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:

How To Assess The Knee Differently May 16, 2024

Show notes

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

Related links:

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

Show notes

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

Show notes

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

Related links:

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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

Show notes

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:

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