Tough to Treat

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**Tough to Treat**

Welcome to Tough to Treat: A Physiotherapists’ Guide to Managing Those Complex Patients, with your hosts Erica Meloe and Susan Clinton, who discuss how they successfully treated patients that others could not. Via case history discussion, they share their physical therapy expertise from treating long standing pelvic pain to persistent neck pain. They present a holistic and integrative view on assessing and treating chronic pain. Unique movement strategies and specific patient exercise prescription are also presented so you can be ahead of the curve when it comes to treating these types of patients. Oftentimes, the source of the problem is not where you think it is!! For example, chronic low back pain emanating from the neck. Or hip pain coming from the foot. It pays to look up and down the kinetic chain!

Podcast music: “Fearless First” Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

Latest Episodes:

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

Show notes

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

Show notes

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

Show notes

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!

A glance at this episode:

[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

Related Links:

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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: