Tough to Treat

Pelvis Driver In A Male Weightlifter

May 04, 2023 08:00 - 39 minutes - 26.8 MB

This episode is all about low back pain with a pelvis component in a 33-year-old male weightlifter. Erica and Susan discuss how his history of chronic low back pain along with some bowel issues played a significant role in how he recruits muscles under load. Some highlights include why pelvic taping helped in this case, how to perform the same movement pattern in different positions, why assessing the pelvis was necessary, and the clinical reasoning as to how to differentiate w...

Assessing The Knee Differently

April 27, 2023 20:00 - 10 minutes - 8.88 MB

In this "shortie" episode Erica discusses different ways she assesses the knee. There are 3 parts to the knee joint and assessing a movement pattern that takes into account all these regions is key. It's not all about patellar tracking, right? More often than not, one part of the knee is being compressed because of some overactivity in the muscles surrounding it. The main takeaway is that evaluating these regions takes precision and it's worth it to spend a few ex...

Foot Drivers - The Prequel to the Foot Progression Exercises

April 20, 2023 08:00 - 37 minutes - 25.9 MB

Erica and Susan have presented several podcasts discussing the exercise progression of the foot as the primary and secondary driver. Today they discuss the idea of taking the movement pattern down a couple of steps in preparation for the foot to handle loads, change the body posture, and progress to appropriate AP sway. The clinical reasoning process is key for understanding how the foot should be working before strengthening and challenging movement patterns can be improved. A g...

Anatomy and Physiology Interactions of the GI System - Part 2

April 13, 2023 08:00 - 15 minutes - 10.7 MB

This is part 2 of a short webinar on the interactions of the functional anatomy and physiology of the GI system, presented by Susan Clinton. This will give listeners a nice story of these systems in aspects of digestion and this affects other systems. A glance at this episode: [1:25] The importance of good digestion and intestinal mucosa [3:!7] Chemical digestion of food [5:51] Digestive enzymes [8:05] The village of Villi [9:59] Mass movements in the large intestine [11:38...

What Do Weightlifting And Poledancing Have In Common?

April 06, 2023 08:00 - 39 minutes - 25.8 MB

Answer: A dominant movement pattern that is the same across all this patient's activities. No 1- weightlifters brace and dump their shoulder blades when they rack squat. A very common pattern for this movement, especially when you are lifting over #200 +. The problem is when this becomes dominant for all movements. Healthy systems need choices, plural. The nervous system then grades the strategy depending on the movement and load needed. What happens when someone uses this strate...

Anatomy and Physiology Interactions of the GI System - Part 1

March 30, 2023 08:00 - 17 minutes - 10.9 MB

This is part 1 of a short webinar on the interactions of the functional anatomy and physiology of the GI system. Listen to the unique anatomical arrangements and the neurophysiology connections. A glance at this episode: [1:00] Where the visceral organs are located in the abdominal cavity [3:35] The neurology of the GI System [5:44] The parasympathetic and sympathetic pathways of the gut [7:32] Nervous pathways from the brain to the spine [9:34] Muscarinic receptors in the ...

Hypermobility and Low Back Pain

March 16, 2023 08:00 - 48 minutes - 35.4 MB

How do you rehab someone who is VERY hypermobile and suffers from persistent low back pain? Carefully and specifically! When someone who is hypermobile complains of continued and persistent back pain, your first thought is, " Is this an overactive system? An underactive system? Or both?". This re-release of an episode from 2018 highlights the beauty of a specific exercise progression tailored to the patient's meaningful movement and her dominant impairment. Listen as we go throug...

Why Has My Patient Stopped Improving?

March 09, 2023 09:00 - 16 minutes - 11.5 MB

Ep 152: Why Has My Patient Stopped Improving? In this episode, Erica discusses the fine points of what to do when your patient stops improving. AKA a plateau. Problem-solving through a patient plateau requires sound clinical reasoning and a reflection back to the patient's story. Looking at the injury and movement history-there can be a clue there. Change their COM and reassess another movement pattern. Listen in as Erica gives you the steps to take when this happens to you. A case...

Estrogen Levels and Changes in the Musculoskeletal System

March 02, 2023 09:00 - 15 minutes - 10.4 MB

In previous episodes, Susan and Erica discussed the effects of decreased estrogen at peri and post-menopause with tendinopathies. In this episode, Susan provides the next half of the discussion, from a webinar, on hormones (particularly estrogen) and their effect on the musculoskeletal system throughout the lifespan. Did you know that HRT does not have an effect on tendons? Join the conversation, this will be so helpful in considering your Tough to Treat female clients. A glan...

Shoulder Girdle Hypermobility vs. Thoracic Stiffness - Where is the Balance

February 23, 2023 09:00 - 28 minutes - 20.4 MB

Many of our episodes have included clients on the hypermobile end of the spectrum with a stiff thorax. How do you balance increasing thorax movement around a hypermobile shoulder girdle region? How do you use some sound clinical reasoning to design an exercise program that can bring motor control to the shoulder girdle and improve thoracic mobility? Join us as we bring this clinical scenario to light with the rehab program of an archer complaining of a stiff neck and inability to in...

Advanced Clinical Reasoning With Your Toughest Patients

February 16, 2023 09:00 - 20 minutes - 14.1 MB

In this episode, Erica throws out some clinical gems when it comes to clinical reasoning through these scenarios. What do you do when your patient says, "I am 85% better but I am still getting (insert symptom) when I do (insert activity)." or " I am so much better but my foot hurts on and off when I still sit at my desk". The key is "what does my patient need at this point in time?" Using 2 examples from her patient caseload, Erica discusses how changing the activity and the enviro...

Down Training Non-Optimal Movement Patterns to Make Exercise More Effective

February 09, 2023 09:00 - 31 minutes - 21.2 MB

In this episode, Erica and Susan discuss how to identify someone's non-optimal movement pattern, aka the "dominant pattern" or "the impairment", and use it to your advantage when positioning and prescribing exercise. Think of it this way: If someone has a strong movement pattern, whether it is compensatory or not, they need choices to move in and out of it. More often than not, exercises that are being prescribed reinforce this maladaptive pattern. They discuss ways to position peop...

Hormone Balance - Estrogen and Why it Matters

February 02, 2023 09:00 - 11 minutes - 7.8 MB

Hormones have a significant influence not only within the balance of the endocrine system but also the effect on the MSK system. Join a discussion Susan has had in a course about hormonal health in females. This piece takes a nice dive into estrogen balance throughout the reproductive years. A glance at this episode: [1:03] Estrogen and the effect on the body [3:00] What happens to estrogen in the body [4:45] Hydroperoxide and estrogen dials [6:01] How to make cortisol in ...

Shoulder Stiffness - When the Tissue is the Driver!

January 26, 2023 09:00 - 37 minutes - 25.2 MB

Shoulder pain, stiffness, and lack of functional mobility are not uncommon in clients with post-breast cancer. Join us as we discuss the evaluation and treatment sequence that addresses the particular soft tissue involvement and drivers of this client's limitation—hint: several tissue issues are involved. The clinical reasoning around the client's story is key here! A glance at this episode: [2:04] Susan introduces her patient's history [7:34] Shoulder girdles and head positio...

Manual Therapy Or Not? Hands Off Or Hands On? Or Both?

January 19, 2023 16:35 - 15 minutes - 12 MB

When do you make the clinical decision to put your hands on your patient or take them off? We are changing brain maps and our hands act as facilitators of movement. You need a clinical decision tree to decide which muscles to release and which ones to let go of. A clinical pearl: as your patient moves forward in their program, certain muscles will appear in more loaded movement patterns that you will NOT see in a passive position, like supine. Don't miss this. What is manual therapy...

Grow Your Clinical Expertise By Learning How To Treat The Complex Patient (Part 2)

January 12, 2023 09:00 - 34 minutes - 25.1 MB

Join Susan and Erica while they present case studies to highlight clinical reasoning. This is part 2 of a 2-part series from a webinar. These case studies include pregnancy-related pelvic girdle pain, an athlete with shoulder pain, and a few more. Follow along and recognize the unique clinical reasoning for each client. A glance at this episode: [2:26] What is a cross-legged squat [6:00] What is a complex exercise program [8:28] Assessing the patient and how far they can wa...

Grow Your Clinical Expertise By Learning How To Treat The Complex Patient (Part 1)

January 05, 2023 09:00 - 1 hour - 44.4 MB

In this 2 part episode, Susan and Erica discuss what it takes to become a clinical expert, and how that translates into effectively assessing and treating the "tough to treat". They highlight common errors in clinical reasoning and how to avoid them. They also discuss common red and yellow flags and when to trust your gut. This is part of what makes an expert. Remember, the organization and structure of a clinician's knowledge are more important than the content itself. Learning how to a...

Breath and the Chest Wall

December 21, 2022 09:00 - 9 minutes - 6.04 MB

Let's talk about breathing patterns. Somewhere along the line, chest movement with diaphragm movement became unpopular. Was this because people equated the term "chest breathing" with "accessory muscle breathing". Join Susan as she discusses the differences, explores how breath drives pelvic function and why we have so much stiffness in the thorax!

Foot and Hip Pain? Why You Treat The Thorax

December 15, 2022 09:00 - 32 minutes - 22 MB

Your patient has a dysfunctional thorax and it's driving their symptoms, wherever they are. How can you clinically reason treating a non-painful thorax for distal symptoms, such as the foot and hip? The body translates the head, thorax, and the pelvis over the feet for many reasons. Offloading a painful foot, knee, hip is one reason, the other can be an ingrained movement pattern that has been there for years because of an old injury or from a dominant movement or sport history. Join Sus...

How To Increase Proprioception - An Updated Approach

December 08, 2022 14:08 - 14 minutes - 11.6 MB

What are the clues and the keys to increasing somatosensory awareness in your patients? Putting someone on a dynadisc or a foam pad does not cut it anymore when your patient lacks sufficient motor control to move well. Make the clinical decision-does my patient need this NOW? Proprioception challenges the individual movement system in many different ways. In this episode, Erica discusses new and novel ways to highlight proprioception in your treatment programs. Be creative! One of the examp...

A Fencer With Bilateral Calf Pain - Where's The Driver?

December 01, 2022 09:00 - 53 minutes - 38.9 MB

What is the cause of bilateral calf pain in this young fencer? From start to finish, it shows the power of a thorough evaluation, a specific exercise progression, and a return to the sport she loves. When it comes to exercise progression in persistent pain, think about context. How can you improve optimal movement patterning by changing the context? Think about this one. You can intervene via the visual system, eyes open, eyes closed. How about changing their base of support? Wide to narrow...

Neurophysiological Underpinnings of the Trigeminal System - Part 1

November 17, 2022 09:00 - 10 minutes - 7.44 MB

In this short episode, Susan discusses the upper cervical region and its effects on the rest of the body: core, pelvic floor dysfunction, muscle recruitment, balance, dizziness, etc. Join Susan as she takes a journey into the remarkable system from one of her lectures. Erl Pettman's work has long influenced Susan on her clinical reasoning and the importance of convergence of symptoms throughout the body from the upper cervical spine and the cervical trigeminal nucleus. Retraining this region...

Lumbosacral Pain Presentation - A Typical Clinical Pattern

November 10, 2022 09:00 - 33 minutes - 22.8 MB

In this episode, Susan and Erica discuss a series of patients that all presented lumbosacral pain. Clinical pattern recognition is an important part of the assessment process. The pattern does not dictate the intervention process, but the inability or ability of the pattern to change in the assessment and intervention process is key. This practical presentation of a typical female with lumbosacral pain demonstrates the recognition of the clinical pattern. Once this is discovered, what are...

What To Do When Your Treatment Stops Working

November 03, 2022 08:00 - 9 minutes - 7.74 MB

In this short episode, Erica discusses her perspective on what to do when your patient plateaus. We’ve all been there. The proverbial plateau. Your patient is doing well and then all of a sudden they get stuck. Why? More often than not, there is a secondary region of the body that has cropped up. Go back to your patient’s movement and injury history. There will most likely be a clue there. Also, do you trial exercise at the beginning of the treatment session? If you don’t, you sh...

Treating Knee OA The Smart Way

October 27, 2022 08:00 - 32 minutes - 22.1 MB

In this episode, Erica and Susan discuss how to begin and progress treatment with a knee OA without exacerbating their symptoms. Knee pain can be quite provoking as we age, especially for those older adults who have always been active and want to stay that way. Osteoarthritis is fairly common, however, exercise designed for this patient population tends to fall short and can often exacerbate the symptoms. Is there an articular problem? Yes, often times that’s where it starts. But it c...

The Gut-Brain Axis - Stress, Pain, and Balance

October 20, 2022 08:00 - 12 minutes - 9.4 MB

Join Susan as she shares a segment from a course she teaches on GI Dysfunction. This clip is dedicated to the Gut-Brain Axis and why the complex interactions can have such a direct effect on the behavior of the movement, endocrine, nervous and visceral systems. It is all about balance and the direct need to make sense of input and the actions necessary. A glance at this episode: [0:40] Susan shares an old story about working top down [1:50] Sympathetic and parasympathetic pathways [...

Shoulder and Arm Pain - What is Really the Driver?

October 13, 2022 08:00 - 38 minutes - 26.2 MB

In this episode, Susan and Erica discuss how very old drivers can present in a novel situation, as well as why new drivers will appear if compensatory patterns are allowed to become dominant. Susan’s patient in this episode came to her with shoulder pain which quickly led to full-on arm pain. Susan discusses how she used clinical reasoning and the patient’s history to find the driver. The driver here is not obvious and did require some deep investigation. Shoulder problems can be the focus...

Hip Pain In A Golfer: Why It's Not Going Away

October 06, 2022 08:00 - 9 minutes - 7.56 MB

In this short episode, Erica highlights the importance of center of mass by assessing a semi-competitive golfer with hip pain. He suffered an avulsion fracture of his iliopsoas tendon with resulting surgery. Two years later, he became symptomatic in his hip after golfing for consecutive days. Hip pain is quite common in golf because of the rotary nature of the sport, but you have to wonder why this happened. Here’s what you need to consider: After someone has an injury or even surgery, th...

Racquet Sports & Back Pain: Why You Should Look At The Foot

September 29, 2022 08:00 - 42 minutes - 28.7 MB

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 dr...

When You Should Tape and Why

September 22, 2022 08:00 - 13 minutes - 11.3 MB

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 interve...

Low Back Pain: Regional vs. Movement System Considerations

September 15, 2022 08:00 - 35 minutes - 26.1 MB

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...

Exercise Progression for the Tough to Treat Shoulder

August 25, 2022 08:00 - 25 minutes - 20.5 MB

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 impairm...

Hypermobility and Low Back Pain

August 11, 2022 08:00 - 50 minutes - 37.5 MB

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...

Exercise Progression For Neck Pain And Headaches

July 28, 2022 08:00 - 34 minutes - 24.3 MB

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 nec...

Hip Pain, Hypermobility, and a Subtle Driver!

July 14, 2022 08:08 - 31 minutes - 24.1 MB

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 discus...

Reframing The Narrative For A More Effective Assessment

June 30, 2022 08:00 - 26 minutes - 19.5 MB

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 t...

Choosing The Best Functional Movement For Your Assessment

June 23, 2022 23:49 - 14 minutes - 12.8 MB

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 yo...

Junior Golfer with an Unusual Source to his Knee Pain

June 16, 2022 08:00 - 55 minutes - 39.1 MB

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 picki...

Myth Busting - Rethinking Pregnancy Related Pelvic Girdle Pain

May 19, 2022 14:03 - 42 minutes - 78.4 MB

There is usually a ten-year lag from published research to accepted practice in clinical arenas. Pelvic girdle pain in Pregnancy is no exception. Join us as we discuss the most important systemic and movement system presentations that can greatly impact this population. In this episode, we cover unhelpful language, true risk factors, and functional problem-solving for these clients. We also discuss what is really happening in the biopsychosocial approach - and especially why self-efficacy is...

Smart Exercise Progression

May 05, 2022 17:56 - 32 minutes - 60 MB

What constitutes an effective and efficient exercise progression? How do you smartly move someone through a movement program targetting their driver? Do not get hung up on someone's symptomatic region if that's not what is driving their symptoms. In this episode 2 cases are presented where their drivers were distal to their symptomatic areas. Categories of movement, neutral to non neutral, as well as unloaded to loaded are discussed with specific exercise progression. Remember: you are build...

Smart Exercise Progression

May 05, 2022 17:56 - 32 minutes - 60 MB

What constitutes an effective and efficient exercise progression? How do you smartly move someone through a movement program targetting their driver? Do not get hung up on someone's symptomatic region if that's not what is driving their symptoms. In this episode 2 cases are presented where their drivers were distal to their symptomatic areas. Categories of movement, neutral to non neutral, as well as unloaded to loaded are discussed with specific exercise progression. Remember: you are build...

CV joints and bladder urgency - is there a connection?

April 21, 2022 06:00 - 41 minutes - 75.2 MB

Clients report urgency/frequency and are most often treated with medication and pelvic floor PT. When only a regional approach to the pelvic floor over-recruitment is considered, many of the underlying drivers can be missed. Consider the client on this podcast and join us as we explore how multiple drivers can influence the hypersensitivity of the bladder. Taking into consideration the possibility of a knee driver and a visceral driver (constipation) can only explain one part of the system ch...

The Foot and Diaphragm- Their Connection To This Skier's Hip Pain

April 07, 2022 06:00 - 32 minutes - 60 MB

What happens when you take away a compensation? Movement patterns change for starters. But what if these new strategies are not optimal for whatever activity you are trying to do? New sport you want to master? That's where the reality unfolds. Healthy systems need choices and when you take away a compensation or a movement pattern that no longer works (i.e. painful), your brain is forced to develop another strategy. In this episode we talk about a patient from episodes 109 and 110, who has ma...

Persistent insertional tendonopathy - the importance of the systems approach

March 24, 2022 06:00 - 36 minutes - 66.9 MB

The movement system is adaptable until there is maladaptation! Why is tendonopathy so difficult to treat? What if straight eccentric loading doesn't work? Join us as we discuss this female client and the unique consideration of the system changes that have led to the development and persistence of her persistent heel pain. Yes, this includes pelvic health and the cervical spine! check us out at toughtotreat.com

Persistent Shin Pain-Where is the Driver(s)? Hint: Not the Lumbar Spine

February 24, 2022 07:00 - 43 minutes - 78.9 MB

Can there be 2 drivers to someone's shin pain? Of course! What is the relationship between them? Are they directly connected? Is there some underlying neurally driven mechanism? Or both? This episode digs deep into why certain positions like sitting in a specific environment versus other sitting positions make him worse. Why would biking be ok for someone and sitting in an office chair not be? Think about that one for a second. Susan and Erica discuss this patient's past movement history whi...

The Psoas Triangle

February 10, 2022 15:18 - 42 minutes - 78.6 MB

Differentials of common segment's neurology - Join us as we discuss the shared neurology of the T12/L1 region and how this can be a driver to anterior hip and groin pain. We are looking at multitudes of clients that show up with various aspects of what Erl Pettman discusses in his work of the psoas triangle.

Designing Exercise Progressions For The Tough To Treat

January 27, 2022 07:00 - 33 minutes - 60.5 MB

How do you design a sound, clinically reasoned exercise progression? Taking into account multiple drivers? If someone has low back pain, do you give them core stability exercises? I hope not, unless they have an abdominal wall deficit! In this episode Susan and Erica talk about a patient from episode 81 and what constitutes an approporiate exercise progression for someone whose drivers were in his foot and thorax. They go into detail the various categories of exercise and how you would clini...

Persistent Pubic Symphysis Pain/Right Anterior Hip Pain

January 13, 2022 07:00 - 40 minutes - 73.6 MB

10-20% of women with pelvic girdle pain in pregnancy will persist into the post-partum era. Join us as we share a discussion on the history that led to the eventual battery of relevant tests/measures and interventions that were not only meaningful to the client, but also were achievable in her very busy time of life with small children. Join our new Premium Podcast Club: toughtotreat.supercast.com

Does the Elbow Always Drive Elbow Pain?

December 30, 2021 07:00 - 38 minutes - 69.5 MB

A fall on an outstretched elbow (FOOSH) with resulting elbow pain. Not your typical overuse or mechanical injury common to this region of the body. What happens when your differential diagnosis leads you somewhere else? Susan and Erica discuss the backbone of the initial assessment as well as treatment specific strategies that will help you get these patients better quicker. They also relate some great clinical pearls behind coming up with a hypothesis as to why elbow pain can be driven from...

5 Symptomatic Regions Of The Body With One Main Driver- Part 2

December 02, 2021 07:00 - 38 minutes - 71.2 MB

After listening to Part 1 of this case (episode 109), how would you design an exercise progression? Remember you need to find the driver first. Designing a movement program based on this patient's symptoms would NOT work, as his driver(s) lie elsewhere. Once you are confident you've found it, think about the impairment. Does he have an overactive superficial system or underactivity somewhere else or both? Sound clinical reasoning dictates that you need to downtrain the old strategy first. Li...

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