Tough to Treat

Latest Episodes:

Pain Without a Diagnosis: The Complexities of Managing Medically Unexplained Symptoms Jul 27, 2023

Show notes

In this episode, we delve into the perplexing realm of medically unexplained pain and the challenges it presents for healthcare professionals.

Join us as we navigate the complex landscape of patients who continue to experience pain despite thorough medical examinations revealing no discernible underlying cause.

We explore the frustrations and uncertainties faced by both patients and practitioners in these cases, as well as the importance of validating patients' experiences and concerns.

We share insights on the various factors that contribute to medically unexplained symptoms, including psychological and emotional aspects, and discuss the potential impact of stress, trauma, and other psychosocial factors on pain perception.

We also explore evidence-based approaches for managing and treating these conditions, ranging from interdisciplinary pain management techniques to the role of psychological interventions.

Join us as we shed light on this often misunderstood aspect of patient care and strive to find solutions for those living with medically unexplained pain.

A glance at this episode:

[5:01] Managing patient expectations
[9:21] What's the challenge?
[14:08] How to help patients figure out what they need
[17:29] Determining if your patient needs time off
[22:20] Identifying what once-a-week treatment means for your patient
[27:01] What would it take to move the patient's expectations
[33:24] Managing expectations of referral sources
39:38] Knowing when to refer out

Related links:

Decoding Persistent Hip Labral Tears - It's Not Always What We Think Jul 20, 2023

Show notes

Have you ever had patients with "diagnoses" of labral tears on MR only to find out that the hip was not the driver?

Of course, you have.

In this short episode, Erica responds to a case sent in from one of the listeners regarding persistent hip pain.

She asks Erica what would be important to look at and how to proceed with the information at her disposal.

There was not a lot of background on this case; so listen as she highlights what's important to rule in and rule out.

Rule out the systemic and chemical drivers. Visceral issues, blood flow disruption, and connective tissue damage all need to get ruled out.

Then look at the connections between the regions of the body- rule out the foot, rule out the thorax. These are 2 VERY common regions of adaptation to hip labral tears.

Don't get fooled into treating the pain generator, unless it's the driver, which it usually is not in the persistent cases.

A glance at this episode:

[2:13] The patient's history of hip pain
[4:08] What you want to look at in this case
[6:18] Hip injury assessment
[7:57] The GI system and its relationship to symptoms
[9:47] Imaging, gait analysis-other tools
[11:55] Diagnostics for hip and foot pain
[14:15] Clinical assessment of the hip
[16:20] How you flag chemical drivers
[19:02] Functional movement patterns

Related links:

Chronic Low Back Pain and Constipation - Why it Matters! Jul 13, 2023

Show notes

Clients often have chronic low back pain as a primary or secondary issue.

It is often combined in complex presentations where addressing one issue is usually not going to generate optimal results.

In this episode, Susan and Erica discuss the obvious and not-so-obvious drivers in this client with chronic low back pain and constipation/bloating!

They discuss the varied evidence that helps to determine not only the main drivers of this presentation but also the reality of utilization of the full systems and whole body consideration in care.

Breath and balance play an important role. Don't miss it!

A glance at this episode:

[3:56] Physical therapy for lower back pain
[7:46] Chronic low back pain and chronic constipation
[12:55] The thoracic spine and chronic low back pain
[18:47] The importance of balance
[21:37] Breathwork and the sympathetic nervous system
[28:41] Reframing the question

Related links:

Pelvic Girdle Pain: Current Concepts Part 2 Jul 06, 2023

Show notes

Clinical practice guidelines provide the practitioner with the most up-to-date research on a certain diagnosis or condition.

Join Susan in a two-part interview about Pelvic Girdle Pain in the Antepartum Population.

In part 2 there is a discussion around systemic vs. biomechanical drivers and the effect of cortisol and stress.

The clinician is asked to review their confirmational biases, consider changing from the relaxin conversation, and listen to the client's story.

Interventions are driven by these stories, movement pattern changes, load transfer, and sensory input.

A glance at this episode:

[0:40] Pelvic girdle pain and pregnancy
[2:17] Relaxing the pelvic girdle joints
[4:27] The importance of looking at the population
[5:24] How to listen to a patient's story
[7:37] Taking the titles of functional outcome measures off the forms
[9:50] How to reduce load transfer
[12:04] What does a belt do for patients

Related links:

Unraveling a Compression Fracture in a Young Male Jun 29, 2023

Show notes

Compression fractures are commonly associated with osteoporosis in older adults.

However, what happens when these fractures occur in young males?

In this episode, Erica and Susan discuss a patient who sustained a T6 compression fracture.

It is intriguing to note that it is a young male in his 20's not an older woman in her 70s.

Do they require different treatments?

Detecting a compression fracture is not difficult thanks to musculoskeletal imaging.

However, considering the radiological changes that occur at the vertebral level with compression fractures can sometimes make exercise progression difficult.

They discuss an initial treatment plan for him and what needs to happen to help him tolerate sustained sitting and standing.

A glance at this episode:

[2:06] Introduction to patient & history
[4:09] Suffering a compression fracture
[7:19] Trunk rotation and alignment
[9:06] Foam roller exercises
[12:03] Thoracic posterior vs anterior translation
[13:58] How to get traction on a foam roller
[17:27] Etiology of compression fractures
[19:00] Sustained positioning and compression

Related links:

Meeting Patient Expectations- Navigating the Journey to Progress Jun 22, 2023

Show notes

This is an excerpt from Erica's DCP course call in February of 2023.

In this episode, she delves into the crucial aspect of meeting patient expectations and facilitating their progress.

She explores the dynamic relationship between healthcare providers and patients, discussing effective strategies for understanding, managing, and aligning expectations throughout the treatment journey.

Join her as she navigates the complexities of patient satisfaction, communication, and empowerment, offering insights and practical tips to foster positive patient-provider relationships and drive meaningful progress.

A glance at this episode:

[2:02] How to develop a script for complex patients
[3:44] How to ask patients how committed they are to recovery
[7:49] The pelvic girdle and hip drivers
[9:01] Treatment time expectations
[10:10] How long it will take the patient to get back to their activities
[11:37] Setting expectations during visits

Related links:

When Shoulder Pain is Dominant, but Not the Driver! Jun 15, 2023

Show notes

Shoulder pain, like any other joint can present as primary pain and be the #1 reason a client may seek help!

In many cases, treating the apparent joint dysfunction (because it checks all of the boxes) may not result in optimal outcomes.

Join the conversation as Susan and Erica explore the reasons and important timelines in the client's history that led to her shoulder pain.

Most importantly follow the clinical reasoning that led to the real driver of this issue.

Bonus - we also offer a great discussion of a good exercise progression!

A glance at this episode:

[1:39] Shoulder pain and internal rotation
[7:52] Which side of the table should you work from
[12:40] Learning to tape the wrist
[20:00] Opening the hands
[22:46] Using the yoga blocks
[27:58] Grip strength as a sign of health

Related links:

Pelvic Girdle Pain: Current Concepts Part 1 Jun 08, 2023

Show notes

Join Susan in a two-part interview about Pelvic Girdle Pain in the Antepartum Population.

Clinical practice guidelines provide the practitioner with the most up-to-date research on a certain diagnosis or condition.

In part 1 there is a rich discussion of what Clinical Practice Guidelines are, risk factors for developing pelvic girdle pain, and most importantly, the language change around the pelvic joints' stability and instability.

A glance at this episode:

[2:16] What is pelvic girdle pain
[3:36] Pelvic pain prevalence and risk factors
[5:56] What drives the pain experience
[8:19] Pelvic girdle and osteoporosis
[10:35] How the brain creates patterns in response to pain

Related links:

From Neck Pain to Shoulder Pain: Unraveling the Links Between the Two Jun 01, 2023

Show notes

Does stretching work when a muscle is over-recruited?

Not if you don't change the movement pattern.

This is an excellent follow-up to episode #162, showing how you clinically reason through another weightlifting injury.

Join Susan and Erica as they discuss a patient who sustained a shoulder/neck injury during a "basic" tricep extension exercise.

The main takeaways are twofold: You must assess the connections between the 2 drivers and treating one region alone will not improve this patient's symptoms.

Why?

Because if you look at his mechanism of injury plus his old movement history as a rower, you will understand that these connections exist and why one region was more dominant, depending if it was OKC or CKC.

Enjoy!

A glance at this episode:

[3:01] Physical therapy for a hip injury
[6:29] Looking at the head and neck area
[12:58] Lumbar spine rotation and compression fracture
[15:58] Understanding the movement pattern
[19:50] Treating both areas of the body
[26:20] Sensory input to the joints
[32:23] The best way to recruit deep muscles

Related links:

Unique Release Positions for the Shoulder: Positioning for Optimal Results May 25, 2023

Show notes

The purpose of release is to train. Remember that.

Long gone are the passive release positions for patients.

Think about the connections in the regions of the body to each other and then design a position that engages those long vectors connecting one region of the body to each other.

An example, is the use of head rotation and the GHJ, to engage the barriers BETWEEN those regions of the body to each other.

Join Erica as she discusses a unique way to achieve end-range shoulder flexion for a neck driver.

A glance at this episode: