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 Increase Patient Adherence To Exercise Oct 05, 2023

Show notes

How do you increase patient compliance with their exercise program?

This can be very frustrating for both the therapist and the patient.

In this shortie episode, Erica discusses how she helps keep her patients on track with their movement program.

She often says, "If it's not trialed, then the chances of your patient doing the exercise are reduced at least 10-fold."

What is the goal of exercise?

Ultimately, it's about training the brain and optimizing movement.

You need to get the patient to "buy in". What will they buy into? Results. Plan and simple.

Some of the best results come from a team effort. Establishing a collaboration with your patient and increasing self-efficacy will get them where they need to go.

A glance at this episode:

[1:16] Patient compliance and adherence in therapy
[4:28] Exercises for persistent pain patients
[8:16] Patient adherence to home exercises and individualized treatment approaches
[10:56] Active involvement in exercise programs for better patient outcomes

Related links:

Unraveling the Web of Neuralgia: Navigating the Cervical Spine Sep 28, 2023

Show notes

In this episode Susan and Erica welcome a Tough To Treat listener, Megan Barclay.

Megan brings a case of a patient who continues to suffer neuralgia after a bout of shingles, along with persistent neck pain.

Listen to the client's history, significant findings, and differentials as we navigate this client's journey and discuss relevant findings.

There is also a rich discussion on possible interventions targeting many points of the trigeminal system and cranial region.

A glance at this episode:

[1:25] Neck pain and potential causes and drivers
[8:39] Post-shingles symptoms and treatment
[16:32] Patient's neck and shoulder pain, possible causes and treatments
[24:38] Treating a patient with neck and head issues
[28:55] Pain perception and treatment for cervical and lumbar issues
[30:16] Improving balance and reducing trigeminal symptoms through exercises
[33:31] Treating neck and back issues with physical therapy and nutrition
[41:09] Treating a patient with shingles
[43:28] Shingles treatment and empowerment
[46:12] Exercise and posture for chronic pain management

Related links:

Breath, Voice and HRV as Predictors and Interventions in Pelvic Health - Part 2 Sep 21, 2023

Show notes

Look beyond the traditional regional approach of the pelvic and pelvic floor and understand how discovering and addressing dysfunctions of the trigeminal and respiratory system including the voice and heart rate variability can have an impact on pelvic health.

HRV is a well-researched indicator of the balance between the Sympathetic and the Parasympathetic nervous systems.

The balance has a large impact on the performance of the GI system and can influence pain, motility, and inflammation.

Working with Breath, Voice, and HRV can not only predict dysfunction but is an excellent metric to guide interventions in different domains.

This 2 part replay of a webinar is designed to expand your current practice through evidence-based and biologically plausible methods of examination and intervention into the thoracic, and cervical systems harnessing the breath and the voice can optimize respiratory mechanics and heart rate variability.

A glance at this episode:

[1:22] Why the vascular system is important
[2:55] What happens when we get into chronic stressors
[5:33] Nerves that fire together
[7:30] The trigeminal system and stress response
[10:35] The trigeminal system is the entire sensory system
[12:45] What is referred nociception central sensitization
[14:57] Cervical nerves and the brain
[17:31] Connections to the vagal system
[19:04] Breathing postures and sleep

Related links:

Breath, Voice and HRV as Predictors and Interventions in Pelvic Health - Part 1 Sep 14, 2023

Show notes

Look beyond the traditional regional approach of the pelvis and pelvic floor and understand how discovering and addressing dysfunctions of the trigeminal and respiratory system including the voice and heart rate variability can have an impact on pelvic health.

HRV is a well-researched indicator of the balance between the Sympathetic and the Parasympathetic nervous systems.

The balance has a large impact on the performance of the GI system and can influence pain, motility, and inflammation.

Working with Breath, Voice, and HRV can not only predict dysfunction but is an excellent metric to guide interventions in different domains.

A glance at this episode:

[1:41] Pelvic floor and breathing patterns
[4:12] What is GI dysfunction and why is it so prevalent
[5:41] The diaphragm and coughing and sneezing
8:22] The diaphragm needs to match the demands of the activity
[10:26] The diaphragm position
[12:25] The diaphragm and the chest wall
[15:09] How the diaphragm is connected to the regional nerves and inflammation
[17:21] Psoas as a trunk muscle vs. hip flexor

Related links:

The Mystery of This Man's Struggle With Pelvic Girdle Pain and the Breath Sep 07, 2023

Show notes

In this episode, we dive into the often overlooked and misunderstood world of male health, exploring the complexities of groin pain, the challenges of taking deep breaths, and the impact on his pelvic girdle pain.

The history will give you the answer.

This is a complex case with many parts but listening to his story helps you to prioritize which regions of the body you need to rule out.

Visceral connections are key to this presentation.

Join Susan and Erica as they unravel the potential causes, shed light on some of his drivers, and offer insights to help those facing similar issues.

Don't miss this great conversation that aims to bring awareness to a topic that affects both men and women.

A glance at this episode:

[0:01] Intro to episode and patient
[8:41] Why the patient is experiencing paresthesias along with itching
[11:15] Breathwork and the visceral driver
[15:27] Pelvic floor and the breath
[18:12] Assessing hip pain
[23:53] A head lift and why it brings on his symptoms
[29:52] The effects of decompression on head rotation
[32:28] Yoga and the thorax
[37:08] Down dog and child's pose
[43:11] Finding the driver and the root cause of his problem

Related links:

Shoulder Pain- A Motor Control Problem? Aug 31, 2023

Show notes

When does motor control come into play when someone has persistent shoulder pain?

Is it soft tissue related, a joint problem, or a neuromuscular repatterning issue?

Or something else?

How does our nervous system adjust?

In this episode, we talk about the multiple sources of this person's shoulder pain and how retraining his arm lift was the key to his recovery.

And we mean retraining, the right way.

A glance at this episode:

[7:27] Assessing symptoms associated with cycling
[8:47] The brachial plexus and its connection to hip pain
[12:57] Manual therapy for the shoulder?
[16:25] Drivers of this dominant postural pattern
[18:49] Mechanics of the shoulder joint
[23:52] Recovering the superior glide, why it's necessary
[28:49] Repatterning optimal shoulder movement

Related links:

SI Joint Pain - An Updated Approach Aug 24, 2023

Show notes

Here is the clinical story of a client that is presenting with pain/sensitivity in the area of the (R) posterior pelvis.

A common area of symptoms for many patients. But there are many potential drivers and the need to differentially diagnose is crucial. Why? Because you won't want to miss the hidden connections that are so often present in patients, that when missed, can make the difference between a successful outcome and a patient who walks away unhappy.

In this episode, we discuss what has been unhelpful for her with regard to past interventions and why the biopsychosocial approach and creating the therapeutic alliance are so important to give her the ability to improve her movement system.

Meaningful activities, violating expectations, and movement system changes were key to her healing journey.

A glance at this episode:

[1:35] History of the patient
[5:30] Digging deeper to find the driver
[9:19] Lifestyle changes that work
[15:00] Establishing an alliance to explore fears
[25:30] Making the evaluation meaningful to the patient
[33:23] The reset exercise
[37:33] The problem with a sagittal plane squat

Related links:

Finding Hidden Connections In Functional Movements- Why They Matter Aug 17, 2023

Show notes

In this episode, Erica explores the intersection of functional movement and persistent pain, offering a comprehensive blueprint for understanding and addressing movement dysfunctions that may contribute to ongoing discomfort.

Join her as she discusses her insights and tips with examples from her patient caseload.

Erica also speaks to functional movements that will help you find "hidden" drivers in other regions of the body.

Whether you're dealing with persistent pain or are a healthcare provider seeing those persistent cases, this episode equips you with advanced clinical reasoning knowledge and tools to create a solid assessment so you don't miss important connections.

A glance at this episode:

[2:41] Assessing low back pain
[4:45] How to assess the squat the right way
[6:57] Looking at functional movement patterns
[9:11] Non-optimal movement patterning, symptomatic or not
[11:08] Sling squats and heel raises
[13:12] Inversion patters
[14:57] How to evaluate neck pain
[16:53] The connections in the body and they relate to functional movement

Related links:

A Stiff 1st MTP Joint can Affect Everything! Aug 10, 2023

Show notes

One of the most overlooked joints in the lower quarter is the first MTP joint unless that is the primary complaint of the client.

How does the stiffness of the 1st MTP joint affect gait and lower quarter movement of all kinds?

We spend some great time with discussions of differential diagnosis, and practical interventions and share some new discoveries.

Hint: the exam and intervention do not always center around the stiff 1st MTP - there is likely a primary driver elsewhere.

A glance at this episode:

[5:05] Compensate and adjust your feet
[11:23] Maintaining the pyramid of the foot
[13:54] How to assess the foot position
[17:17] Assessing the big toe
[20:17] How to treat plantar flexion inversion
[24:37] How to get started with the squat
[27:46] What shoes to wear for diabetic feet

Related links:

HRV as A Predictor and Intervention in Sleep and Stress Aug 03, 2023

Show notes

Heart rate variability is getting a lot of press recently.

Join Susan as she presents a webinar on HRV as a predictor and intervention in sleep and stress.

It doesn't take complicated interventions to make real changes in our health!

A glance at this episode:

[1:59] What is heart rate variability
[4:07] Inhibition of the flight or fight system
[6:26] How you measure heart rate variability
[8:58] When to measure heart rate variability
[13:38] The cycles of sleep
[15:31] Memory and sleep
[18:07] Prolonged poor response to stress
[20:07] Aerobic fitness and heart rate variability
[22:05] Biofeedback and the readiness measure

Related links:

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