Tough to Treat

Latest Episodes:

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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: