Tough to Treat

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...

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...

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...

Consideration of lateral hip pain requires a thoughtful clinical reasoning process to discover the physiology/movement patterns as well as neural contributions required to make a diagnosis and successfully build an intervention that lasts. One size does not fit all - join us as we discuss the findings in this "not so unique" case and the discovery of the underlying movement patterns, impairments a...

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...

What happens when you have 2 regions of the body that when treated together give your patient the best movement options and no pain? But, when they are treated separately, not only is the patient worse, but their movement lacks coordination and ease. This episode highlights someone who has over 5 regions of the body that are meaningful and symptomatic. Literally from head to toe! Listen as Erica a...

Do you have thoughts on the driver from part 1? In part 2 we take you through the discovery and clinical reasoning parts to determine the primary driver for this client's symptoms. For intervention - think of the easiest steps to begin to find a way into the system to make large changes. Listen in as Susan and Erica discuss how symptoms can be present in various positions but can be changed throug...

We always discuss history and relevant events. In this episode we take a deeper dive into all aspects of the story in the BPS lens. Join us for our discussion on the importance of uncovering significant historical peices regardless of the referral or medical diagnosis. You have an opportunity to put on your clinical reasoning cap with us as we set up this clinical case in Part 1! Check us out: Tou...

Does all hip pain require strengthening? Of course not! And certainly not in this persistent case. This episode shows you the importance of digging deep into the history and really learning how to connect the dots. From the way the patient walks and what that means for symptom provocation to exposing the vestibular system as a potential driver. Other candidates include the foot, thorax and neck. L...

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! Check us out: toughtotreat.com

Save yourself time by learning how to find the driver quicker. This is the case of a neck driven shoulder- but not in the way you think! Do all shoulder patients need strengthening? Not really. We talk about how to hone in on the impairment and narrow the assessment down to a few movements that will help you successfully clinically reason through most upper extremity issues. We also discuss novel...

Ankle sprain rehab can seem so straight forward - decrease swelling, improve ROM and strength - right? Wait, why are a good number not improving and returning to previous activities? Once again, the client's story and history can really lead us further into the complexity of the foot/ankle joint and all of the systems that need to be considered in returning this region to full function. Clinical P...

Clinical pearl alert! This episode tells the story of 3 patients and their treatment progressions. Typical symptoms but atypical drivers. What types of exercises do you prescribe for your patient when their symptom is in their feet and their driver lies in their thorax? What is their impairment? This is a discussion of how you would SPECIFICALLY treat and develop a well thought out exercise progre...

Here is the clinical story of a client that is presenting with pain/sensitivity in the area of the (R) posterior pelvis. In this episode we discuss what has been unhelpful for her with regard to past interventions and why the biospsychosocial approach and creating the therapeutic alliance is so important to give her the ability to improve her movement system. Meaningful activities, violating expec...

What do you do when a patient plateaus? Doesn't improve? Join us for our first Q and A broadcast on how to clnically reason through a patient's treatment program when their progress starts to slow down. We discuss a specific patient example and what constitutes a solid progressive exercise program. This also includes reset exercises to restore optimal motor patterning so she can identify what move...

What do you do when a patient plateaus? Doesn't improve? Join us for our first Q and A broadcast on how to clnically reason through a patient's treatment program when their progress starts to slow down. We discuss a specific patient example and what constitutes a solid progressive exercise program. This also includes reset exercises to restore optimal motor patterning so she can identify what move...

Join us for a special episode on the shoulder. This is a re-release of one of our most popular episodes to date. As a bonus, we present 3 case studies of patients with typical shoulder pain who have different drivers and certainly different exercise programs. Sometimes the key to helping a patient's persistent shoulder pain is looking at all of the underlying inputs into their system. What are the...

Join us for Part 2 of our discussion on functional movement patterns. How can you make your assessment more efficient and reliable? We discuss what to look for when evaluating someone's ability to move in and out of certain movements. How do you determine if a dysfunctional foot is driving your client's hip pain when squatting? Or if poor thoracic control is responsible for low back pain when asse...

Why would someone who is 3 months post fibular fracture get worse after a basic theraband ankle exercise? Not everyone needs inversion and eversion theraband exercises. Right? This is an in depth clinical discussion on understanding the "why" hidden in the patient narrative. And a specific process on how to assess the whole foot and not just the ankle. We also discuss why this patient's center of...

When working with young athletes it is easy to have early success in treating the acute or subacute injuries. What happens when the latest injury reveals a very chronic situation elsewhere in the body? Don't be fooled by generalized and chronic complaints underlying the present situation in these teenagers. They may improve quickly in one respect, but looking deeper can help them improve adaptatio...

How does the knee affect so many parts of the body? Join us for this discussion on this important intermediate joint of the lower kinetic chain and how dysfunction here can alter the movement system for the whole person. Check us out: Toughtotreat.com

Does chest pain raise your eyebrows? Red flag? Or wild goose chase? This case is an insight into a classic endurance athlete and how his past injuries reveal a true deficit which can be the potential driver for his current symptoms. These symptoms that only occur 3-4 hours after a bike ride. We discuss viscero-somatic cross talk, the cardiac sinus and its biomechanics as well as a how to start tre...

This episode features a case of shoulder pain with unusual drivers due to their distal proximity. Join us as we discuss this interesting clinical case on a very active man with chronic shoulder pain, fear avoidance, anxiety and some unique clinical reasoning to help him recover! Check us out: Toughtotreat.com

What do you automatically think when someone tells you they have knee pain? It's worse with walking SW and walking FW. And the patient cannot sleep sidelying because his knee hurts when he sleeps on either side. He can squat no problem. Are you thinking what we're thinking? Susan and Erica unpack this patient's story and dive into specific hints or cues that the patient gives to indicate that it's...

In this episode Susan and Erica discuss the many ways the thorax can be the driver for a multitude of upper and lower extremity issues. This important region of the body tends to be the cause for a lot of movement dysfunction we often see. As an example, the thorax is an important component in driving foot pain as well as issues in the pelvic girdle. If you can get the thorax moving differently, t...