that will help you find "hidden" drivers in other regions of the body.

Whether you're dealing with persistent pain or are a healthcare provider seeing those persistent cases, this episode equips you with advanced clinical reasoning knowledge and tools to create a solid assessment so you don't miss important connections.

A glance at this episode:

[2:41] Assessing low back pain
[4:45] How to assess the squat the right way
[6:57] Looking at functional movement patterns
[9:11] Non-optimal movement patterning, symptomatic or not
[11:08] Sling squats and heel raises
[13:12] Inversion patters
[14:57] How to evaluate neck pain
[16:53] The connections in the body and they relate to functional movement

Related links:

A Stiff 1st MTP Joint can Affect Everything! Aug 10, 2023

One of the most overlooked joints in the lower quarter is the first MTP joint unless that is the primary complaint of the client.

How does the stiffness of the 1st MTP joint affect gait and lower quarter movement of all kinds?

We spend some great time with discussions of differential diagnosis, and practical interventions and share some new discoveries.

Hint: the exam and intervention do not always center around the stiff 1st MTP - there is likely a primary driver elsewhere.

A glance at this episode:

[5:05] Compensate and adjust your feet
[11:23] Maintaining the pyramid of the foot
[13:54] How to assess the foot position
[17:17] Assessing the big toe
[20:17] How to treat plantar flexion inversion
[24:37] How to get started with the squat
[27:46] What shoes to wear for diabetic feet

Related links:

HRV as A Predictor and Intervention in Sleep and Stress Aug 03, 2023

Heart rate variability is getting a lot of press recently.

Join Susan as she presents a webinar on HRV as a predictor and intervention in sleep and stress.

It doesn't take complicated interventions to make real changes in our health!

A glance at this episode:

[1:59] What is heart rate variability
[4:07] Inhibition of the flight or fight system
[6:26] How you measure heart rate variability
[8:58] When to measure heart rate variability
[13:38] The cycles of sleep
[15:31] Memory and sleep
[18:07] Prolonged poor response to stress
[20:07] Aerobic fitness and heart rate variability
[22:05] Biofeedback and the readiness measure

Related links:

Pain Without a Diagnosis: The Complexities of Managing Medically Unexplained Symptoms Jul 27, 2023

In this episode, we delve into the perplexing realm of medically unexplained pain and the challenges it presents for healthcare professionals.

Join us as we navigate the complex landscape of patients who continue to experience pain despite thorough medical examinations revealing no discernible underlying cause.

We explore the frustrations and uncertainties faced by both patients and practitioners in these cases, as well as the importance of validating patients' experiences and concerns.

We share insights on the various factors that contribute to medically unexplained symptoms, including psychological and emotional aspects, and discuss the potential impact of stress, trauma, and other psychosocial factors on pain perception.

We also explore evidence-based approaches for managing and treating these conditions, ranging from interdisciplinary pain management techniques to the role of psychological interventions.

Join us as we shed light on this often misunderstood aspect of patient care and strive to find solutions for those living with medically unexplained pain.

A glance at this episode:

[5:01] Managing patient expectations
[9:21] What’s the challenge?
[14:08] How to help patients figure out what they need
[17:29] Determining if your patient needs time off
[22:20] Identifying what once-a-week treatment means for your patient
[27:01] What would it take to move the patient’s expectations
[33:24] Managing expectations of referral sources
39:38] Knowing when to refer out

Related links:

Decoding Persistent Hip Labral Tears - It's Not Always What We Think Jul 20, 2023

Have you ever had patients with "diagnoses" of labral tears on MR only to find out that the hip was not the driver?

Of course, you have.

In this short episode, Erica responds to a case sent in from one of the listeners regarding persistent hip pain.

She asks Erica what would be important to look at and how to proceed with the information at her disposal.

There was not a lot of background on this case; so listen as she highlights what's important to rule in and rule out.

Rule out the systemic and chemical drivers. Visceral issues, blood flow disruption, and connective tissue damage all need to get ruled out.

Then look at the connections between the regions of the body- rule out the foot, rule out the thorax. These are 2 VERY common regions of adaptation to hip labral tears.

Don't get fooled into treating the pain generator, unless it's the driver, which it usually is not in the persistent cases.

A glance at this episode:

[2:13] The patient’s history of hip pain
[4:08] What you want to look at in this case
[6:18] Hip injury assessment
[7:57] The GI system and its relationship to symptoms
[9:47] Imaging, gait analysis-other tools
[11:55] Diagnostics for hip and foot pain
[14:15] Clinical assessment of the hip
[16:20] How you flag chemical drivers
[19:02] Functional movement patterns

Related links:

Chronic Low Back Pain and Constipation - Why it Matters! Jul 13, 2023

Clients often have chronic low back pain as a primary or secondary issue.

It is often combined in complex presentations where addressing one issue is usually not going to generate optimal results.

In this episode, Susan and Erica discuss the obvious and not-so-obvious drivers in this client with chronic low back pain and constipation/bloating!

They discuss the varied evidence that helps to determine not only the main drivers of this presentation but also the reality of utilization of the full systems and whole body consideration in care.

Breath and balance play an important role. Don't miss it!

A glance at this episode:

[3:56] Physical therapy for lower back pain
[7:46] Chronic low back pain and chronic constipation
[12:55] The thoracic spine and chronic low back pain
[18:47] The importance of balance
[21:37] Breathwork and the sympathetic nervous system
[28:41] Reframing the question

Related links:

Pelvic Girdle Pain: Current Concepts Part 2 Jul 06, 2023

Clinical practice guidelines provide the practitioner with the most up-to-date research on a certain diagnosis or condition.

Join Susan in a two-part interview about Pelvic Girdle Pain in the Antepartum Population.

In part 2 there is a discussion around systemic vs. biomechanical drivers and the effect of cortisol and stress.

The clinician is asked to review their confirmational biases, consider changing from the relaxin conversation, and listen to the client's story.

Interventions are driven by these stories, movement pattern changes, load transfer, and sensory input.

A glance at this episode:

[0:40] Pelvic girdle pain and pregnancy
[2:17] Relaxing the pelvic girdle joints
[4:27] The importance of looking at the population
[5:24] How to listen to a patient’s story
[7:37] Taking the titles of functional outcome measures off the forms
[9:50] How to reduce load transfer
[12:04] What does a belt do for patients

Related links:

Unraveling a Compression Fracture in a Young Male Jun 29, 2023

Compression fractures are commonly associated with osteoporosis in older adults.

However, what happens when these fractures occur in young males?

In this episode, Erica and Susan discuss a patient who sustained a T6 compression fracture.

It is intriguing to note that it is a young male in his 20's not an older woman in her 70s.

Do they require different treatments?

Detecting a compression fracture is not difficult thanks to musculoskeletal imaging.

However, considering the radiological changes that occur at the vertebral level with compression fractures can sometimes make exercise progression difficult.

They discuss an initial treatment plan for him and what needs to happen to help him tolerate sustained sitting and standing.

A glance at this episode:

[2:06] Introduction to patient & history
[4:09] Suffering a compression fracture
[7:19] Trunk rotation and alignment
[9:06] Foam roller exercises
[12:03] Thoracic posterior vs anterior translation
[13:58] How to get traction on a foam roller
[17:27] Etiology of compression fractures
[19:00] Sustained positioning and compression

Related links:

Meeting Patient Expectations- Navigating the Journey to Progress Jun 22, 2023

This is an excerpt from Erica's DCP course call in February of 2023.

In this episode, she delves into the crucial aspect of meeting patient expectations and facilitating their progress.

She explores the dynamic relationship between healthcare providers and patients, discussing effective strategies for understanding, managing, and aligning expectations throughout the treatment journey.

Join her as she navigates the complexities of patient satisfaction, communication, and empowerment, offering insights and practical tips to foster positive patient-provider relationships and drive meaningful progress.

A glance at this episode:

[2:02] How to develop a script for complex patients
[3:44] How to ask patients how committed they are to recovery
[7:49] The pelvic girdle and hip drivers
[9:01] Treatment time expectations
[10:10] How long it will take the patient to get back to their activities
[11:37] Setting expectations during visits

Related links:

When Shoulder Pain is Dominant, but Not the Driver! Jun 15, 2023

Shoulder pain, like any other joint can present as primary pain and be the #1 reason a client may seek help!

In many cases, treating the apparent joint dysfunction (because it checks all of the boxes) may not result in optimal outcomes.

Join the conversation as Susan and Erica explore the reasons and important timelines in the client's history that led to her shoulder pain.

Most importantly follow the clinical reasoning that led to the real driver of this issue.

Bonus - we also offer a great discussion of a good exercise progression!

A glance at this episode:

[1:39] Shoulder pain and internal rotation
[7:52] Which side of the table should you work from
[12:40] Learning to tape the wrist
[20:00] Opening the hands
[22:46] Using the yoga blocks
[27:58] Grip strength as a sign of health

Related links:

Pelvic Girdle Pain: Current Concepts Part 1 Jun 08, 2023

Join Susan in a two-part interview about Pelvic Girdle Pain in the Antepartum Population.

Clinical practice guidelines provide the practitioner with the most up-to-date research on a certain diagnosis or condition.

In part 1 there is a rich discussion of what Clinical Practice Guidelines are, risk factors for developing pelvic girdle pain, and most importantly, the language change around the pelvic joints' stability and instability.

A glance at this episode:

[2:16] What is pelvic girdle pain
[3:36] Pelvic pain prevalence and risk factors
[5:56] What drives the pain experience
[8:19] Pelvic girdle and osteoporosis
[10:35] How the brain creates patterns in response to pain

Related links:

From Neck Pain to Shoulder Pain: Unraveling the Links Between the Two Jun 01, 2023

Does stretching work when a muscle is over-recruited?

Not if you don't change the movement pattern.

This is an excellent follow-up to episode #162, showing how you clinically reason through another weightlifting injury.

Join Susan and Erica as they discuss a patient who sustained a shoulder/neck injury during a "basic" tricep extension exercise.

The main takeaways are twofold: You must assess the connections between the 2 drivers and treating one region alone will not improve this patient's symptoms.

Why?

Because if you look at his mechanism of injury plus his old movement history as a rower, you will understand that these connections exist and why one region was more dominant, depending if it was OKC or CKC.

Enjoy!

A glance at this episode:

[3:01] Physical therapy for a hip injury
[6:29] Looking at the head and neck area
[12:58] Lumbar spine rotation and compression fracture
[15:58] Understanding the movement pattern
[19:50] Treating both areas of the body
[26:20] Sensory input to the joints
[32:23] The best way to recruit deep muscles

Related links:

Unique Release Positions for the Shoulder: Positioning for Optimal Results May 25, 2023

The purpose of release is to train. Remember that.

Long gone are the passive release positions for patients.

Think about the connections in the regions of the body to each other and then design a position that engages those long vectors connecting one region of the body to each other.

An example, is the use of head rotation and the GHJ, to engage the barriers BETWEEN those regions of the body to each other.

Join Erica as she discusses a unique way to achieve end-range shoulder flexion for a neck driver.

A glance at this episode:

[2:00] The connection between the head and neck
[4:02] How to engage barriers between different regions of the body
[7:18] What are the main drivers for shoulder dysfunction?
[9:18] What drives symptoms at end of range shoulder flexion?

Related links:

Complex Chronic Low Back Pain - When A Regional Approach Will Not be the Best Option May 18, 2023

Where do you start with a client with complex regional pain that has full-body implications?

Listen to their story, look for the change talk, and gain active participation by allowing them to lead the way in a judgment-free zone.

Sometimes, clients know what they need to do, they just don't know how to implement the changes and find simple action steps.

Join us as we talk about this interesting case of a surgeon hijacked by his work environment, which has accumulated several body system symptoms from GI dysfunction, neural tension, pain, and pressure system dysfunction.

This starts with simple action steps and progresses to a complete lifestyle change.

A glance at this episode:

[1:58] What does microsurgery look like
[4:52] How to deal with the pain of surgery
[10:14] Looking at the problem in this case
[13:01] Breathing to relieve neural tension
[15:37] Rolling a towel method
[22:16] Solving the problem of constipation
[22:25] Tai Chi pros and cons
[31:00] Tennis balls and headstands

Related links:

Trigeminal System Referral Pattern May 11, 2023

What is the referral pattern for the Trigeminal System?

What does that mean for our clients?

The cervical nucleus of the trigeminal system can have profound effects on multi-body symptoms

Join Susan as she describes this unique and vital phenomenon.

A glance at this episode:

[1:45] Trigeminal system as a sensory experience
[3:06] The interconnecting cranial nerves
[3:51] How the trigeminal system affects the voice
[5:17] Trigeminal ganglion and the spinal nucleus
[7:54] How to bring your heart rate down
[8:31] Trigeminal system and tooth pain
[10:32] Lateral spinal thalamic track and ventral trigeminal limb
[12:28] Convergence of the trigeminal nerve
[14:02] How chewing gum impacts the sympathetic nervous system

Related links:

Pelvis Driver In A Male Weightlifter May 04, 2023

This episode is all about low back pain with a pelvis component in a 33-year-old male weightlifter.

Erica and Susan discuss how his history of chronic low back pain along with some bowel issues played a significant role in how he recruits muscles under load.

Some highlights include why pelvic taping helped in this case, how to perform the same movement pattern in different positions, why assessing the pelvis was necessary, and the clinical reasoning as to how to differentiate whether it was an overactive anterior-posterior chain.

A glance at this episode:

[5:42] What triggered this patient’s symptoms
[8:33] The primary driver for his low back pain, it's not what you think
[12:49] What's the lower extremity component of his problem
[19:50] Diarrhea, constipation, and how it relates to his symptoms
[25:38] Letting go of the coccygeal muscles
[32:25] Mass movement patterns and internal rotation

Related links:

Assessing The Knee Differently Apr 27, 2023

In this "shortie" episode Erica discusses different ways she assesses the knee.

There are 3 parts to the knee joint and assessing a movement pattern that takes into account all these regions is key.

It's not all about patellar tracking, right?

More often than not, one part of the knee is being compressed because of some overactivity in the muscles surrounding it.

The main takeaway is that evaluating these regions takes precision and it's worth it to spend a few extra minutes doing so. Your patients will appreciate the specificity.

A glance at this episode:

•[1:45] Why the knee is the victim

•[2:57] Knee assessment

•[5:08] Clinical pearl on knee mechanics

•[7:03] How to assess the knee in 3D

•[8:48] Assessing the knee with a body twist

Related links:

Foot Drivers - The Prequel to the Foot Progression Exercises Apr 20, 2023

Erica and Susan have presented several podcasts discussing the exercise progression of the foot as the primary and secondary driver.

Today they discuss the idea of taking the movement pattern down a couple of steps in preparation for the foot to handle loads, change the body posture, and progress to appropriate AP sway.

The clinical reasoning process is key for understanding how the foot should be working before strengthening and challenging movement patterns can be improved.

A glance at this episode:

[7:36] How to get the foot to turn on to work
[11:05] Creating a tripod position for the foot
[15:32] How to mobilize your feet
[20:17] Neural tension work and increasing mobility
[24:45] The split squat position
[28:18] How do you learn to squat down
[33:23] The importance of building volume at low levels

The other episode mentioned in this podcast on exercise progressions for the tough to treat foot. Episode # 76.

Related links:

Anatomy and Physiology Interactions of the GI System - Part 2 Apr 13, 2023

This is part 2 of a short webinar on the interactions of the functional anatomy and physiology of the GI system, presented by Susan Clinton.

This will give listeners a nice story of these systems in aspects of digestion and this affects other systems.

A glance at this episode:

[1:25] The importance of good digestion and intestinal mucosa
[3:!7] Chemical digestion of food
[5:51] Digestive enzymes
[8:05] The village of Villi
[9:59] Mass movements in the large intestine
[11:38] The rectal inhibitory reflex
[13:43] The descending colon and rectum

Related links:

What Do Weightlifting And Poledancing Have In Common? Apr 06, 2023

Answer: A dominant movement pattern that is the same across all this patient's activities.

No 1- weightlifters brace and dump their shoulder blades when they rack squat. A very common pattern for this movement, especially when you are lifting over #200 +.

The problem is when this becomes dominant for all movements.

Healthy systems need choices, plural. The nervous system then grades the strategy depending on the movement and load needed.

What happens when someone uses this strategy to pole dance?

No 2-a rigid thorax does not serve here. The main impairment in our clinical practice is not a stiff thoracic spine but one with a loss of control.

Imagine that?

How does that transcend into low back pain?

Listen in as Erica and Susan discuss how to down train this common problem and give this patient more choices for optimal movement.

A glance at this episode:

[8:24] Stretching and why it isn't helpful here
[13:11] Movement options at home
[17:04] The importance of hands-on work and the wall squat
[21:28] Abdominal synergy
[25:21] The diaphragm and what it takes to move well
[30:58] Connections to the neck
[35:00] Adaptation for athletes with lower back pain

Related links:

Anatomy and Physiology Interactions of the GI System - Part 1 Mar 30, 2023

This is part 1 of a short webinar on the interactions of the functional anatomy and physiology of the GI system.

Listen to the unique anatomical arrangements and the neurophysiology connections.

A glance at this episode:

[1:00] Where the visceral organs are located in the abdominal cavity
[3:35] The neurology of the GI System
[5:44] The parasympathetic and sympathetic pathways of the gut
[7:32] Nervous pathways from the brain to the spine
[9:34] Muscarinic receptors in the digestive system
[11:14] What is the mesenteric system
[13:22] Endocrine cells in the gut
[15:32] Why stress over time can be damaging to the gut system

Related links:

Hypermobility and Low Back Pain Mar 16, 2023

How do you rehab someone who is VERY hypermobile and suffers from persistent low back pain?

Carefully and specifically!

When someone who is hypermobile complains of continued and persistent back pain, your first thought is, " Is this an overactive system? An underactive system? Or both?".

This re-release of an episode from 2018 highlights the beauty of a specific exercise progression tailored to the patient's meaningful movement and her dominant impairment.

Listen as we go through the clinical reasoning process to determine what types of movement patterns will work and what ones won't.

Doing the right thing at the right time is clinical expertise.

A glance at this episode:

[5:55] Hypermobility Syndrome and the pelvic floor
[12:11] How and why her back extensors are overworking
[19:44] Taping-does it help here?
[24:42] Recruitment of the diaphragm in back pain
[28:34] Taking out the overactivity-Posterior pelvic tilt on all fours
[32:33] Spinning and mirroring that into exercise
[36:35] Not a stretching issue but a coordination problem
[39:55] Flexion based stabilization and progression
[44:38] Resistance bands on the bike

Related links:

Why Has My Patient Stopped Improving? Mar 09, 2023

Ep 152: Why Has My Patient Stopped Improving?

In this episode, Erica discusses the fine points of what to do when your patient stops improving. AKA a plateau.

Problem-solving through a patient plateau requires sound clinical reasoning and a reflection back to the patient's story. Looking at the injury and movement history-there can be a clue there. Change their COM and reassess another movement pattern.

Listen in as Erica gives you the steps to take when this happens to you. A case example is also presented to illustrate the point. Ultimately, challenging the human movement system in different ways along with an objective look at the patient's narrative will give you your answer.

A glance at this episode:

[2:15] Going back to the patient’s story
[4:06] Reassess another movement pattern
[5:50] Why another assessment tool is crucial
[7:45] When to problem solve through a plateau
[10:02] The first injury sets them up and their movement history keeps them there
[12:01] How to assess center of mass
[13:52] Training the center of mass in a functional movement pattern
[15:16] Why the knee mattered

Related links:

Estrogen Levels and Changes in the Musculoskeletal System Mar 02, 2023

In previous episodes, Susan and Erica discussed the effects of decreased estrogen at peri and post-menopause with tendinopathies.

In this episode, Susan provides the next half of the discussion, from a webinar, on hormones (particularly estrogen) and their effect on the musculoskeletal system throughout the lifespan.

Did you know that HRT does not have an effect on tendons?

Join the conversation, this will be so helpful in considering your Tough to Treat female clients.

A glance at this episode:

[0:59] What happens when we have too much estrogen
[3:28] What does it mean to develop tendinosis
[5:12] Hormone replacement therapy and muscle health
[7:25] Isometric loading vs loaded eccentric exercise
[9:28] Sustainability of exercise programs
[11:39] What else is going on with these athletes
[13:31] Is birth control the right answer

Related links:

Shoulder Girdle Hypermobility vs. Thoracic Stiffness - Where is the Balance Feb 23, 2023

Many of our episodes have included clients on the hypermobile end of the spectrum with a stiff thorax.

How do you balance increasing thorax movement around a hypermobile shoulder girdle region?

How do you use some sound clinical reasoning to design an exercise program that can bring motor control to the shoulder girdle and improve thoracic mobility?

Join us as we bring this clinical scenario to light with the rehab program of an archer complaining of a stiff neck and inability to increase power!

This case involves the neurological, musculoskeletal, respiratory, and central nervous systems to make meaningful changes. A full approach to looking at the gaze and the upper CV joints, adding breath for the thorax, and an interesting motor control program are discussed in the light of clinical reasoning.

A glance at this episode:

[3:10] Patient’s history and current condition
[7:10] Upper cervical stiffness
[10:05] Joint stiffness
[11:48] Shoulder stabilization exercise
[15:05] Changes of the thoracic motion
[19:15] Kneeling to reconnect the ocular reflex
[23:42] Practice makes permanent but not perfect

Related links:

Advanced Clinical Reasoning With Your Toughest Patients Feb 16, 2023

In this episode, Erica throws out some clinical gems when it comes to clinical reasoning through these scenarios.

What do you do when your patient says, "I am 85% better but I am still getting (insert symptom) when I do (insert activity)." or " I am so much better but my foot hurts on and off when I still sit at my desk".

The key is "what does my patient need at this point in time?"

Using 2 examples from her patient caseload, Erica discusses how changing the activity and the environment may be the last piece of the clinical puzzle.

Erica also discusses the concept of "centering". If someone lives on their left side, as was the case with these 2 patients, how can you use this concept to give them more options for loading to the right?

We need choices for movement- loading one side of your body for long periods takes away those choices and limits our options. This MUST be trained for your patient to have success.

A glance at this episode:

[2:05] Introduction to patient’s history
[5:06] Advanced clinical reasoning
[7:24] Changing input into the nervous system
[9:48] How can you change the environment to suit your patient
[11:30] Example of a patient with lower back pain
[13:43] Do you need to treat the right knee and foot
[15:55] Centering exercises for strength training
[18:10] Kneeling strength training and centering

Related links:

Down Training Non-Optimal Movement Patterns to Make Exercise More Effective Feb 09, 2023

In this episode, Erica and Susan discuss how to identify someone's non-optimal movement pattern, aka the "dominant pattern" or "the impairment", and use it to your advantage when positioning and prescribing exercise.

Think of it this way: If someone has a strong movement pattern, whether it is compensatory or not, they need choices to move in and out of it.

More often than not, exercises that are being prescribed reinforce this maladaptive pattern.

They discuss ways to position people who have thoracolumbar solid gripping strategies in order to uncover a source of weakness or inhibition elsewhere.

Additionally, positions for hip flexor dominance are also discussed.

As always, these are real examples from their patient caseload.

A glance at this episode:

[3:16] Identifying the patient’s impairment by changing up the movement pattern
[7:43] Integrating and changing the exercise tool
[9:59] How we can position people to turn off their non-optimal strategy
[12:10] Positioning via various modes of exercise
[14:50] Translating exercises to home training
[20:46] Exercises to increase mobility in their new pattern
[23:40] How to position patients with overactive hip flexors
[26:00] Side bending to the opposite side-how to use it to your advantage

Related links:

Hormone Balance - Estrogen and Why it Matters Feb 02, 2023

Hormones have a significant influence not only within the balance of the endocrine system but also the effect on the MSK system.

Join a discussion Susan has had in a course about hormonal health in females.

This piece takes a nice dive into estrogen balance throughout the reproductive years.

A glance at this episode:

[1:03] Estrogen and the effect on the body
[3:00] What happens to estrogen in the body
[4:45] Hydroperoxide and estrogen dials
[6:01] How to make cortisol in the body
[8:03] High and low levels of estrogen
[9:49] Central sensitization and central sensitivity

Related links:

Shoulder Stiffness - When the Tissue is the Driver! Jan 26, 2023

Shoulder pain, stiffness, and lack of functional mobility are not uncommon in clients with post-breast cancer.

Join us as we discuss the evaluation and treatment sequence that addresses the particular soft tissue involvement and drivers of this client's limitation—hint: several tissue issues are involved.

The clinical reasoning around the client's story is key here!

A glance at this episode:

[2:04] Susan introduces her patient's history
[7:34] Shoulder girdles and head position
[10:34] Flexion of the cervical spine
[16:40] Looking at passive vs. active range of motion
[19:19] How Susan started the abduction exercise
[24:21] Towel roll exercise for mobility
[27:27] How to add movement into decompression
[33:29] The thorax is 360 right and left

Related links:

Manual Therapy Or Not? Hands Off Or Hands On? Or Both? Jan 19, 2023

When do you make the clinical decision to put your hands on your patient or take them off?

We are changing brain maps and our hands act as facilitators of movement. You need a clinical decision tree to decide which muscles to release and which ones to let go of.

A clinical pearl: as your patient moves forward in their program, certain muscles will appear in more loaded movement patterns that you will NOT see in a passive position, like supine.

Don't miss this. What is manual therapy?

The next time you see a patient, pause and ask yourself, "why am I putting my hands on this region of the body? ". Is it to show them that you do "hands-on" therapy? Or something else?

A glance at this episode:

[2:57] Once you know the driver, what will you do with it
[4:36] Irrelevant muscles may not be prevalent in a supine position
[6:35] How to get patients in the prone position for manual therapy
[8:15] When to do manual therapy and when to not
[10:37] Hands-on versus passive
[13:02] What is manual therapy

Related links:

Grow Your Clinical Expertise By Learning How To Treat The Complex Patient (Part 2) Jan 12, 2023

Join Susan and Erica while they present case studies to highlight clinical reasoning.

This is part 2 of a 2-part series from a webinar.

These case studies include pregnancy-related pelvic girdle pain, an athlete with shoulder pain, and a few more.

Follow along and recognize the unique clinical reasoning for each client.

A glance at this episode:

[2:26] What is a cross-legged squat
[6:00] What is a complex exercise program
[8:28] Assessing the patient and how far they can walk without pain
[13:44] Why you need to really take care of yourself, but a lot of people aren’t
[15:39] Assessments from the front of the room
[19:42] Changing the neurophysiological input to the system
[22:14] Common patterns in patients with chronic neck pain
[26:15] Changing the context changes the experience and changes the brain
[28:53] Positive transference to performance

Related links:

Grow Your Clinical Expertise By Learning How To Treat The Complex Patient (Part 1) Jan 05, 2023

In this 2 part episode, Susan and Erica discuss what it takes to become a clinical expert, and how that translates into effectively assessing and treating the "tough to treat".

They highlight common errors in clinical reasoning and how to avoid them. They also discuss common red and yellow flags and when to trust your gut.

This is part of what makes an expert.

Remember, the organization and structure of a clinician's knowledge are more important than the content itself. Learning how to ask the right questions will lead you to the driver more quicker.

A glance at this episode:

[5:48] The importance of critical thinking in clinical practice
[10:44] Clinical red flags and clinical yellow flags
[12:35] Red flags that go along with back pain
[18:08] Central sensitization is a good outcome measure
[20:51] What does a successful outcome look like
[26:47] How to get someone from free contemplative to contemplative
[29:41] A brief case study of two patients with low back pain
[35:24] What’s optimal for these patients
[41:19] Nerves are bloodsuckers and need to move
[48:32] How to know when to change posture
[55:23] Case study of a client with progressive pain in back of pelvis

Related links:

Breath and the Chest Wall Dec 21, 2022

Was this because people equated the term "chest breathing" with "accessory muscle breathing".

Foot and Hip Pain? Why You Treat The Thorax Dec 15, 2022

Your patient has a dysfunctional thorax and it's driving their symptoms, wherever they are. How can you clinically reason treating a non-painful thorax for distal symptoms, such as the foot and hip?

The body translates the head, thorax, and the pelvis over the feet for many reasons. Offloading a painful foot, knee, hip is one reason, the other can be an ingrained movement pattern that has been there for years because of an old injury or from a dominant movement or sport history.

Join Susan and Erica as they discuss thoracic drivers and how they can relate to hip and foot dysfunction. They discuss patterns of non-optimal movement in the thorax and how you would progress exercise appropriately in these patients.

A glance at this episode:

[2:13] The thoracic driver is part of the body that is not moving well
[6:47] How do you know if it’s a thoracic driver
[8:40] What’s driving the pain
[15:12] Working into the thorax to improve proprioception
[19:02] Compression on the dominant side of the body
[20:34] Looking further into more drivers
[25:52] The importance of proprioceptors and proprioception

Related links:

How To Increase Proprioception - An Updated Approach Dec 08, 2022

What are the clues and the keys to increasing somatosensory awareness in your patients? Putting someone on a dynadisc or a foam pad does not cut it anymore when your patient lacks sufficient motor control to move well. Make the clinical decision-does my patient need this NOW? Proprioception challenges the individual movement system in many different ways. In this episode, Erica discusses new and novel ways to highlight proprioception in your treatment programs. Be creative! One of the examples Erica discusses is how she uses therabands and velocity to achieve this goal.

A glance at this episode:

[2:20] Proprioception in orthopedic patients
[4:39] What is proprioceptors and how do you improve it
[6:30] How do you stimulate the nervous system to increase proprioception
[9:03] Exercise for non-athlete populations
[12:29] How to train proprioception in hyper-mobile patients

A Fencer With Bilateral Calf Pain - Where's The Driver? Dec 01, 2022

Neurophysiological Underpinnings of the Trigeminal System - Part 1 Nov 17, 2022

In this short episode, Susan discusses the upper cervical region and its effects on the rest of the body: core, pelvic floor dysfunction, muscle recruitment, balance, dizziness, etc. Join Susan as she takes a journey into the remarkable system from one of her lectures. Erl Pettman's work has long influenced Susan on her clinical reasoning and the importance of convergence of symptoms throughout the body from the upper cervical spine and the cervical trigeminal nucleus. Retraining this region is one of the reasons we "recommend" the Clock Yourself App - for the cervico-occular-vestibular reflex training.

A glance at this episode:

[1:36] Trigeminal system
[3:02] What is C5 C6 nerve root irritation
[4:28] The three different nuclei for the trigeminal system
[7:15] The biggest threat to mankind
[8:21] The trigeminal system is a sensory experience

Related Links:

Lumbosacral Pain Presentation - A Typical Clinical Pattern Nov 10, 2022

In this episode, Susan and Erica discuss a series of patients that all presented lumbosacral pain. Clinical pattern recognition is an important part of the assessment process.

The pattern does not dictate the intervention process, but the inability or ability of the pattern to change in the assessment and intervention process is key. This practical presentation of a typical female with lumbosacral pain demonstrates the recognition of the clinical pattern. Once this is discovered, what are the best ways to intervene? Where do you start and what do you look for? Is it better to start and the impairment level or the meaningful functional movement level? How quickly do you change and discover the next layer. The obvious presentation requires some keen clinical reasoning to progress the "one size does not fit all" presentation.

A glance at this episode:

[1:46] The symptoms that these patients are bringing
[2:58] Extension is causing pain in these patients
[4:43] Ruling out the hip
[10:14] Gaining rotation in the side they’re missing
[12:36] How to improve hip extension
[17:42] Finding the driver
[19:17] Single-leg stance on the right side
[24:15] If you’re making someone worse by removing a movement pattern, it’s not the right time
[28:13] Clinical patterns in the hip

Related Links:

What To Do When Your Treatment Stops Working Nov 03, 2022

In this short episode, Erica discusses her perspective on what to do when your patient plateaus.

We’ve all been there. The proverbial plateau. Your patient is doing well and then all of a sudden they get stuck. Why?

More often than not, there is a secondary region of the body that has cropped up. Go back to your patient’s movement and injury history. There will most likely be a clue there.

Also, do you trial exercise at the beginning of the treatment session?

If you don’t, you should.

Another reason why someone has plateaued is that their exercise program is too hard. Or too easy. Seems obvious, right?

Many therapists just add exercise at the end and don’t bother to observe the patient performing the exercise.

The most common scenario is this: Your patient has restored to their dominant non-optimal movement pattern as the program progresses and you may have missed it.

Join Erica as she discusses this in the context of a few patients.

A glance at this episode:

[4:22] The patient could have a secondary driver that you need to treat
[5:34] The patient might plateau when you start to load their system
[6:24] Patient example #1
[7:30] Patient example #2
[8:55] Thinking out of the box and using clinical reasoning

Related Links:

Treating Knee OA The Smart Way Oct 27, 2022

In this episode, Erica and Susan discuss how to begin and progress treatment with a knee OA without exacerbating their symptoms. Knee pain can be quite provoking as we age, especially for those older adults who have always been active and want to stay that way.

Osteoarthritis is fairly common, however, exercise designed for this patient population tends to fall short and can often exacerbate the symptoms.

Is there an articular problem?

Yes, often times that’s where it starts. But it cannot stop there.

These patients must be progressed through a SMART exercise progression in a graded fashion. This is done by changing position, context, load and range.

A glance at this episode:

[2:45] An 81-year-old patient who wants to run a marathon
[3:50] Patient’s past movement history
[7:10] Erica walks through her exam
[10:00] Susan’s view on the patient so far based on his history
[11:02] How Erica worked with the patient
[13:21] Basic exercise for the patient
[15:00] Susan’s advice on exercise
[16:55] Using a ball to help with squats
[18:02] Looking at the impairment for the patient
[19:02] What you could use if you don’t have access to gym equipment
[22:10] Some stretches that Erica gave her patient
[24:45] Erica continues to lateral step ups
[27:16] How she got her patient to squat
[29:15] The clinical reasoning on what the patient was having trouble with

Related Links:

Tough To Treat Website
Erica’s Course: Decoding the Complex Patient - Launching in a few weeks. Get on the waitlist now!
Susan’s Pelvic Health Education Subscription
Access the Transcript

The Gut-Brain Axis - Stress, Pain, and Balance Oct 20, 2022

Join Susan as she shares a segment from a course she teaches on GI Dysfunction. This clip is dedicated to the Gut-Brain Axis and why the complex interactions can have such a direct effect on the behavior of the movement, endocrine, nervous and visceral systems. It is all about balance and the direct need to make sense of input and the actions necessary.

A glance at this episode:

[0:40] Susan shares an old story about working top down
[1:50] Sympathetic and parasympathetic pathways
[2:35] The vagal pathway
[3:48] Susan discusses ‘eye brain’ vs. ‘old brain’
[4:55] The limbic system
[6:01] ‘Gut brain’
[8:08] An example of serotonin working at its best
[10:23] All of the things that can influence the gut

Related Links:

Kelly McGonigal's Book ‘The Upside of Stress’
Tough To Treat Website
Erica’s Course: Decoding the Complex Patient - Launching in a few weeks. Get on the waitlist now!
Susan’s Pelvic Health Education Subscription
Access the Transcript

Shoulder and Arm Pain - What is Really the Driver? Oct 13, 2022

In this episode, Susan and Erica discuss how very old drivers can present in a novel situation, as well as why new drivers will appear if compensatory patterns are allowed to become dominant. Susan’s patient in this episode came to her with shoulder pain which quickly led to full-on arm pain. Susan discusses how she used clinical reasoning and the patient’s history to find the driver. The driver here is not obvious and did require some deep investigation.

Shoulder problems can be the focus of the problem with the area having faulty movement patterns associated with the pain. This is especially prominent in acute pain. Follow Erica and Susan on this case with selective tissue testing to tease out the root level of nerve pain and shoulder movement dysfunction. See how this patient gained her mobility back in her shoulder and neck.

A glance at this episode:

[2:14] Susan’s patient gets shoulder pain after pressure washing her house
[4:21] Susan has her patient move around to get a better diagnosis
[5:36] After reviewing her movements, Susan starts to question if this is even a shoulder issue
[8:04] Susan starts to take the next step with her patient
[11:52] Susan decides where she needs to focus to take pressure off the shoulder
[13:37] The driver is finally discovered
[14:12] Erica talks about clinical reasoning in this case
[16:30] Techniques used to help the cervical spine
[17:17] How Susan incorporated taping with this patient
[21:00] Susan discusses sensory input
[22:20] Additional tips to help Susan’s patient
[25:35] How Susan’s patient does in the next few days after treatment
[27:00] Exercises Susan sends her patient home with
[28:36] One week later her patient is doing much better
[30:57] Erica clarifies if the patient was in supine or sitting when starting the exercises
[31:50] Susan goes in depth with the exercises she used to help her patient
[33:32] Erica asks if the patient’s movement ever came back
[35:44] Other areas that Susan looked at in the patient
[37:11] Erica’s clinical reasoning on the case

Related Links:

Tough To Treat Website
Erica’s Course: Decoding the Complex Patient - Launching in a few weeks. Get on the waitlist now!
View this episode on YouTube
Susan’s Pelvic Health Education Subscription

Hip Pain In A Golfer: Why It's Not Going Away Oct 06, 2022

In this short episode, Erica highlights the importance of center of mass by assessing a semi-competitive golfer with hip pain. He suffered an avulsion fracture of his iliopsoas tendon with resulting surgery. Two years later, he became symptomatic in his hip after golfing for consecutive days.

Hip pain is quite common in golf because of the rotary nature of the sport, but you have to wonder why this happened. Here’s what you need to consider: After someone has an injury or even surgery, they will generally offload that side of their body. This is understandable, but the majority of people do NOT regain their center of mass because they have not trained this way.

Golf is a sport of weight shifts and finding center with a narrow base of support. This short episode highlights why this is crucial and where his real driver was. Spoiler alert, it wasn’t his hip!

A glance at this episode:

[2:39] The golfer’s history and his previous surgeries
[3:57] Erica's assessment and differential diagnosis
[6:08] The treatment plan and exercise progression
[8:30] What the patient’s primary and secondary drivers were

Related Links:

Tough To Treat Website
Erica’s Course: Decoding the Complex Patient - Launching in a few weeks. Get on the waitlist now!
Susan’s Pelvic Health Education Subscription
Access the Transcript

Racquet Sports & Back Pain: Why You Should Look At The Foot Sep 29, 2022

In this episode, Susan and Erica discuss a young squash player with long-standing low back pain.

They highlight the importance of injury and movement history.

What do we know of squash players?

What regions of the body are stressed in this sport?

Look at different movement patterns to tease out the driver. How can you apply your clinical reasoning using a timeline of his injury history coupled with the dominant movement patterning inherent in that sport to figure out where his drivers lie?

Hint: there was more than one area.

Not surprising-this is very common.

They also discuss a sound exercise progression giving listeners options for changing context and load.

Enjoy!

A glance at this episode:

[3:21] The patient’s history
[7:56] Dominant movement patterns in tennis and squash players
[13:29] Erica’s differential diagnosis
[27:06] Erica’s treatment plan and progression

Related Links:

Tough To Treat Website
Erica’s Course: Decoding the Complex Patient
Susan’s Pelvic Health Education Subscription
Access the Transcript

When You Should Tape and Why Sep 22, 2022

In this short episode, Erica gives her perspective on when and why you should tape. This is one of the most commonly asked questions in her practice and this episode reveals Erica’s perspective on taping all throughout the body. She also shares the types of taping techniques that she uses whether it’s for supportive purposes or facilitatory purposes, or just nervous system input.

Taping can be a controversial topic in physical therapy. However, there is a time and a place for such interventions. Clinical reasoning dictates that we have a reason for why we do what we do and when it is appropriate. When you are trying to optimize a movement pattern for your patients, you need building blocks upon which to build new habits. Taping can be one such step. Not everybody needs this and not everybody loves this. That is where your clinical reasoning comes in. As an example, if you find that someone's dominant movement pattern is thoracic lateral translation to the left because of a long history of rowing as a left sweep, taping can be a helpful adjunct to your treatment to help facilitate optimal movement and build awareness.

In this episode, you’ll hear:

Erica’s take on the use of tape in the clinic
The type of tape she uses
The type of taping techniques she implements and what it’s purpose is

A glance at this episode:

[2:56] Relieving neck and shoulder pain by taping for scapular unloading
[4:24] Restoring neuromuscular balance in the scapulothoracic joint
[4:51] Why taping doesn’t help the shoulder
[5:26] Upper rib taping to help with thoracic drivers
[7:19] Hip taping for greater external rotation
[8:12] Taping the pelvis based on compression
[9:26] Medial subtalar joint taping
[10:09] Taping the first ray of the foot to neutralize the subtalar joint

Related Links:

Low Back Pain: Regional vs. Movement System Considerations Sep 15, 2022

Low back pain is a descriptive term at best, indicating where symptoms present.

Discover the history and the movement system examination and interventions that led to the successful reduction of symptoms.

[3:30] How one driver can affect another causing confusion in the actual driver
[6:36] Movement pattern is a dominant pattern as you adapt
[9:19] What is really going on here
[17:48] When she rotates her leg externally, now we can see a driver
[20:43] Do you treat the chicken or the egg
[23:59] The knee is a potential driver of pain and stiffness
[26:42] Using the Nordic Stick to help with knee pain
[29:44] The importance of finding the driver of the movement system

Tough To Treat Website
Erica’s Course: Decoding the Complex Patient
Susan’s Pelvic Health Education Subscription
Access the Transcript

Exercise Progression for the Tough to Treat Shoulder Aug 25, 2022

The shoulder can be tough to treat at times, right?

It consists of many regions of the body and in order to design an exercise progression that gets results, you must:

*Down train the old dominant strategy first *Be innovative with release positions to tease out certain muscles that are overactive *Train volume of easy exercise at a low level *Use hands and knees as a treatment and exercise progression

This episode discusses all this and much more!

Remember, consider the impairment. Once you have this, then you can begin to formulate an effective exercise progression that works.

A glance at this episode:

[1:15] How to efficiently progress someone with a shoulder problem
[5:07] Glenohumeral Joint Dysfunction
[14:16] Exercise progression for glenohumeral joint issues
[16:26] Working with the patient to find out what cues work
[19:00] You need to read the patient’s strategy before you train the new one
[21:32] Advice for patients who have shoulder issues

Related Links:

Tough To Treat Website
Erica’s Course: Decoding the Complex Patient
Susan’s Pelvic Health Education Subscription
Access the Transcript

Hypermobility and Low Back Pain Aug 11, 2022

How do you rehab someone who is VERY hypermobile and suffers from persistent low back pain? And their driver is NOT the lumbar spine. This episode highlights the beauty of a specific exercise progression tailored to the patient's meaningful movement as well as their driver. A very important principle of successful and long lasting improvement is training new movement strategies and giving the body healthy choices to move. We want our patients to have options to move and move well. Listen as we go through the clinical reasoning process to determine what types of movement patterns will work and what ones won't. Doing the right thing at the right time is clinical expertise. We have some fantastic freebies on our website www.toughtotreat.com. We have a clinical pearl pdf on the tough to treat as well as sleep tips for persistent pain. Check out our podcast membership www.toughtotreat.supercast.com. It's our podcast plus SO much more. We give you an extra episode per month, only for subscribers, plus an "Ask Us Anything" monthly as well. It's a great way to get some mentoring!

Exercise Progression For Neck Pain And Headaches Jul 28, 2022

This episode highlights exercise progression for a patient with neck pain and concurrent headaches. This elusive driver can often be lost when it comes to exercise progression. Hint: the neck is one of the foundations for the movement system. And just because the neck is the driver, this doesn't mean that you exclude all other regions of the body. Why? Because EVERYTHING IS CONNECTED. We discuss how to design a movement program for both the upper and lower quarter while highlighting the neck. This region of the body does not move in isolation. Involving the eyes is KEY with these types of patients, especially in someone who has headaches. We have talked about this before on other episodes. Vision is often an overlooked part of the head/neck complex when it comes to exercise. Don't miss this.

Hip Pain, Hypermobility, and a Subtle Driver! Jul 14, 2022

Working with a ballet dancer with hip pain, even with a very subtle driver, means continuing to look at the full movement system in its entirety! Regional exercises targeted at the hip may not solve the issue and stretching may contribute further to the problems. Listen to the story, ask questions, and find out where the real issues are! Some pain issues may not show up in the regular human movement, but in meaningful movement within the requirements of the performance. Join us as we discuss this unique case, how the issue was explored and interventions applied. Hint, what do retest and resets do for independence for this athlete.

A glance at this episode:

[3:28] Overview of patient
[6:29] Assessment of the patient
[16:02] Test/Retest
[21:32] Progressing the driver by loading it
[25:22] Reset exercise to empower the patient

Related Links:

Reframing The Narrative For A More Effective Assessment Jun 30, 2022

Can you find clues in your patient's narrative that will help you find the driver quicker? Make your assessment more efficient and save you time? Think about someone's movement and injury history and how that can be relevant to their current symptoms. Their initial injuries will SET THEM UP for compensatory movement patterning down the road. There are 2 case examples in this episode that highlight the importance of how the movement and injury histories revealed the driver(s).

A glance at this episode:

[2:53] Case topic 1 - Past movement history
[4:37] Patient study example
[9:33] What to assess
[15:12] Case example 2
[17:38] What to assess

Related Links:

Choosing The Best Functional Movement For Your Assessment Jun 23, 2022

Success=picking the best functional movement to assess with your patient. Can you imagine shaving minutes off of your initial evaluation time? And at the same time, connecting with your patient in a way that not only increases the therapeutic alliance but will help you find the driver quicker.

A glance at this episode:

[1:21] How to assess functional movement patterns that have meaning for your patient
[2:45] How do you know if you’re feeling pain
[3:50] What are you doing when you’re sitting
[5:58] The purpose of the exercise to help the patient connect to the movement
[7:30] The power of the lower quarter as a potential driver
[10:39] When you need to get the patient involved in the process
[12:09] Why looking at their compensation is important

Related Links:

Junior Golfer with an Unusual Source to his Knee Pain Jun 16, 2022

Erica and Susan discuss in this podcast how treating the left hip as well as the left side of the low back, got rid of this young golfer’s knee pain. A functional and interactive evaluation really hones in on where the true source of his knee pain lies.

Assessing center of mass (COM) here is crucial. Think about golf, you don’t need a wide stance. Most of your patients will look different depending on how wide or narrow their stance is. Don’t miss it.

We also discuss the concept of picking a “meaningful” movement to assess with your patient. This alone will help you hone in on the driver quicker.

Did you know that right knee pain can be caused by an imbalance in your center of mass?

This is a rebroadcast of a popular earlier episode.

A glance at this episode:

[1:24] Introduction to the driver and knee pain
[7:54] The story of a golfer with knee pain
[15:25] The expectation
[20:09] Why you go right into the sport-specific problem
[26:56] The power of videotaping people in motion
[34:39] Recognizing left and right sides of the body
[37:16] Mirror box
[46:41] Why the need to reinforce
[50:30] Trying something new

Related Links:

Myth Busting - Rethinking Pregnancy Related Pelvic Girdle Pain May 19, 2022

There is usually a ten-year lag from published research to accepted practice in clinical arenas. Pelvic girdle pain in Pregnancy is no exception. Join us as we discuss the most important systemic and movement system presentations that can greatly impact this population. In this episode, we cover unhelpful language, true risk factors, and functional problem-solving for these clients. We also discuss what is really happening in the biopsychosocial approach - and especially why self-efficacy is so important.

A glance at this episode:

[3:30] Background on Pelvic Girdle Pain
[9:34] What language you should be using when working with pregnant women with pelvic pain
[18:43] Do pelvic girdle belts work
[21:16] Sleep is a huge issue
[25:25] 3 powerful questions for pregnant patients
[27:47] The benefit of exercise throughout pregnancy
[32:27] Dispelling the myths about movement in pregnancy
[38:45] Finding out eating habits about your patient

Related Links:

Smart Exercise Progression May 05, 2022

What constitutes an effective and efficient exercise progression? How do you smartly move someone through a movement program targetting their driver? Do not get hung up on someone's symptomatic region if that's not what is driving their symptoms. In this episode 2 cases are presented where their drivers were distal to their symptomatic areas. Categories of movement, neutral to non neutral, as well as unloaded to loaded are discussed with specific exercise progression. Remember: you are building new brain maps here. Variance and clinically reasoning through a smart movement progression will get your patient far.

Smart Exercise Progression May 05, 2022

What constitutes an effective and efficient exercise progression? How do you smartly move someone through a movement program targetting their driver? Do not get hung up on someone's symptomatic region if that's not what is driving their symptoms. In this episode 2 cases are presented where their drivers were distal to their symptomatic areas. Categories of movement, neutral to non neutral, as well as unloaded to loaded are discussed with specific exercise progression. Remember: you are building new brain maps here. Variance and clinically reasoning through a smart movement progression will get your patient far.

CV joints and bladder urgency - is there a connection? Apr 21, 2022

Clients report urgency/frequency and are most often treated with medication and pelvic floor PT. When only a regional approach to the pelvic floor over-recruitment is considered, many of the underlying drivers can be missed. Consider the client on this podcast and join us as we explore how multiple drivers can influence the hypersensitivity of the bladder. Taking into consideration the possibility of a knee driver and a visceral driver (constipation) can only explain one part of the system change. What about other possibilities that can be discovered and explored in the movement exam. (Hint: Lifestyle/work pattern dominance and consequences).

The Foot and Diaphragm- Their Connection To This Skier's Hip Pain Apr 07, 2022

What happens when you take away a compensation? Movement patterns change for starters. But what if these new strategies are not optimal for whatever activity you are trying to do? New sport you want to master? That's where the reality unfolds. Healthy systems need choices and when you take away a compensation or a movement pattern that no longer works (i.e. painful), your brain is forced to develop another strategy. In this episode we talk about a patient from episodes 109 and 110, who has made fantastic gains but started skiing again. He resorted to an old movement strategy which included a non-optimal breathing pattern, over recruiting his diaphragm and ultimately a gripping strategy throughout his anterior chain. Hint: ski boot takes away compensatory foot pattern. We also discuss some great treatment strategies for integrating his foot in a NEW functional pattern so he can gain capacity for higher load activities such as skiing and upright movements where the foot is involved. Check us out at Toughtotreat.com

Persistent insertional tendonopathy - the importance of the systems approach Mar 24, 2022

The movement system is adaptable until there is maladaptation! Why is tendonopathy so difficult to treat? What if straight eccentric loading doesn't work? Join us as we discuss this female client and the unique consideration of the system changes that have led to the development and persistence of her persistent heel pain. Yes, this includes pelvic health and the cervical spine!

check us out at toughtotreat.com

Persistent Shin Pain-Where is the Driver(s)? Hint: Not the Lumbar Spine Feb 24, 2022

Can there be 2 drivers to someone's shin pain? Of course! What is the relationship between them? Are they directly connected? Is there some underlying neurally driven mechanism? Or both? This episode digs deep into why certain positions like sitting in a specific environment versus other sitting positions make him worse. Why would biking be ok for someone and sitting in an office chair not be? Think about that one for a second. Susan and Erica discuss this patient's past movement history which plays a SIGNIFICANT role in his issue. You will have to listen to the episode to see what that is.

The Psoas Triangle Feb 10, 2022

Differentials of common segment's neurology - Join us as we discuss the shared neurology of the T12/L1 region and how this can be a driver to anterior hip and groin pain. We are looking at multitudes of clients that show up with various aspects of what Erl Pettman discusses in his work of the psoas triangle.

Designing Exercise Progressions For The Tough To Treat Jan 27, 2022

How do you design a sound, clinically reasoned exercise progression? Taking into account multiple drivers? If someone has low back pain, do you give them core stability exercises? I hope not, unless they have an abdominal wall deficit! In this episode Susan and Erica talk about a patient from episode 81 and what constitutes an approporiate exercise progression for someone whose drivers were in his foot and thorax. They go into detail the various categories of exercise and how you would clinically reason giving one exercise over another. Link to episode #81-https://toughtotreat.com/81-elite-soccer-player-with-low-back-pain/. Join our new Premium Podcast Club: toughtotreat.supercast.com

Persistent Pubic Symphysis Pain/Right Anterior Hip Pain Jan 13, 2022

10-20% of women with pelvic girdle pain in pregnancy will persist into the post-partum era. Join us as we share a discussion on the history that led to the eventual battery of relevant tests/measures and interventions that were not only meaningful to the client, but also were achievable in her very busy time of life with small children. Join our new Premium Podcast Club: toughtotreat.supercast.com

Does the Elbow Always Drive Elbow Pain? Dec 30, 2021

A fall on an outstretched elbow (FOOSH) with resulting elbow pain. Not your typical overuse or mechanical injury common to this region of the body. What happens when your differential diagnosis leads you somewhere else? Susan and Erica discuss the backbone of the initial assessment as well as treatment specific strategies that will help you get these patients better quicker. They also relate some great clinical pearls behind coming up with a hypothesis as to why elbow pain can be driven from another region of the body. Join our new Premium Podcast Club: toughtotreat.supercast.com

A Case of Lateral Hip Pain Dec 15, 2021

Consideration of lateral hip pain requires a thoughtful clinical reasoning process to discover the physiology/movement patterns as well as neural contributions required to make a diagnosis and successfully build an intervention that lasts. One size does not fit all - join us as we discuss the findings in this "not so unique" case and the discovery of the underlying movement patterns, impairments and why lateral rotator strengthening is not always the answer.

Join our new Premium Podcast Club! For details click here: toughtotreat.supercast.com

5 Symptomatic Regions Of The Body With One Main Driver- Part 2 Dec 02, 2021

After listening to Part 1 of this case (episode 109), how would you design an exercise progression? Remember you need to find the driver first. Designing a movement program based on this patient's symptoms would NOT work, as his driver(s) lie elsewhere. Once you are confident you've found it, think about the impairment. Does he have an overactive superficial system or underactivity somewhere else or both? Sound clinical reasoning dictates that you need to downtrain the old strategy first. Listen as Erica and Susan finish their discussion on where his driver lies and how you would design an effective treatment session as well as a sound exercise progression.

5 Symptomatic Regions Of The Body With One Main Driver Nov 18, 2021

What happens when you have 2 regions of the body that when treated together give your patient the best movement options and no pain? But, when they are treated separately, not only is the patient worse, but their movement lacks coordination and ease. This episode highlights someone who has over 5 regions of the body that are meaningful and symptomatic. Literally from head to toe! Listen as Erica and Susan discuss in Part 1 of this case, how you can differentiate between these regions to effectively design an effective treatment session and a sound exercise progression. Of note, take away the compensation and see where the real work begins!

Check us out: Toughtotreat.com

Complex Persistent Pain - Part 2 Where is the driver? Nov 04, 2021

Do you have thoughts on the driver from part 1? In part 2 we take you through the discovery and clinical reasoning parts to determine the primary driver for this client's symptoms. For intervention - think of the easiest steps to begin to find a way into the system to make large changes. Listen in as Susan and Erica discuss how symptoms can be present in various positions but can be changed through focus on the one major system here.

Check us out: ToughToTreat.com

Complex Persistent Pain - Part 1 Where is the driver? Oct 21, 2021

We always discuss history and relevant events. In this episode we take a deeper dive into all aspects of the story in the BPS lens. Join us for our discussion on the importance of uncovering significant historical peices regardless of the referral or medical diagnosis. You have an opportunity to put on your clinical reasoning cap with us as we set up this clinical case in Part 1!

Check us out: Toughtotreat.com

Persistent Unsolved Hip Pain Oct 07, 2021

Does all hip pain require strengthening? Of course not! And certainly not in this persistent case. This episode shows you the importance of digging deep into the history and really learning how to connect the dots. From the way the patient walks and what that means for symptom provocation to exposing the vestibular system as a potential driver. Other candidates include the foot, thorax and neck. Listen to find out how Susan and Erica problem solve together to come up with other ways to assess and treat this interesting patient!

Check us out: taughttreat.com

Nociplastic Pain and a Visceral Driver Sep 16, 2021

What do you do when a client presents with a myriad of LQ symptoms without a clear regional driver? Look to the history and keep asking questions even further back than the recent onset or episodic flare. Join us as we discuss complex neurology of a visceral driver that has signs of dysfunction and a somatic pain presentation. Once again, the history is so important!

Check us out: toughtotreat.com

"X" Marks The Spot-Navigating The True Source Of Shoulder Pain Aug 26, 2021

Save yourself time by learning how to find the driver quicker. This is the case of a neck driven shoulder- but not in the way you think! Do all shoulder patients need strengthening? Not really. We talk about how to hone in on the impairment and narrow the assessment down to a few movements that will help you successfully clinically reason through most upper extremity issues. We also discuss novel ways to give your patient a home program based on their impairment, the smart way.

Check us out: Toughtotreat.com

Complex Ankle Sprains - What is Missing? Aug 12, 2021

Ankle sprain rehab can seem so straight forward - decrease swelling, improve ROM and strength - right? Wait, why are a good number not improving and returning to previous activities? Once again, the client's story and history can really lead us further into the complexity of the foot/ankle joint and all of the systems that need to be considered in returning this region to full function. Clinical Pearl Alert - Neural tension from the cutaneous nerves!

Check us out: Toughtotreat.com

Treatment Progressions for the Tough To Treat- Clinical Pearls Jul 15, 2021

Clinical pearl alert! This episode tells the story of 3 patients and their treatment progressions. Typical symptoms but atypical drivers. What types of exercises do you prescribe for your patient when their symptom is in their feet and their driver lies in their thorax? What is their impairment? This is a discussion of how you would SPECIFICALLY treat and develop a well thought out exercise progression. Using your clincal reasoning doesn't stop with assessment.

Check us out: Toughtotreat.com

SI Joint Pain - An Updated Approach Jul 01, 2021

Here is the clinical story of a client that is presenting with pain/sensitivity in the area of the (R) posterior pelvis. In this episode we discuss what has been unhelpful for her with regard to past interventions and why the biospsychosocial approach and creating the therapeutic alliance is so important to give her the ability to improve her movement system. Meaningful activities, violating expectations and movement system changes were key to her healing journey.

Check us out: Toughtotreat.com

What To Do When Your Patient Plateaus Jun 17, 2021

What do you do when a patient plateaus? Doesn't improve? Join us for our first Q and A broadcast on how to clnically reason through a patient's treatment program when their progress starts to slow down. We discuss a specific patient example and what constitutes a solid progressive exercise program. This also includes reset exercises to restore optimal motor patterning so she can identify what movements are hindering her progress and what she can do to get herself out of a flare up.

Check us out: Toughtotreat.com

What To Do When Your Patient Plateaus Jun 17, 2021

What do you do when a patient plateaus? Doesn't improve? Join us for our first Q and A broadcast on how to clnically reason through a patient's treatment program when their progress starts to slow down. We discuss a specific patient example and what constitutes a solid progressive exercise program. This also includes reset exercises to restore optimal motor patterning so she can identify what movements are hindering her progress and what she can do to get herself out of a flare up.

Check us out: Toughtotreat.com

Clinical Pearls for the Shoulder-Understanding the Connections in the Upper Quarter Jun 03, 2021

Join us for a special episode on the shoulder. This is a re-release of one of our most popular episodes to date. As a bonus, we present 3 case studies of patients with typical shoulder pain who have different drivers and certainly different exercise programs. Sometimes the key to helping a patient's persistent shoulder pain is looking at all of the underlying inputs into their system. What are the connections in the upper quarter? How do they relate to the patient's meaningful movement?

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The Key To Functional Movement Assessments May 20, 2021

Join us for Part 2 of our discussion on functional movement patterns. How can you make your assessment more efficient and reliable? We discuss what to look for when evaluating someone's ability to move in and out of certain movements. How do you determine if a dysfunctional foot is driving your client's hip pain when squatting? Or if poor thoracic control is responsible for low back pain when assessing someone take a step forward? We discuss some basic movement patterns and how to break them down so you as a clinician can hone in on the driver quicker.

"Why Does My Foot Hurt? What's Going On?" May 05, 2021

Why would someone who is 3 months post fibular fracture get worse after a basic theraband ankle exercise? Not everyone needs inversion and eversion theraband exercises. Right? This is an in depth clinical discussion on understanding the "why" hidden in the patient narrative. And a specific process on how to assess the whole foot and not just the ankle. We also discuss why this patient's center of mass is biased TOWARDS her INVOLVED side and what implications this has for treatment.

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Musculoskeletal Driver of Hip Pain in a Young Dancer Apr 22, 2021

When working with young athletes it is easy to have early success in treating the acute or subacute injuries. What happens when the latest injury reveals a very chronic situation elsewhere in the body? Don't be fooled by generalized and chronic complaints underlying the present situation in these teenagers. They may improve quickly in one respect, but looking deeper can help them improve adaptation strategies that will help further down the road and even alleviate a chronic situation. Join us as we discuss the chronic MSK driver to hip pain irritability in this young athlete.

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The Knee and its Relationship to the Whole Person Apr 08, 2021

How does the knee affect so many parts of the body? Join us for this discussion on this important intermediate joint of the lower kinetic chain and how dysfunction here can alter the movement system for the whole person.

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Chest Pain In An Endurance Athlete Mar 26, 2021

Does chest pain raise your eyebrows? Red flag? Or wild goose chase? This case is an insight into a classic endurance athlete and how his past injuries reveal a true deficit which can be the potential driver for his current symptoms. These symptoms that only occur 3-4 hours after a bike ride. We discuss viscero-somatic cross talk, the cardiac sinus and its biomechanics as well as a how to start treatment in someone who has many moving parts!!

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Shoulder Pain and Distal Drivers Mar 11, 2021

This episode features a case of shoulder pain with unusual drivers due to their distal proximity. Join us as we discuss this interesting clinical case on a very active man with chronic shoulder pain, fear avoidance, anxiety and some unique clinical reasoning to help him recover!

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Not Your Ordinary Knee Patient Feb 25, 2021

What do you automatically think when someone tells you they have knee pain? It's worse with walking SW and walking FW. And the patient cannot sleep sidelying because his knee hurts when he sleeps on either side. He can squat no problem. Are you thinking what we're thinking? Susan and Erica unpack this patient's story and dive into specific hints or cues that the patient gives to indicate that it's more than just the knee. Treatment? Well, that depends on the driver, doesn't it? The most important piece and message in this episode is the clinical reasoning behind why this may not be your ordinary knee patient.

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Thoracic Mobility Beyond The Breath Feb 22, 2021

In this episode Susan and Erica discuss the many ways the thorax can be the driver for a multitude of upper and lower extremity issues. This important region of the body tends to be the cause for a lot of movement dysfunction we often see. As an example, the thorax is an important component in driving foot pain as well as issues in the pelvic girdle. If you can get the thorax moving differently, this can help people out of old movement patterns that do not serve them and restore global movement patterning across many tasks.

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Ankle fracture rehab - what is missing? Jan 28, 2021

As health care providers and rehab professionals, there is the story that ankle fracture rehab is simple. Makes sense right? A regional intervention over an obvious acute traumatic event. But what is missing and why do so many individuals recovering from this injury (post-surgical) are having difficulty months and years down the road? Join us as we explore the Biopsychosocial approach to this individual who felt her rehab care was dismissive to her real fears and complaints. How to navigate the waters when peripheral symptoms migrate to central sensitization. Of special interest here is where the secondary driver actually becomes the primary driver!

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Does Hip Pain Always Come From The Hip? Jan 14, 2021

When someone complains of persistent hip pain, what do you think? Is the source the hip? It may be the pain generator but at this point, is the primary reason why they have hip pain because of some dysfunction intrinsic to the hip? Most likely not. Simple example- right persistent hip pain with going up stairs and standing on one leg. In standing, all their weight is on the right leg, why? Probably because of an old injury to their left side or an ingrained movement pattern they have adopted over the years. At any rate, they have lost options for movement and their left side cannot adapt, so they over use and over recruit their right hip, as a possible scenario. Listen for more!

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The Shoulder Is Connected To Everything Dec 31, 2020

Join us for a fun discussion on the relationship of the shoulder to the rest of the body. Learn about all the connections between the shoulder, the cranium, the neck, the upper thorax and much more! Did you know that an old clavicle fracture on your left can be responsible for right shoulder pain?

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Double Vision Post Partum, Cause or Effect? Dec 17, 2020

Tune in for an interesting discussion on a woman presenting with complaints of double vision 8 months after the birth of her third child. A coincidence? Maybe, maybe not. Either way, it needs to get addressed. Is this dural? Trigeminal wind-up? Listen in for the clinical reasoning process as well as some novel treatment techniques that worked. Check us out: Toughtotreat.com

Neural Tension and Beyond Dec 03, 2020

Can neural tension be responsible for a tight hip? Absolutely! Would you believe that neural tension in the right hip can be responsible for left hip pain? Listen as Susan and Erica discuss the many possibilities of unsolved persistent pain. They also discuss several cases where neural tension plays a role in many typical musculoskeletal issues. Check us out: Toughtotreat.com

Neck Pain/Back Pain - Where Do You Start? Nov 19, 2020

Finding clients with subjective pain in the low back and cervical region is not an uncommon presentation. The bias is to treat the most acute region and hope the other region gets better as a result. What happens when you look closely at the story, listen to the client and find a very unlikely driver of maladaption in this clinical case? Join us as Susan and Erica unravel this clinical presentation and align the intervention with the client's goals.

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How To Master Functional Movement Assessment Nov 05, 2020

Functional movement re-patterning is the key to changing someone's movement strategy. But how do you choose the right one, so you are more organized and efficient in your assessments? And how can you clinically reason so you can hone in on one area to get better results? Understanding the inter-regional relationships in the body as someone moves may be the game changer for you and your client. How does the foot relate to the shoulder as you squat and reach over head? How does neural tension affect your ability to perform a narrow based lunge or squat? Listen in as Susan and Erica discuss this and much more!

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Training the Tough To Treat Shoulder Oct 22, 2020

How many neck problems are really disguised as shoulder issues? A lot actually! It is extremely common to overwork some of those small muscles of the neck at the expense of a true shoulder weakness. And why is traditional cuff strengthening not always the way to start with these patients? Listen as Susan and Erica do a deep dive into this patient's underlying issue and discuss various ways to bridge the gap between early phases of exercise to higher loads. What positions do you start with? How can you provide neural input into the system without aggravating symptoms? Check us out: Toughtotreat.com

Pelvic Pain - Things Are Not Always As They Seem! Oct 08, 2020

Don't let the diagnosis be your guide, listen to the whole story, and be curious outside of pattern recognition. Is the original thought about the case straight forward. Or is it as Sherlock Holmes says: "When you have eliminated the impossible, whatever remains, however improbable, must be the truth?". Have you indeed eliminated all of the impossible? In this episode, we discuss the reasoning behind this client who has a complex presentation of symptom progression following a traumatic accident. Join us as we explore the nuances of "test-retest" in this case study.

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Elite Soccer Player with Low Back Pain Sep 24, 2020

Why can't this athlete get rid of his low back pain? "Running- I have no problem with" "Lateral-side to side-movements really aggravate me". " Why?" How do we make a differential diagnosis here? And with significant unilateral calf weakness to add into the mix. Four ankle sprains and a 4th metatarsal fracture later, plus a "stress reaction" at L5, why wouldn't his low back be the source of his problem? Join us as we clinically reason through multiple facets of his case. Check us out: Toughtotreat.com

Full Squat vs. Partial Squat? Sep 10, 2020

A recent article on various depths of squats revealed information that a full squat is more beneficial than partial squats in improving function and pain over time. Have a listen as we explore interesting comments/bias/evidence on why we rely on the squat as a revealing part of our examination and interventions.

Follow link: https://www.tandfonline.com/doi/abs/10.1080/17461391.2019.1612952?journalCode=tejs20

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Medial Elbow Pain and Tingling/Numbness Aug 27, 2020

Another case with elbow issues! This case involves neural tension, pins/needles, and catastrophization. What is the best way to begin to work with someone who has multiple issues around fear of neural symptoms without neuro changes? Join us as we discuss dosing, position changes, problem solving and fear reduction in this interesting case.

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Demystifying Tennis Elbow Aug 13, 2020

Tennis elbow is one of those conditions that is extremely frustrating for both patient and practitioner alike. It turns into a persistent problem very fast. This was another one of our popular FB Lives we did recently. We unpacked the myths and theories around tennis elbow and what to do to treat it. Is it neurally driven? Cervical Spine driven? Does it emanate from poor shoulder mechanics? Or does it come from poor thoracic control? The key word here is "myths". Your pain generator may be the elbow, but the longer it persists, the driver(s) behind this frustrating problem migrate away from the elbow pretty quickly. Where do they go? Check us out: ToughtoTreat.com

Runners With Recurrent Knee Pain-Finding The Driver Jul 30, 2020

We all have patients for whatever reason, who always come back for the same problem over and over again. Even if they haven't been back for over 5 years. Our bodies tend to take the path of least resistance and more often than not, when someone has fully recovered and they're back doing what they want, something happens and they return with the SAME problem in the SAME place. Why? Is that their achilles heel, so to speak? Or has their strategy changed because of something new in their life?

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Exercise progressions for the tough to treat foot Jul 16, 2020

Your client has low back, hip, or pelvic girdle pain as examples, and you determine that the foot is the driver for these symptoms. What types of exercises would you prescribe to get them back to where they want to be? This is where you take the clinical reasoning to the next level! Whether it's loaded or unloaded, movement re-patterning requires you to really "connect the dots" in the body when it comes to moving someone through a sound exercise progression. This was initially recorded as one of our popular FB lives and we decided to share it as a podcast as well!!

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Are patients really good historians? Jul 02, 2020

What happens when your patient/client forgets to tell you key pieces to their history? It happens alot - and sometimes can have great impact on our decision making within the evaluation or treatment sessions. It is not their fault, it is just the way the central nervous system prioritizes events. Helping our clients remember and string these events together can not only help them solve their problem, but might be just the piece they need to integrate for healing.

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Does scapula stabilization always work? Jun 18, 2020

This episode is about a weightlifter who suffered a T1 avulsion fracture, had surgery to remove the fragment and still had symptoms. Why? Because the avulsion was not the cause for this patient's lingering symptoms. Neuromuscular holding strategies as well as poor motor patterning were still there post-operatively. Think about what a weightlifter does before he performs a heavy lift and it will give you a clue as to what we needed to change.

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Post-partum back and abdominal pain - what is the priority? Jun 10, 2020

Let's continue with the 3 powerful questions in determing the direction and priority of intervention. Immediate post-partum females can present with a myriad of complaints that often go "unheard" or "untold". The fears surrounding these symptoms can greatly change the person's ability to move forward with confidence in their body and their ability to achieve their life vision. Join us as we explore simple, but powerful ways to help this individual change her beliefs and tackle her fears while gaining confidence in her movements.

Herniated disc? Or Fear of sitting? May 21, 2020

What do you do when your patient tells you she has not sat for 9 months? And furthermore, a healthcare practitioner told her this! How do you "debunk" this myth of not sitting while at the same time give her body the ability to toelrate sitting postures? Imagination, contextual change as well as letting the patient take control of the session. What? The patient takes control? Listen as Susan and Erica talk about giving the patient new and novel ways of movement while at the same time changing the patient's unhealthy belief that sitting is bad for you.

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Pelvic girdle pain and the BPS approach May 07, 2020

What are your three powerful questions that you use with your clients? Join Erica and I as we talk about working with clients from a full biopsychosocial approach. Does this mean all you do is pain education? How do clinicians best use the total approach to help clients regain self efficacy and manage their symptoms. There are also some great pearls around pelvic girdle pain in pregnancy as well.

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I Hurt Everywhere Apr 23, 2020

Who hasn't heard this? This patient was seen in the clinic once just prior to the COVID-19 crisis and then progressed virtually from there. When someone says, " I hurt everywhere" and their symptoms appear randomly, how do you find a meaningful movement to assess? In particular, one that encompasses the whole body/whole person. Not an easy task, for sure, especially for someone who has significant amounts of anxiety related to movement and exercise. And with a past medical history of concussion, trauma and failed treatments. Listen as Susan and Erica take a deep dive into what is really going on here.

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Chronic Achilles Insertional Tendonosis Apr 09, 2020

What do we really know about the achilles tendon and the various forms of tendonosis? What do you do when the eccentric exercise programs outlined in the literature do not bring about a significant change of symptoms? Join us to explore some of the facets of tendonosis and a clinical discussion on changing interventions.

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Higher Load Exercise Progressions and Secondary Drivers Mar 26, 2020

Success-your patient's original symptoms are gone and you are moving along with their program. They are progressing to higher loads, higher impact as well as incorporating tri-planar movement into their exercise. Then another region of the body starts to hurt. Why? Secondary and even tertiary drivers can appear at higher loads; even when they do not appear at the beginning. Be aware of this as your patient progresses. Susan and Erica discuss this fun case as they paint the clinical picture and offer many options for treatment.

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Foot numbness - differentials and interventions Mar 12, 2020

Have you ever had a patient where the story and the problems they were having were easy to solve, but your thoughts were - "It can't be this simple?" Follow along with us as we discuss the differentials and treatment of a gentleman with numbness on the balls of his feet. It may not be what you are thinking - and then again, maybe it is!

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5 years Post-Partum with Persistent Low Back Pain Feb 27, 2020

This patient has had low back pain since she was a child. She has coped well until the birth of her own children. The innate response to threat here is the inabillity to arch her back. Her system cannot lengthen and she cannot do a back bend or sit and perform an anterior pelvic tilt. But she can get into prone on elbows and extend no problem. Post-partum is ALWAYS post-partum and her standing strategy is reflective of this.

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Heel pain - is it always a MSK issue? Feb 13, 2020

What goes through your mind in pattern recognition when you hear the word heel pain? What do you begin to think - and then their story actually does not reflect the functional limitations expected. Join the co-hosts as they discuss the impact of multimodal issues that could be affecting this clinical presentation.

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Butt pain-where's it coming from? The low back? Hip? Pelvis? Jan 30, 2020

One main symptom but 3 potential drivers. Is this person's glute pain coming from his hip? Low back? Pelvis? In this episode Erica and Susan discuss the differential diagnosis of a patient's butt pain which gets worse with sitting and driving. They discuss how multiple exam findings can lead you to one diagnosis but when all the pieces of this clinical puzzle are put together, a different story appears.

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063: Hip arthritis! Update from #37 Jan 16, 2020

What do you do when you run into a true hip joint limitation with persistent pain. altered patterns of movement and loss of the closed pack position? Join us as we explore the update of the female injured on her boat in Podcast #37 - what has improved, what has changed! Most importantly - how to help someone really work a new movement pattern and achieve ROM/Mobilization in some non-threatening ways!

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062: Persistent shin pain & a lateral shift-implications for gait Jan 02, 2020

Is a lateral shift a reaction to an irritated nerve root? Or is it part of a functional scoliosis? Or neither? This patient experienced persistent right shin pain with prolonged walking. A year ago she noticed a significant shift in her pelvis to the right. This episode highlights the importance of identifying the non-optimal movement strategy and prescribing exercise to correct it. We discuss how to re-pattern her movements with a focus on the "why" she moves a certain way vs just training a muscle in an isolated non-meaningful exercise.

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061: Back pain, stiffness and the search for the cause! Dec 19, 2019

What happens when you are an athlete and have endured many injuries in your life that have all healed, and now you have a back injury that is stubborn and is now a persistent pain issue. Compound this issue with a diagnosis of a torn lumbar ligament and the thoughts of instability/grinding joints/bone on bone and other thoughts take over the movement system. Join us as we explore some strategies and option for changing fear and moving in novel ways.

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060: Changing symptoms- a motor control problem or something else? Dec 05, 2019

We have all been through this-as providers or patients. One day your low back hurts on the right, the next day it's the left, and 2 days later it's your right hip and the saga goes on and on and on. Why? Is it because there is a movement control problem and you are just running out of options? Or is there perhaps another systems impairment that is contributing to all of this? Join us as we clinically reason through a male patient of Erica's who is experiencing these symptoms. Hormones are not just the domain of the female.

More information at www.toughtotreat.com

059: Stress urinary incontinence - muscle weakness or load transfer? Nov 14, 2019

What flashes through your mind with a diagnosis of SUI - muscle weakness? That is certainly one hypothesis! Listen in on this episode where we explore another client with a "systems" problem that is much more involved than just simple pelvic floor muscle exercises.

More information at www.toughtotreat.com

058: Foot pain of questionable origin Oct 31, 2019

Failed epidurals, back surgery and you still have buttock pain along with foot pain. Why? We all know back surgery is not always the answer, but why would someone's symptoms persist after all these interventions? Why would walking barefoot in the sand make this person feel better? Is the strategy different or is the nerve root still aggravated after all these interventions or both?

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057: Elbow pain or cervical? Oct 17, 2019

Join us on this podcast as we work through the differentials of this complex post-partum client with the onset of elbow joint pain. Issues that have become so problematic, it's interfering with her sleep. Is it the elbow or the cervical spine - or neural tension?

www.toughtotreat.com

056: Is this patient tough to treat? Oct 03, 2019

How does someone who has had 4 sessions of PT somewhere else become complex? The answer: She got the wrong treatment. And what happened? It sensitized her nervous system to the point that she was afraid that she was never going to get better. Ever hear of less is more? If you intervene at the right time with the right treatment, less is DEFINITELY more.

More episodes at www.toughtotreat.com

055: Back pain or leg pain - why is it getting worse? Sep 19, 2019

Explore the narrative of this client with persistent hip and leg pain for over 20 years. In this episode we explore the behaviors and mitigating factors that have increased the symptoms and are slowly turning this person with confronter behavior into an avoider. Sometimes the small changes can have a huge impact.

Find out more at www.toughtotreat.com

054: Leaking and Running - A solution Sep 05, 2019

You have not run in over a year because of a foot and hip injury. Finally, it's all coming together-you have less hip pain and your foot pain has been gone for weeks. You are cleared for a return to run program and then after 2 minutes into it, you leak. Does this sound familiar to you or your patients? In this episode we bring in the patient who has these symptoms. This is a rare glimpse into "real time" clinical reasoning. We highlight some unique treatment ideas as well as provide the patient with a strategy she can tap into when she does leak.

Physical Therapy with Tough To Treat hosts Erica Meloe and Susan Clinton

053: Is an overactive TFL a poor movement strategy? Aug 22, 2019

Your patient cannot sit and cannot squat in the gym without lateral hip pain. They believe it is their overactive TFL. But is it the cause of the problem? Most likely, it is NOT. Why would someone have increased tone in a muscle? Think about a movement pattern where someone's center of mass is shifted to one side because of an old contralateral foot injury? You injure your foot and you weight shift off of that side where you stay that way for YEARS. Until one day, you run out of options. Sound familiar?

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052: A shoulder or a neck problem - what is important to the patient? Aug 08, 2019

Shoulder pain - or neck pain? Does it really matter to the intervention? What does the client believe and expect? How do you manage client expectations in this scenario? Join us in a rich discussion about this client's self-efficacy and managing expectations while reducing fear. Sound clinical reasoning shows you the value of asking the right questions to guide you in your treatment. www.toughtotreat.com

051: Is it really the nerve root? Jul 25, 2019

Searing shin pain, low back pain, night sweats, unable to sleep or walk-is it the disc? The nerve root? A sensitive nervous system? Or something else? Or all of the above? Join us as we make a differential diagnosis on this gentleman's problem. Once again, listening to his story will give you clues as to how to begin the objective exam.

Find out more at www.toughtotreat

050: Finding the real story through the narrative Jul 04, 2019

Do you ever wonder if there is a better way to evaluate the complex patient? What do you do when the body diagram is full with a long history? I think we all are used to hearing our client's stories - but do we really listen to their full narrative? This can be the key to finding out what's important to them and sometimes, the simplest solution is revealed through their story along with the physical exam. Have a listen to this story and the key components!

Sign up for our newsletter at www.toughtotreat.com We have some awesome free PDF's on assessing and treating complex patients!

049: Game Changing Exercise Progressions Jun 20, 2019

Do you want better outcomes with your patients? What do you do when a patient has plateaued? Or they're not improving as fast as they should be? One of the answers could be your exercise progression. Are you truly treating the source of the patient's problem with a specific movement program geared towards the SOURCE and NOT the symptom? What is the key to effective exercise progression? In this episode, Erica discusses what has been a real game-changer in her practice. That is: appropriate exercise progression for common drivers that she sees. She shares clinical pearls from her caseload and tools of the trade that have really helped her.

Visit our website: www.toughtotreat.com

048: Complicated thigh numbness-is it really the nerve? Jun 06, 2019

What happens when someone's thigh goes numb and does not go away? The nerve is obviously angry but what is the driver? What could possibly cause someone's thigh to go numb? Do hormones play a role in this case? Is it hypermobility? Is it the foot? Susan and Erica discuss all the possibilities for this particular patient's presentation and present SPECIFIC movements/exercises that the patient will do in order to calm that thigh down.

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047: Fear avoidance with low back & pelvic pain May 23, 2019

Low back pain - the need to stretch and fear avoidance complications. What happens if the movement or postures you believe to be good are really problematic? We have delved into low back pain and the constant need to stretch, but sometimes it can also become more complex due to our thoughts and beliefs. Here are some good strategies for helping someone move and confronting their beliefs.

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046: Leg pain and peripheral nerves May 09, 2019

What happens when someone suffers a traumatic injury, then lives with it for 8 months? Listen to this episode and find out. Susan and I discuss a former patient of mine who lived with hypersensitivity, bruising and swelling in her lower limb for months!! Think about what that does to your system? We also discuss developing a hypothesis/diagnosis based upon the subjective history. It is something we should do with every single patient. That is what makes you an expert. Furthermore, what happens when a patient's objective signs are worse after your treatment? I mean, right after, before they leave your office. We give you some tips and strategies to avoid this situation and give your patient a much better outcome.

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045: Female with bilateral hip pain? Is it really a hip joint problem? Apr 25, 2019

Join in on this differential diagnosis and use of evidence to help determine the underlying cause and progressive movements to help this very strong and resilient female overcome nagging hip pain for over 5 years. Pain can be complex and contextual, it can also have a metabolic component as well. Consistency is the key to addressing her issue and progressing her program.

Visit our website at www.toughtotreat.com

044: Dancer with Pelvic Pain-Is it Really the Pelvis? Apr 11, 2019

Does this dancer with persistent left-sided pelvic girdle pain need to have her SI joint manipulated all the time? The answer is an obvious no! In this episode, we discuss how a professional dancer was able to get rid of her pelvic pain by looking up the chain. Remember- it is the movement strategy that counts. Digging deep into the demands of her performance, was the key to finding a solution for her. We also address the relevant exercise progression. If the symptom is the pelvis and the cause is somewhere else, how would you design a movement program for her? Listen and find out!

Visit our site at www.toughtotreat.com

043: Neurogenic pain and complex metabolic issues Mar 28, 2019

This episode features a gentleman with complex metabolic issues, neurogenic pain and an interesting cross-section of mechanical MSK issues. Join us as we sort out the history and discuss the treatment interventions based on his unique story and the best way for him to function.

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042: Complex issues with pain and fear avoidance Mar 14, 2019

Tough To Treat Masterclass: In this episode we have guest PT, Alaina Newell, who presents us with one of her tough male patients with a primary complaint of abdominal issues. Sometimes what our patients present with is only the tip of the iceberg. We clinically reason through the evaluation but move very quickly into diagnosis and movement. It is interesting how the story of this complex case unfolds over time. We brainstorm some great treatment ideas and various ways to change this gentlemen's fear avoidance. This is a fascinating story that can teach us all a lesson that healing is very individual. Visit our website at www.toughtotreat.com

041: Not Your Ordinary Hip Problem Feb 28, 2019

What do you do when your patient tells you that she hurts everywhere? In this episode, Susan and I discuss a patient with an EXTENSIVE injury history who happens to be a runner. Do these compensations over the years end up being what is the root cause of the problem? Or are there some cognitive and emotional barriers to recovery? The main issue here is hip pain. This is not your ordinary hip issue. Subjective includes, "ripping", "burning" and "a dead leg". Does the pelvis play a role? The foot? An old clavicle fracture? Listen and find out!!

Visit our website www.toughtotreat.com

040: Is spinal stenosis a mystery? Feb 14, 2019

Tough To Treat Masterclass: In this episode we have guest PT, Daria Oller, who presents us with one of her tough spinal patients. Is spinal stenosis a mystery? Not really.... We clinically reason through the evaluation but move very quickly into diagnosis and movement. We brainstorm some great treatment ideas and various ways to change this gentleman's compromised movement pattern. And it's not just the physical, this person has a significant fear based component to his problem, which can potentially prolong healing.

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039: Left sided pain and tightness in a professional dancer Jan 31, 2019

Professional dancers tend to push through tightness, discomfort and pain. Not surprising! Often times the care they seek does not really address the driver(s) of their symptoms. More often than not, it is treat the painful part and move on. That is not a recipe for long term relief. Listen to this girl's story and see how we evaluated and addressed her symptoms. Sometimes less is more.

Visit our website www.toughtotreat.com

038: What is the real cause of her elbow pain? Jan 17, 2019

Does elbow pain really emanate from the elbow? Sometimes it does. But the longer people wait to seek help, the higher the likelihood there is another driver. And therein lies the challenge. Join us as we clinically reason through this patient's elbow/arm pain and the ensuing treatment progression and exercise prescription.

Visit our website: ToughtoTreat.com

037: Hip and back injury at Sea! Jan 03, 2019

What happens when someone gets injured while living on their sailboat at sea? This episode explores the clinical reasoning and intervention process from a virtual platform to help this lady through an unexpected injury to her hip and back and navigating the functions needed on a sailboat.

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036: Shoulder Pain- A motor control problem? Dec 20, 2018

When does motor control come into play when someone has persistent shoulder pain? Is it soft tissue related, a joint problem or a neuromuscular repatterning issue? Or something else? How does our nervous system adjust? In this episode we talk about the multiple sources to this person's shoulder pain and how retraining his arm lift was the key to his recovery.

Visit our website: toughtotreat.com

035: Post-partum pelvic pain and urgency Dec 06, 2018

There are many ways to approach pelvic pain and symptoms of urinary urge incontinence, but did you know that how the MSK system moves can affect these symptoms as well? On this podcast, we take a dive into the movement system, past/present autoimmune history and post-partum process while changing this client's symptoms as well as her urinary incontinence. In turn she regains control over her pelvic pain!

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034: Hypermobility and low back pain Nov 22, 2018

How do you rehab someone who is VERY hypermobile and suffers from persistent low back pain? Carefully and specifically! This episode highlights the beauty of a specific exercise progression tailored to the patient's meaningful movement. Listen as we go through the clinical reasoning process to determine what types of movement patterns will work and what ones won't. Doing the right thing at the right time is clinical expertise.

Visit our website: toughtotreat.com

033: Shoulder pain biomechanical or systemic of origin? Nov 08, 2018

Explore the origin of this client's shoulder pain as we discuss a biomechanical vs. systemic history and how the pain experience had changed her ability to fully participate in life and exercise.

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032: Differential diagnosis of posterior thigh pain in a young female Oct 25, 2018

When a 12 year old comes to you with complaints of posterior thigh pain that is not going away, your radar should go up. Especially, when she presented with knee issues previously which were alleviated within 3 visits. Being a good listener is extremely important; but in this case, being a good questioner provided the answer.

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