Tough to Treat

Latest Episodes:

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

Show notes

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

Show notes

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

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

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!

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

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

Show notes

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

Show notes

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

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Junior Golfer With Persistent Unsolved Knee Pain Jul 11, 2024

Show notes

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

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

Show notes

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

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

Show notes

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

Show notes

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

Show notes

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

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