Tough to Treat

This episode dives into some of the evidence on resistance vs. high-velocity power training in postmenopausal women and its impact on bone mineral density (BMD). Research is highlighted showing that high-speed training protocols may stimulate bone more effectively than traditional resistance training by increasing strain rates and promoting osteogenic adaptation. You'll learn how moving with speed and control helps strengthen bones and prevents age-related decline better than slow, heavy lifting alone. Some of Erica's research for her doctoral dissertation is discussed and she then presents a case study of a menopausal patient with insidious-onset shoulder pain and offers some clinical pearls as to why, especially in anyone who has played a racquet sport, the shoulder is not the only driver. She also highlights a few targeted interventions that allowed this woman to weight lift and strengthen her shoulder without feeding into her symptoms.   The content contained therein, including text, images, audio, or other formats, were created for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.    Related links: Tough To Treat Website Erica's Website Susan's Website        

In this episode, Erica dives into the latest research exploring how menopause affects physical performance in women—highlighting changes in power and strength. These findings are reshaping how we approach exercise and rehab in midlife women. Next, she shares an update on her dissertation, which compares premenopausal and postmenopausal women on key physical performance metrics. Erica discusses early patterns emerging from the data, including potential implications for exercise training and rehab prescription. She wraps up with a clinical case involving a woman in menopause experiencing persistent neck and shoulder pain, along with difficulty breathing. She breaks down the history along with a few clinical pearls outlining how past injuries have and continue to contribute to this woman's issues. Erica also breaks down her exercise program, discussing the do's and don'ts of exercise progression.   Hormonal changes can contribute to musculoskeletal tension and diaphragmatic dysfunction- we know this. But do we really educate our patients on this? Many do not. Whether you're a clinician, researcher, or someone navigating midlife changes, this episode offers insight, evidence, and strategies for supporting well-being during menopause.   Related links: Tough To Treat Website Erica' Website Susan's Website

In this episode, we answer the most common questions we get from listeners. We dive into course recommendations, highlighting resources for continuing education, mentoring and evidence-based practices.   A key focus is on clinical reasoning strategies—how to approach complex cases and integrate patient-specific factors into your decision-making. We also discuss the value of spending the majority of your first session taking the patient's story.   Your patients will make you a better physical therapist, if you listen to them. Be curious and let it lead you towards mastery.   A glance at this episode: [2:27] Courses and Continuous Learning [12:11] Starting the Podcast and Building a Community [13:17] Mentorship and Clinical Reasoning [19:10] Treatment Sessions and Client Engagement [22:56] The Role of Patients in Clinical Learning [26:41] Reflecting on the Year and Planning for the Future   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Clients self-refer for many reasons and we find ourselves on the front line of health care screening. Join Susan and Erica as they uncover key elements in a client's history and narrative around long-standing shoulder pain. Simplistic presentations usually mask true underlying considerations including the client's beliefs and red flags.   A glance at this episode: [1:41] Client's Initial Presentation and History [4:07] Exploring Past Injuries and Chronic Bike Riding [6:56] Impact of Corporate Life and Breast Cancer on Health [13:08] Concerns About Bone Health and DEXA Scan [15:21] Addressing Left Shoulder Pain and Movement Dysfunction [17:51] Implementing Modified Exercises and Pilates [39:28] Discussing the Power of the Narrative and Patient Advocacy [40:13] Connecting Patient Goals to Treatment Outcomes [45:17] Final Thoughts and Episode Closing   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

In this episode, we explore the surprising journey of a boxer battling chronic shoulder pain that left him struggling to do even the most basic workout. Despite focusing on his shoulder, it turns out the root of his problem lay elsewhere—his elbow. Is that surprising? It was in his injury history. Do not discount the power of an old injury that could come back and haunt you. And think about the load on the elbow when you're doing a push or pull-up. Join us as we clinically reason through this interesting case from start to finish.   A glance at this episode: [0:01] Introduction and Patient Background [7:03] Initial Assessment and Observations [11:56] Exploring the Root Causes [14:12] Addressing the Pull-Up Challenge [32:06] Implementing Exercise Program [36:32] Final Thoughts and Key Takeaways   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Susan and Erica are back together for the Fall season! Chronic knee pain can be much more than a regional event. Susan presents a client with an extensive timeline and clinical reasoning as to why it is important to consider the entire system in this integrated approach. The key here is also maintaining relevance and sustainability for the client.   A glance at this episode: [1:18] Explanation of Episode Structure and Content [2:59] Introduction to the Client Case Study [5:30] Client's Medical History and Injuries [12:47] Initial Assessment and Observations [13:33] Treatment Plan and Initial Intervention [31:02] Follow-Up and Client Feedback [31:17] Advanced Treatment and Future Plans [31:31] Conclusion and Encouragement for Listeners   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

In this episode, Erica explores the often-overlooked relationship between hip pain and knee function during walking when the patient does NOT have knee pain. Join in as she dives into the role of the knee in compensating for hip dysfunction, and how a thorough knee assessment can uncover hidden contributors to hip discomfort. Remember: old injuries have a way of sneaking up on us and becoming one of the drivers of our current problem. An old hamstring tear 5 years ago as a contributor to this patient's problem? Think again.   A glance at this episode: [2:23] Patient Background and Injury History [3:46] Assessment and Initial Findings [6:33] Knee and Hip Mechanics [10:11] Terminal Knee Extension and Treatment Approach [20:43] Clinical Reasoning and Patient Outcome [20:58] Conclusion and Call to Action   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Shoulder pain, like any other joint can present as primary pain and can be the #1 reason a client may be seeking help! In many cases, treating the obvious joint dysfunction (because it checks all of the boxes) may not result in optimal outcomes. Join the conversation as Susan and Erica explore the various reasons and important timelines in the client's history that has 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 blocks for yoga blocks [27:58] Grip strength as a sign of health   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

In this episode, Erica discusses the why behind shoulder problems, comparing the unique challenges faced by tennis players and non-tennis players alike. She explains why traditional shoulder treatment often fails these types of patients. A significant relationship between the shoulder and another region of the body is often missed. Erica also tells the story of one of her patients who does play tennis and the reason why he can do a full pushup but can't lift his arm over his head. For our physio listeners, oftentimes you can progress patients through a full range of CKC exercises but the OKC piece does not progress as quickly.   A glance at this episode: [0:01] Erica's Summer Vacation and Introduction to the Episode [2:30] Clinical Pearls for Tennis Players [6:15] Assessing Upper Thorax and Glenohumeral Joint Compression [12:53] Treatment Approach for Upper Thorax and Glenohumeral Joint Issues [15:54] Progressing Patients with Glenohumeral Issues [16:14] Clinical Pearls for Closed Chain Exercises [20:37] Conclusion and Encouragement for Practitioners Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

One of the most overlooked joints in the lower quarter is the first MTP joint unless that is the client's primary complaint. How does the stiffness of the MTP joint affect gait and lower quarter movement of all kinds? We spend some great time discussing differential diagnosis and practical interventions and sharing 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: [0:01] Introduction and Podcast Rebroadcast [2:13] Overview of Stiff First MTP Joint [4:21] Compensation and Adaptation [6:30] Assessment and Treatment Approaches [23:22] Exercise and Proprioception [25:47] Shoe Recommendations and Adaptations [34:17] Conclusion and Final Thoughts   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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. And why not have them do their exercises to their favorite music? These are just some examples. Look at your patients through a different lens and then see positive change.   A glance at this episode: [0:01] Introduction and Case Overview [7:46] Initial Assessment and Clinical Reasoning  [10:27] Hypermobility and Initial Treatment [20:14] Progression and Additional Techniques [32:40] Advanced Techniques and Future Plans  [52:04] Conclusion and Reflection   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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. And why not have them do their exercises to their favorite music? These are just some examples. Look at your patients through a different lens and then you'll see positive change.   A glance at this episode: [0:01] Diaphragm function, GI dysfunction, and postural control [7:51] GI dysfunction and its impact on abdominal wall muscles and posture [13:39] Abdominal dysfunction and diaphragm movement in relation to chronic low back pain [20:36] Treating chronic low back pain through abdominal wall retraining [25:09] Abdominal wall deficit and diaphragm dysfunction in chronic low back pain patients [32:07] Treating gas and bloating through diaphragm therapy 36:32] Treating GI dysfunction through breathwork and positioning Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

How do you rehab someone who is VERY hypermobile and suffers from persistent low back pain? Carefully and specifically! This episode highlights the beauty of a specific exercise progression tailored to the patient's meaningful movement. Listen as we go through the clinical reasoning process to determine what types of movement patterns will work and what ones won't.  Doing the right thing at the right time is clinical expertise.   A glance at this episode: [5:13] Hypermobility and pain management for a 24-year-old woman [11:26] Hypermobility, muscle imbalances, and control issues in a patient with back pain [19:00] Shoulder subluxation and its relation to past injuries and yoga practice [23:57] Diaphragm recruitment in back pain patients [27:47] Addressing short girl syndrome in a dancer [32:03] Using tape and Pilates equipment to improve abdominal strength and stability for a hypermobile patient [35:51] Improving posture and flexibility through exercises on a reformer machine [39:23] Exercises for a spin instructor with tight hip flexors [43:34] Exercises for hypermobile individuals to improve motor control and recruitment   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript

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! Visit our website: toughtotreat.com   A glance at this episode: [0:01] Low back pain and pelvic health issues, client with gradual onset of stress urinary incontinence [2:16] Pelvic health and trauma history after a recent fall [7:21] Patient's foot and leg issues, including supination and knee pain [13:08] Addressing knee issues through breathing and positioning [15:50] Knee and back pain treatment using bridging and lunge exercises [22:01] Treating knee pain and low back pain through exercises and manual therapy [27:45] Treating patients with movement system changes to address low back pain and pelvic health issues Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Now, this is a CHALLENGING one! Ever have those patients who have been everywhere, had everything done to them (injections, surgeries, acupuncture) and nothing helped?  Well, this is your lucky day because this episode really takes us down the chain from head to toe with someone who had low back pain. Pretty standard, right?  But this was FAR from standard. Hint: her low back was not the source of her problem. Why do you think that is? Remember, we bring all of our compensations to our life events. And our movement and injury history sets us up and our dominant patterning keeps us there.   Visit our website: toughtotreat.com   A glance at this episode: [0:01] Complex medical history and treatment options [7:06] Chronic pain and potential causes [12:14] Pelvic issues and postural compensations [18:41] Pelvic and foot issues, possible nervous system impairment [23:21] Decompression techniques for a patient with nervous system issues [26:31] Yoga and physical therapy for a patient with neck pain [29:13] Treating a patient with chronic pain using movement patterns and cranial work [35:07] Standing and carrying issues, loading exercises suggested [40:07] Exercises for back pain relief, including cycling, Nordic walking, and rock climbing [42:28] Using yoga and rock climbing to improve standing tolerance for a client with chronic pain [47:30] Treating patient with chronic pelvic pain Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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!   A glance at this episode: [0:01] Left lower quadrant pain, nociceptive input from visceral driver [2:23] Pelvic pain and potential visceral driver [8:05] Bladder issues and pelvic floor tension [10:49] Bladder irritants and pelvic health with a patient [16:49] Lower back pain and posture with a physical therapist [20:04] Pelvic floor exercises and visceral manipulation for pelvic pain relief [24:34] Pelvic floor exercises and core strength for bladder control [26:45] Improving driving skills and addressing bladder issues [32:49] Visceral mobilization and pelvic floor issues Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Golf is a sport of weight shifts and a narrow base of support. What happens when your knee can't adapt to an altered base of support? This is what exactly happened here with this case. This young golfer, in standing (and standing is VERY relevant for the golf swing) had an 80/20 load, R/L in this position. And it stayed that way throughout the golf swing. This begs the question: Did you know that right knee pain can be caused by an imbalance in your center of mass? If you continuously load your painful side, that has some serious implications for loading. Erica and Susan discuss in this episode how treating the left hip as well as the left side of the low back, got rid of this young golfer's knee pain. He needed options for movement to his left side. A functional and interactive evaluation really hones in on where the true source of his knee pain lies. Remember: for persistent, unsolved problems, correlate the patient's history with your objective assessment. Hint: this patient had a history of concussion. You think that would alter his BOS?   A glance at this episode: [0:01] Chronic knee pain in a junior golfer, analyzing the cause and treatment options [4:48] Golf injury treatment and diagnosis [12:19] Golf swing mechanics and potential issues with a young golfer [17:03] Assessing a 12-year-old golf player with knee pain using a thorough history and clinical reasoning [23:49] Using visual aids and manual therapy to help a golfer improve his swing by shifting weight to the left leg [31:33] Using mirror therapy for knee rehabilitation [39:25] Rehabilitating knee injuries via changing the center of mass [43:34] Rehabilitation program for golfers with variance in exercises to improve adaptability [47:36] Physical therapy for a young golfer with a focus on listening and meeting clients where they are   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

In this episode, Erica dives into the intriguing story of a former fighter who faced unexpected challenges with basic exercises like push-ups and pull-ups. She sheds light on how years of specialized training led to muscle imbalances and problems outside the ring.  The "push" and "pull" are different movement patterns. What region(s) of the body are challenged with these movements? Remember the "push" is a 4-point closed chain movement and the "pull" is not.  What do fighters do on a routine basis to their wrists before a fight? Why is the "negative" on a pull-up more important than the push on a push-up?  Listen in as Erica discusses how to make this type of assessment more efficient by really listening to the story, connecting the dots, and ultimately going back to basics to treat another region of the body that was a secondary driver to the "pull". If you want the visual, here is a link to our YouTube channel.   A glance at this episode: [0:01] A patient's medical history and symptoms related to military service and boxing [5:00] Assessing push-ups and shoulder mobility for a patient with a history of rowing [8:18] Assessing a patient's movement patterns and identifying potential issues through observation and testing [12:31] Treating a patient's elbow issues after a history of thoracic injuries   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

This episode is part 2 of episode 213. Utilizing evidence-based research and the latest clinical guidelines, the presentation will examine the multifactorial nature of chronic constipation, including non-pelvic interventions that can complement existing treatments. One key aspect will be the practical application of the balloon catheter, demonstrating its effective use for both assessment and therapeutic interventions.   A glance at this episode: [0:01] Chronic constipation interventions and assessment, including muscle tightness and behavioral factors [3:27] Using balloon catheter for rectal biofeedback to treat constipation [8:37] Constipation, abdominal distension, and neural tension, with exercises to improve GI function and reduce discomfort [14:54] Stress, sleep, and nervous system regulation for chronic problems [20:16] GI health, manometry for constipation in infants, and mindfulness techniques   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Utilizing evidence-based research and the latest clinical guidelines, the presentation will examine the multifactorial nature of chronic constipation, including non-pelvic interventions that can complement existing treatments.  One key aspect will be the practical application of the balloon catheter, demonstrating its effective use for both assessment and therapeutic interventions.   A glance at this episode: [0:01] Chronic constipation and its impact on pelvic floor health [4:24] Constipation and irritable bowel syndrome (IBS) causes, symptoms, and diagnosis [12:18] Bloating and distension in chronic constipation, including causes and treatments [17:07] Diaphragm function in chronic low back pain   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

There are many ways to approach pelvic pain and symptoms of urinary urge incontinence, but did you know that how the MSK system moves can affect these symptoms as well?   On this podcast, we dive into the movement system, past/present autoimmune history, and post-partum process while changing this client's symptoms as well as her urinary incontinence. In turn, she regains control over her pelvic pain!   A glance at this episode: [0:01] Postpartum pelvic pain and urinary incontinence in a 34-year-old woman [2:07] Pregnancy, autoimmune disorders, and migraines [5:36] Postpartum health, nutrition, and urinary incontinence [11:18] Postpartum care and pain management [14:40] Back pain and mobility issues [17:56] Postpartum pelvic floor dysfunction and urgency issues [24:09] Managing urinary incontinence through diet and exercise changes [27:42] Urgency and pain during sex, pelvic exam, and internal rotation [30:22] Pelvic pain and cranial flexion [36:17] Evaluating and treating a patient's urgent symptoms through neural tension and movement [38:54] Breathing techniques for managing urinary urgency and stress Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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 compensatory patterns in physical therapy [8:14] Using vision and palpation to assess knee joint movement and patterning for optimal physical therapy treatment [12:09] Assessing knee pain through body twists and foot rotation Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript

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: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript

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 mobility issues [12:16] Patient's chronic pain and mobility issues [17:02] Proper standing and walking techniques for comfort and mobility [22:00] Standing balance and stretching exercises for improved mobility [26:51] Patient's chronic back pain and potential nerve damage [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: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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: The Franklin Method Fellowship Podcast Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

This episode is a short compilation of an algorithm in looking at basic outcome measures and pain in GI Dysfunction. Susan explores the basics of the history which can give great insight into the addition of more sophisticated outcome measures and pain exploration. Start with the basics and then expand!   A glance at this episode: [0:01] Evaluating and managing pain in people with GI dysfunction [1:18] Abdominal pain and its relationship to GI dysfunction [4:47] Visceral pain and myofascial pain syndromes [9:14] Pelvic health and bowel dysfunction assessment tools [13:12] Bowel habits and GI health assessment   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Join us in episode #200 where Susan and Erica explore the potentiality of the balance system as a primary or secondary driver. With a client's history of injury or illness, there is an event that sets up their system for adaptation. Oftentimes, in regional-specific rehab, the balance system is not considered as a driver. What keeps the client in this adapted pattern may be the primary driver; however, the balance system adapts to keep the entire body and physiology upright against gravity. This system can change, and the need for activity to accomplish this becomes a primary consideration in the assessment and the intervention. Listen in to the conversation and find easy clues to discover in your client assessment for effective interventions.   A glance at this episode: [5:27] Balance system adaptation and rehabilitation [12:43] Balance, vestibular system, and eye movements [21:04] The importance of challenging the balance system and multitasking while keeping balance intact [25:28] Balance challenges and treatment options for various populations [29:53] Improving balance and rotation through exercises [35:30] Pelvic health, balance, and movement patterns [43:47] Balance system importance in exercise and rehabilitation   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

In this episode, we explore the profound connections between personal narratives and the origins of someone's injury. Join Erica as she delves into the stories of individuals who've experienced persistent injuries, and learn how to find clues in their narrative to help you prioritize the movement assessment and eventually find their driver(s). You will learn how to make the connections between the story and their movement patterning. Through the lens of their injury and movement history, we can uncover the reason why someone can't move the way they want. This leads to precise diagnosis and effective treatment. You don't treat the symptomatic region unless it's the driver. There is a video companion piece with slides on our "Tough To Treat" YouTube channel for this episode.   A glance at this episode: [0:55] Finding the patient's primary driver from clues in their narrative [4:30] Post-partum tennis player with neck pain during a push-up, what her story tells you [9:11] How her injury and movement history will lead you to the driver(s) [13:06] What movement(s) to assess and how to make this much more efficient   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

How important are past events to present movement patterns and restrictions? What about past events of herniated lateral discs or hypermobility on the current presentation of the movement system? Clients can heal with faulty movement systems that can show up as new and different presentations in the future. This podcast is from a presentation that links the neuromuscular systems together and provides insight for evaluation and interventions.   A glance at this episode: [0:01] Lumbopelvic pain causes and treatment [5:02] Hip extension and lumbar spine rotation for efficient walking [8:48] Back pain and nerve root impingement [12:17] Hypermobile spine and neural patterning [16:20] Lumbar spine mobility and exercises for pain relief   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

In this empowering episode, we dive deep into the realm of fear-based movement and explore strategies to help patients conquer their anxieties, helping them move towards a more confident and pain-free existence.  Anxiety and fear of movement are real things and can prevail even when we are termed "fit to play", "fit to move" or "pain-free". Just because someone is pain-free, it doesn't mean that they can move well or move without fear.  We discuss the implications of movement anxiety and explore the roots of fear and how it manifests in the body. Our discussion involves 2 specific case studies where fear of a certain movement was stalling their recovery and includes specific techniques and exercises for a positive outcome.  By the end of this episode, you'll be equipped with valuable tools and insights to help your patients move better, even when fear holds them back.   A glance at this episode: [5:37] Interoception, beliefs, and structural integrity in physical therapy [10:12] Fear based pain with lumbar extension  [14:40] Graded exposure to movement [18:29] Movement re-patterning with specificity [26:11] An equestrian who is afraid to sit [30:15] Integrating variance into exercise [34:29] Using props to help patients overcome fear and improve movement patterns Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Discover the art of being an active listener who can pick up clues in your patient's narrative to help you find their driver quicker. This will save you lots of time in your movement assessment. Listen in as Erica discusses how to reframe your patient's story to help you maximize your time with them in the clinic. She discusses clues in their "subjective" that can aid you in prioritizing regions of the body to assess in your movement analysis. This is done with 3 case studies from her practice where she discusses each patient's story (injury and movement history) and what clues she honed in on to effectively make a clinical hypothesis about their driver(s).   A glance at this episode: [4:13] Analyzing movement and injury history and why a timeline matters [9:44] The importance of the narrative in assessing a patient's movement patterns. How to ask the right questions.  [15:17] Why the first injury sets them up and why their movement history keeps them there [20:20] Case study-tennis player who was unable to do a push up.  [23:43] Case study-neural tension restricting UE closed chain activities.  [27:09] Case study- runner with pelvic girdle pain whose driver was her foot Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Welcome to the New Year and one of the topics always discussed by Healthcare providers is burnout and imposter syndrome. Join Susan in this short podcast - Part 2 Taking back your mental fitness. Learn how to identify the voices of your inner Judge and Saboteurs, how to limit their voices, and find a pathway to your Sage Brain!   A glance at this episode: [3:21] Mindfulness techniques for neural plasticity [6:48] Mindfulness and neural pathways for busy people [10:33] Cultivating self-empathy and overcoming judgment [14:09] Positive Intelligence and Self-Improvement   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Welcome to the New Year and one of the topics always discussed by healthcare providers is burnout and imposter syndrome. Join Susan in this short podcast episode - Part 1 Taking back your mental fitness. Learn how to identify the voices of your inner Judge and Saboteurs, how to limit their voices, and find a pathway to your Sage Brain!   A glance at this episode: [4:38] Saboteurs in the brain and their impact on decision-making [9:11] Personality types and their impact on work performance [13:30] The disruptive role of saboteurs in decision-Making [18:27] Mental fitness in healthcare with a focus on saboteurs and sage powers   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Hip pain can be brutal. And more often than not-it's chronic. Not like an acute ankle sprain or even acute low back pain.  People who suffer from hip pain, for whatever reason, sink into the chronic side of musculoskeletal pain.  Let's face it-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, and why lateral rotator strengthening is not always the answer.   A glance at this episode: [2:15] Hip and knee pain case intro [5:08] Chronic hip pain and potential causes [9:35] Loss of mobility and symptoms [12:51] Hip movement and range of motion influences [19:04] Hip mobility and exercise prescription [22:31] Motor planning and motor control [25:45] Hip rotation and postural ramifications [31:12] Pelvic floor muscles and hip rotator imbalance [34:54] Physical therapy exercises for improving balance and reducing neurological symptoms [41:48] Treating hip pain through physical therapy [44:58] Manual therapy techniques for pain management   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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 cause 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.  Suppose you can get the thorax to move differently. In that case, this can help people down-train old movement patterns that do not serve them and ultimately restore global movement patterning across many tasks.  Key point: The thorax can be a key driver, in how someone transfers load after an injury (no matter when that injury took place). It is a region of the body that compensates for pain and dysfunction elsewhere and then ends up being the driver years later. Don't miss it.   A glance at this episode: [3:26] Thoracic mobility and breath control for pain relief [11:19] Breathing and muscle release techniques for thoracic spine mobility [14:26] Using sensory input with a theraband for thoracic mobility [19:19] Using closed kinetic chain exercises for thoracic mobility and abdominal strength [23:49] Assessing and treating shoulder injuries [29:23] Thoracic mobility and its impact on movement patterns [34:20] Thoracic rotation and breathing exercises for runners [43:05] Reintegrating movement patterns for whole-body wellness [47:42] Exercise and posture for older adults [52:12] Posture and movement for homeschooling and virtual work   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Many times, clinicians find that people with correlative GI system dysfunction are very overwhelming. The complexity makes it difficult to know where to begin to intervene.  Join us as Susan discusses some very simple mediations to help improve the GI system with stress, exercise, and sleep. Complex clinical pictures can often change when we address the foundations of health with simple interventions.   A glance at this episode: [1:38] Stress, its effects on the body, and exercise as a remedy [6:38] Exercise and stress management techniques [10:56] Sleep's impact on digestion and overall health [14:16] Improving sleep quality with expert tips   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Susan and Erica welcome Kelly McClain to the podcast to discuss a very complex client with pelvic health, orthopedic, and neurological issues.  Follow along as the client case is presented and we pursue a rich discussion of tying together the systems involved as well as the red flags. Digging deeper into the client's story is key here to help with obvious referrals and also to recognize other systems and issues deeper into the client's history to gain insight.   A glance at this episode: [3:05] Pelvic health issues and treatment [12:28] Patient's symptoms and medical history [20:20] Current medical issues and imaging recommendations [26:14] Clinical reasoning and potential diagnoses [31:08] Manual therapy for perineal pain [33:24] Rectal pain and paraesthesia during squatting [38:44] Treating patients with complex symptoms   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

Why doesn't my groin pain go away?  When someone is an athlete, you must understand what regions of the body are challenged with their sport. With soccer, you think of the thorax, foot, hip, and pelvis from the get-go.  Listen in as Erica discusses the movement she and her patient chose to assess and what they discovered.  Short-term treatment of someone's symptomatic region may help in the short term, but getting them back in the game is another matter entirely. When a person has an issue with a long lever movement like kicking a soccer ball, recognize and respect the length-tension relationships of the muscles involved in the movement, like how someone's lack of adductor power can stem from an overactive posterior tibialis muscle.   A glance at this episode: [4:05] Prioritizing physical therapy treatment based on specific sport and movement patterns [7:19] How to choose an appropriate movement pattern that is relevant to the patient yet specific to their sport [11:07] Where is the non-optimal patterning?  In the set up to the shot or in the kick? [15:21] Improving athletic performance through training optimal movement patterns   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

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 for assessing the whole foot, not just the ankle.  We also discuss why this patient's center of mass is biased toward her involved side and what implications this has for treatment.   A glance at this episode: [5:28] Patient's ankle injury and physical therapy [10:58] Assessing a patient's foot after a prolonged boot immobilization [15:14] Menopause and tendon issues after a fibula fracture [19:17] Rehabilitation strategies for a patient with a booted leg [23:53] Foot and ankle assessment and treatment [29:38] Assessing and treating a patient with lower extremity pain   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

We continue with our GI dysfunction theme in this podcast about food intolerances/sensitivities vs. allergies.  Join Susan as she takes you through the algorithm to understand how to recognize what is the underlying information behind why certain food bothers us and when we should eliminate food.   A glance at this episode: [3:49] Elimination diets for digestive health [7:42] Gluten sensitivity and its effects on the body [11:56] Gut microbiome's role in IBS symptoms and behavioral changes [15:20] Gut microbiome and its impact on health   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

How similar are the neuromuscular responses to pain with chronic low back pain and GI pain? Join Susan and Erica in a great discussion of the role of the diaphragm and how this changes with pain and inhibition/over-recruitment in the system. In chronic low back pain and abdominal bloating/distention the diaphragm becomes a postural control muscle which greatly limits the respiratory ability along with an ineffectual model for spine stiffness and visceral organ pusher. This is an excellent discussion following the podcast episode 185.  A glance at this episode: [3:13] How lying on your back affects breathing and posture [7:42] Abdominal wall dysfunction and its impact on GI function and low back pain [12:05] Abdominal diaphragm dysfunction in chronic low back pain [19:43] Treatment for diaphragm and abdominal wall dysfunction in chronic low back pain [25:24] Abdominal wall deficits and breathwork for chronic low back pain [31:43] Treating gas and bloating through pelvic health therapy [38:24] Treating GI dysfunction and Cushing's syndrome   Articles mentioned in the episode: Postural function of the diaphragm in persons with and without chronic low back pain. Abdomino-phrenic dyssynergia in patients with abdominal bloating and distension. Abdominal and Pelvic Floor Activity Related to Respiratory Diaphragmatic Activity in Subjects with and without Non-Specific Low Back Pain. Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

When do you treat the viscera?  And why?  This episode discusses a bit about the abdominal viscera. It is certainly not all-encompassing by any means. We just want our audience to be aware of the possibilities.  Erica relays some clues in the patient's history as to why you would screen for GI dysfunction. She uses 2 case examples of when the abdominal viscera was the secondary driver in one case and when it was a significant impairment in a patient with a dural driver in the other.  Once again, it all comes down to listening to your patient and connecting the dots.    A glance at this episode: [2:24] GI dysfunction and its relationship to manual therapy [7:10] Abdominal palpation and soft tissue work for low back pain [9:46] Identifying visceral dysfunction in patients with low back pain [14:26] Abdominal viscera and soft tissue restrictions   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

In this episode, Susan and Erica welcome Darcie Pervier to the mic!  Darcie is a pelvic health and orthopedic PT who practices a fully integrative approach to complex client care. Susan, Erica, and Darcie really delve into "brainstorming" various aspects of examination and intervention in connecting some dots on this complex canvas.  Dural issues, fracture healing, bone health red flags, thoracic stiffness, neural tension, and GI visceral systems are tied together to help guide more meaningful interventions for this client.  Hint: How to get a client to do some nervous system regulation when they don't want to!   A glance at this episode: [1:36] Patient's chronic pain and health history [9:47] Patient's medical history and physical exam findings [13:40] Patient's lower back pain and potential neural tension testing [21:24] Cancer survivor's pelvic floor issues and potential treatments [25:50] Patient's strengths and weaknesses in physical therapy exercises [27:59] Treating pelvic floor dysfunction and GI issues through manual therapy [35:37] Abdominal breathwork and body mechanics [41:19] Managing a complex patient with back pain   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

This episode captures a critical aspect of integrating sensory and motor aspects of colorectal rehab from constipation and IBS to fecal incontinence.  The information is categorized under the hyposensitive vs. the hypersensitive quality of symptoms and the motor control from decreased muscle capacity, tissue quality, and motoric coordination.   A glance at this episode: [3:27] Rectal balloon therapy for bowel dysfunction [7:58] Rectal muscle exercises for constipation management [12:46] Rectal sensitivity in IBS patients [17:01] Treating anal inertia through physical therapy   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  

In this episode, Erica and Susan welcome Julia Rosenthal to the mic.  Julia is a physical therapist in NYC. She brings a complex case of a postpartum patient of hers who has symptoms of urinary incontinence as well as other bowel and bladder issues that were made worse after giving birth.  The patient is a personal trainer and used to high-load exercise, so the need to get back to this is strong. She also has complaints of abdominal bloating along with occasional musculoskeletal pain with CKC lower extremity work.  This discussion is rich in treatment interventions for Julia's patient- from nutritional strategies to hormonal interventions to specific exercises the patient can do while feeling like she is loading her system in the necessary ways. Erica and Susan also discuss the importance of the thorax and its relationship to the pelvis and how best to balance these 2 regions of the body.   A glance at this episode: [2:13] Pelvic floor and orthopedic physical therapy for a postpartum woman with GI issues and fecal smearing [9:50] Postpartum bladder issues and musculoskeletal complaints [17:33] Thyroid issues and autoimmune disorders [21:36] Assessment and intervention for a patient with chronic constipation and pelvic floor dysfunction [27:36] Patient's pelvic floor mobility and lifestyle changes [33:06] Abdominal issues and breathing patterns [38:01] Managing IBS symptoms through breathing exercises and mindful eating [44:02] Using Nerva app for mental health [47:31] Exercises for a pregnant woman with thoracic issues [53:27] Addressing a personal trainer's physical and mental health issues [1:00:01] Patient care and therapy approaches.   Related links: Tough To Treat Website Erica's Course: Decoding the Complex Patient Susan's Pelvic Health Education Subscription Access the Transcript  Julia Rosenthal Website Julia Rosenthal IG