Tough to Treat

Latest Episodes:

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

Show notes

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

Show notes

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

Show notes

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 you'll see positive change.

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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: