Physio Edge podcast

When your patient has neck and arm pain, or low back and leg pain from neural tissue pain disorders (NTPD) such as peripheral nerve sensitisation (PNS), how will you treat them? Pain associated with PNS can occasionally be mild and non-irritable, but more often than not, it’s severe, highly irritable, and easy to stir up.

How can you provide treatment that settles their pain, without stirring them up? What advice, education, manual therapy and exercise will you provide to help improve symptoms and speed up recovery? What are the keys to success with PNS patients?

In Physio Edge podcast 104Dr Toby Hall and I discussed PNS, common symptoms, causes, questions to ask, and how to assess and diagnose PNS in your patients. In this followup podcast, the second in our two-part series, Dr Toby Hall and I take you through the next phase - how to treat PNS. You’ll discover:

  • The 7 keys to success with PNS
  • How to successfully treat PNS in the neck and upper limb, AND the low back and lower limb.
  • What education and advice should you provide to your patient about activities to avoid or reduce, and which activities should they increase?
  • What are the most effective exercises for patients with PNS?
  • Should exercise be painful or painless?
  • When is neural mobilisation an effective treatment?
  • When should you avoid using neural mobilisation as a treatment?
  • Is manual therapy effective in PNS?
  • Which manual therapy techniques can you use to improve symptoms and range of movement (ROM) immediately?
  • How to perform effective manual therapy techniques that reduce pain without stirring up your patients.
  • How can you combine neural mobilisation with manual therapy?
  • If you use manual therapy to improve symptoms, what home exercises should patients perform after each treatment session?
Direct download: 107._Treatment_of_peripheral_nerve_sensitisation_with_Dr_Toby_Hall.mp3
Category:general -- posted at: 2:05pm AEDT

Explore cervical radiculopathy, central sensitisation, achilles tendinopathy, hip & groin pain, & strength tests for athletes with Simon Olivotto, Dave Toomey, Paula Peralta & Nick Kendrick.
In this Clinical Edge member Q&A, the Clinical Edge Senior Physio Education & Presentation team discussed:


Cervical radiculopathy patients with an irritable presentation

  • Do imaging findings such as modic changes, alter our management
  • How can you approach treatment of cervical radiculopathy?
  • Are medications indicated?
  • Red flags you need to rule out
  • Are sliders and gliders a useful treatment?

 

Sensitivity to cold or ice

  • How can you use tests to identify sensitivity to cold or ice to guide your treatment?
  • Does ice sensitivity indicate central sensitisation?
  • How does this impact management?
  • If your whiplash patients have sensitivity to cold or ice, how does this impact treatment & prognosis?
  • Which research articles cover this topic?

 

Calf & achilles strengthening

  • When is it best to perform calf raises into dorsiflexion (DF)?
  • When should you avoid strengthening the calf into end of range (EOR) DF?
  • What ankle issues may lead you to avoid strengthening or stretching into EOR DF?

 

Hip joint pain and the acetabular labrum

  • Can we identify when the labrum is responsible for hip or groin pain?
  • What tests are important to perform in patients with hip or groin pain?
  • If deep structures such as the hip joint are painful or injured, does this mean more superficial structures such as the acetabular labrum are also pain generators?

 

Strength assessment & screening of athletes

  • What strength screening tests can you perform in athletes with large demands such as motorcross?
  • Which areas do you need to assess?
  • What are simple and more complex ways to assess strength in different regions of the body?
  • What are important considerations when designing a S&C program for a motocross athlete?
  • Making sense of pain

 

How can you make sense of pain? How can you describe pain to your patients in a way that makes sense, and doesn’t tell them “it’s all in your head”? Find out how to improve your confidence with acute and persistent pain in the upcoming “Making sense of pain” module.

Warning: Contains swearing

 

 

Articles associated with this episode:

 


When you assess your patients shoulder movements, and notice a winging scapula, altered resting position or timing of scapula movement, do you need to treat it? Can we diagnose “Scapular dyskinesis”, and does it matter? How can you simplify your scapular assessment?

In this podcast, Jo Gibson (Clinical Physiotherapy Specialist) explores common beliefs and myths around the scapula, including:

  1. Abnormal scapular kinematics cause pain
  2. We can predict patients that are going to get shoulder pain
  3. Upper traps should be retrained to decrease their activation
  4. Scapular-based interventions are superior to rotator cuff based treatment
  5. There are reliable and valid ways to assess scapular movement

Alongside this mythbusting, you’ll explore:

  • Is there any point assessing the scapula?
  • Is scapular asymmetry normal or abnormal?
  • Is scapular dyskinesis a normal response to exercise or loading?
  • How accurate are we at identifying scapular dyskinesis compared to findings in laboratory studies of scapula movement?
  • What scapular findings will you commonly observe in patients with massive rotator cuff tears, nerve injuries & stiffness?
  • How does rotator cuff fatigue impact scapular movement?
  • How does fear avoidance and worry about particular movements impact muscle activity and movement?
  • When is increased upper traps activity helpful and beneficial?
  • Should we try to decrease upper traps activity in patients with C/Sp driven shoulder pain?
  • Can we preferentially target the scapular or rotator cuff with our exercises?
  • Do improvements in shoulder pain correlate with changes or “improvements” in scapular movement?
  • How do scapular assessment test (SAT) results impact your treatment and exercise prescription?
  • If the SAT improves pain, does that mean we should perform scapular based exercises?
  • Can we use scapular dyskinesia classification to stratify patients or guide our treatment?
  • Is there any reliability in scapular assessment?
  • Does the SAT simply identify those that have a favourable natural history ie are going to get better on their own regardless?
  • Do scapular treatments increase the subacromial space, and does this matter?
  • Is winging post-surgery (posterior stabilisation + labral repair) a product of surgery or does this need to be addressed?
  • How does incorporating the kinetic chain into rehab impact patient movement strategies, scapular and rotator cuff recruitment?
  • Are scapulothoracic bursae relevant to shoulder pain?
  • How can you address patient beliefs and fear avoidance around their shoulder pain?

Articles associated with this episode:

Direct download: 105._Scapular_dyskinesis_-_Does_it_really_matter_with_Jo_Gibson.mp3
Category:general -- posted at: 4:25pm AEDT

When your patient has leg, shoulder or arm pain, how can you identify if their pain is due to neural tissue compression, sensitisation or irritation? How can you differentiate whether pain is from neural tissue or local structures like nearby joints, tendons or muscles? What questions and objective tests will help you diagnose a neural tissue pain disorder (NTPD)?

In this podcast with Dr Toby Hall (Specialist Musculoskeletal Physiotherapist, FACP, PhD), you’ll discover:

  • Three types of neural tissue pain disorders, and how to identify each one
  • What is Peripheral nerve sensitisation (PNS)?
  • What clues in your subjective examination will help you identify PNS?
  • Why do nerves become inflamed or irritated?
  • How to identify & differentiate radiculopathy and radicular pain in patients with radiating limb pain.
  • Do all patients with NTPD have obvious neuro symptoms such as pins and needles, numbness or weakness?
  • Quick screening tests you can use in your assessment to identify PNS.
  • How to identify if your patients shoulder and arm pain is from neural tissue or from local shoulder structures.
  • How to diagnose a NTPD in patients with hip or leg pain.
  • How to perform passive neurodynamic tests such as the straight leg raise (SLR), upper limb neurodynamic test (ULNT), slump test and femoral nerve slump test.
  • What information does a positive or negative neurodynamic test provide?
  • Can we identify the location of a nerve lesion or irritation with our passive neurodynamic tests or palpation?
  • Initial PNS treatment options
  • Is exercise helpful or harmful in patients with PNS?
  • How can you palpate over neural tissue, and what information does this provide?
  • Do opioids provide pain relief, or prolong recovery in patients with NTPD?

This podcast is the first part in a two part series on neural tissue pain disorders with Dr Toby Hall. Part 1 (this podcast) guides you through the types of NTPD, and how to assess and diagnose NTPD. Part 2 (available soon) will take you through how to treat PNS.

I highly recommend listening to this episode (part 1) prior to part 2, to have a thorough understanding of when and how to treat PNS.


A young male patient woke with an acute onset of constant, shooting shoulder pain, is painful into abduction, reluctant to lift his arm, and feels like he’s losing shoulder strength. He has no recent history of injury. 

Can you diagnose this unusual cause of shoulder pain, based on this patient's symptoms and physical tests? What are your differential diagnoses and red flags to keep in mind with this patient? 

In this podcast, Jo Gibson puts your knowledge of shoulder pain and diagnostic skills to the test, and explores how you can treat patients with this diagnosis.

Articles associated with this episode:

Get access to free videos with Jo Gibson on diagnosis of shoulder pain at clinicaledge.co/shoulder

Direct download: 103._An_unusual_cause_of_shoulder_pain_with_Jo_Gibson.mp3
Category:general -- posted at: 1:24pm AEDT

Do you include stretches in your treatment of shoulder pain? Have you ever identified a glenohumeral internal rotation deficit (GIRD) and used the "Sleeper stretch" to help improve internal rotation? Do stretches have any value for shoulder pain, or are there better treatment options?

In this podcast, Jo Gibson (Clinical Physiotherapy Specialist) discusses how to differentiate true capsular stiffness from muscle stiffness, what information GIRD provides, and whether sleeper stretches for shoulder pain are a useful treatment.

Jo explores the current research and clinical implications on your treatment, including:

  • What is the driver of decreased range of movement (ROM)?
  • If we get immediate changes in ROM with a sleeper stretch, does that mean we should use this as a treatment?
  • Is stretching an effective, efficient and evidence-based treatment?
  • Can we use strengthening movements to improve range and cuff recruitment?
  • What exercises can you use with patients with GIRD to improve ROM and cuff recruitment?
  • Humeral retroversion and how torsional load from throwing sports at a young age impact your ROM assessment.
  • If you have a patient with GIRD, what does this tell you?
  • In patients with true capsular stiffness, does stretching in combination with damp heat have a role?
  • Does eccentric strengthening have a role in improving GIRD in patients with true capsular stiffness or fibrosis?
  • How can you use GIRD to monitor your athletes fatigue and recovery?

Links associated with this episode:

Articles associated with this episode:


Shoulder surgery in athletes is common following dislocation. Accelerated post-op shoulder stabilisation rehab protocols include early mobilisation to reduce movement, proprioceptive and strength deficits. This has allowed earlier return to play (RTP), however athletes often still have significant proprioceptive and strength deficits up to 2 years post surgery. Despite getting back to play, athletes may struggle to get back to performance.

Following surgery, contact athletes such as rugby players, throwing athletes and young players have additional RTP challenges. Redislocation risks in contact sports such as rugby are high, leading to poor outcomes. Younger athletes are not skeletally mature, and with early RTP following stabilisation surgery may have higher failure rates. How can you identify and address these challenges?

Which tests and features in a patients history help you determine whether a patient is suitable for an early RTP? In this podcast with Jo Gibson (Clinical Physiotherapy Specialist), you’ll explore:

  • Which shoulder tests are most valuable with your patients?
  • How has emerging evidence challenged our previous approach to RTP testing?
  • What are the risks associated with early RTP following shoulder surgery?
  • How can you help identify athletes at risk of redislocation?
  • Which psychosocial factors impact RTP?
  • How does fear of reinjury and levels of anxiety about their shoulder affect RTP?
  • How does your patient’s sport of choice affects dislocation risks?
  • How is RTP impacted by patients age?
  • How do daily stressors impact RTP and predict outcomes?
  • Which psychosocial factors impact RTP?
  • What is the biggest factor in whether an athlete gets back to play?
  • Which question are key to ask your patients?
  • Which questionnaires can you use with your post-op shoulder patients?
  • Which tests and combinations of tests have been validated and are evidence-based?
  • How can you assess range of movement (ROM)?
  • How can you measure patients strength?
  • How is rate of force development (RFD) affected following shoulder injury?
  • How can you assess RFD?
  • How does fatigue impact strength testing eg testing at the start of training compared to the after training?
  • How does the kinetic chain impact RTP testing for throwers?
  • How can you assess shoulder endurance?
  • RTP tests for swimmers
  • What role does manual therapy have in shoulder rehab?

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Articles associated with this episode:

CLICK HERE to download the articles associated with this podcast

Direct download: 101._Return_to_play_testing_after_shoulder_surgery_with_Jo_Gibson.mp3
Category:general -- posted at: 10:48am AEDT

100 Physio Edge podcast episodes since I discovered a love of podcasts, and created the Physio Edge podcast to help Physio’s, Physical Therapists and other health professionals in their clinical practice with practical information from the leaders in different musculoskeletal and sports injuries. I really enjoy recording each podcast, helping you with your clinical challenges and hearing how the podcast has helped you with your patients.

While recording each of these podcasts, I’ve noticed that one area Physiotherapy experts & leaders have in common is their well developed clinical reasoning. They use effective & efficient clinical problem solving to assess and treat their patients. How can you improve your clinical reasoning to more effectively assess and treat your patients?

In this podcast with the new Clinical Edge Senior Physio education & presentation team - David Toomey (NZ based Musculoskeletal Physio), Jordan Craig (APA Titled Musculoskeletal & Sports Physio) and Simon Olivotto (Specialist Musculoskeletal Physiotherapist, FACP), you’ll explore:

  • Five practical strategies you can use immediately to improve your clinical reasoning and treatment results.
  • Clinical reasoning - what is it and how will it help you with your patients?
  • How to effectively & efficiently assess and treat in short treatment sessions
  • How to create a rehabilitation or training plan for a patient to suit their individual needs.
  • Low back pain patients - How to use clinical reasoning to target your questioning, objective assessment and treatment to your patients needs

Download this podcast now to improve your clinical reasoning and treatment results with these five practical strategies.

Download and subscribe to the podcast on iTunes
Download the podcast now using the best podcast app currently in existence - Overcast
Listen to the podcast on Spotify
Improve your clinical reasoning, assessment and treatment effectiveness, efficiency and results with a free trial Clinical Edge membership
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Articles associated with this episode:

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Patients with shoulder pain, rotator cuff tears and nerve injuries can often be seen shrugging their shoulder while they lift their arm, appearing to overuse their upper fibres of trapezius. Surface EMG research has shown increased activity in UFT in shoulder pain and whiplash patients. To add to this, patients get sore upper traps, and can be adamant that they need regular massage of their upper fibres of trapezius (UFT).

We seem to have plenty of evidence that we need to decrease UFT muscle activity, and help this by providing exercises to target the middle and lower traps.

Is this really the case? Are the upper traps really a bad guy, or a victim caught in the spotlight? Do we need to decrease upper traps muscle activity to help our patients shoulder or neck pain? Or perhaps counter-intuitively, do we need to strengthen upper traps and help them to work together with the surrounding muscles?

In this podcast, Jo Gibson (Clinical Specialist Physio) explores the evidence around the upper fibres of trapezius, and implications on your clinical practice. You’ll discover:

  • What are the myths around upper traps?
  • Are upper fibres of trapezius a bad guy or a victim?
  • Why do upper traps sometimes seem to be overactive?
  • Should we aim to increase the activity in middle and lower traps?
  • What information does surface EMG really provide?
  • Can taping of the scapula change recruitment of the trapezius?
  • Should we strengthen UFT?
  • Why is initial activation of the UFT important in shoulder elevation movements?
  • Why should patients with rotator cuff tears or stiff & painful shoulders use upper traps more with their movements?
  • How can we incorporate UFT strengthening into our shoulder strengthening?
  • What exercises can we use to strengthen UFT without increasing activity in levator scapulae?
  • Why is UFT strengthening important in ACJ injury rehab?
  • In gym goers, what scapula setting errors are commonly used?
  • How do nerve injuries that affect the upper traps impact movement?
  • Do trigger points or soreness indicate that our patients need massage or exercises to decrease UFT activity?

Download this episode now to improve your treatment of shoulder and neck pain.

Download and subscribe to the podcast on iTunes
Listen to the podcast on Spotify
Improve your diagnosis of acute shoulder pain with 3 free videos with Jo Gibson
Improve your confidence and clinical reasoning with a free trial Clinical Edge membership
Let David know what you liked about this podcast on Twitter
Review the podcast on iTunes
Like the podcast on Facebook
Infographics by Clinical Edge
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Articles associated with this episode:

CLICK HERE to download the articles associated with this podcast
Lee JH, Cynn HS, Choi WJ, Jeong HJ, Yoon TL. Various shrug exercises can change scapular kinematics and scapular rotator muscle activities in subjects with scapular downward rotation syndrome. Human movement science. 2016 Feb 1;45:119-29.
Pizzari T, Wickham J, Balster S, Ganderton C, Watson L. Modifying a shrug exercise can facilitate the upward rotator muscles of the scapula. Clinical Biomechanics. 2014 Feb 1;29(2):201-5.

Direct download: Physio_Edge_099_Upper_traps_-_are_they_really_a_bad_guy_with_Jo_Gibson.mp3
Category:general -- posted at: 2:19pm AEDT

Strength training can be used in your treatment and rehab programs to improve your patients strength, load capacity, function & pain, so they can get back into work and the activities they enjoy. In your athletic patients, strength training can be used to help restore power and speed, which are vital for sporting performance.

Would you like to include more strength training in your treatment, but aren’t completely sure about the most effective ways to build strength? Which exercises can you use? How many sets and reps should your patients perform? Will 3 sets of 10 reps build strength effectively? What is power training, when should you focus on improving power, and how can you incorporate power training?

In this podcast with David Joyce - Sports Physiotherapist, S&C expert and co-author of High performance training for sports, and Sports injury prevention and rehabilitation, you will discover:

  • How to use strength training with your patients
  • The most effective ways to help your patients develop strength
  • Set and rep ranges for strength improvements
  • Recent developments in S&C
  • What is power & power training, and how does this compare to strength?
  • When should your patients work on improving power vs strength
  • How to improve power using different areas on the force/velocity curve
  • Power development using bodyweight and barbell exercises
  • Calf strengthening
  • How to incorporate velocity/explosiveness training
  • When are higher reps useful?
  • Does endurance training with higher reps carryover to improved running or cycling
  • When your patients are performing deadlifts or squats, what elements should you monitor?
  • Do biomechanics in a deadlift or squat matter?
  • What rest periods should be used to help develop strength, while maintaining an efficient training routine
  • What is strength training vs conditioning?
  • How can patients perform conditioning for improved fitness?
  • Should conditioning be incorporated into strength training sessions for maximum improvements in strength?
  • Should exercises and sets be performed to temporary muscular failure (when the bar is unable to be lifted for another repetition)
  • Resources to help improve your strength & conditioning

 

 

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Long head of biceps (LHB) tendinopathy and associated anterior shoulder pain can develop in patients that increase their lifting load eg moving house, overhead activities, activities that involve loaded shoulder extension and in throwing athletes. Patients may also develop long head of biceps tendon pain after a traumatic ACJ injury or SLAP tear.

How can you identify and treat LHB tendinopathy? In this podcast with Jo Gibson, you’ll explore:

What causes LHB tendinopathy?

  • What mechanisms of injury commonly cause LHB pain, ACJ injury or SLAP tears?
  • Key traumas you need to keep an eye out for that impact LHB
  • Why do patients with ACJ injuries develop LHB pain?
  • Why do patients with SLAP lesions develop LHB pain?
  • What causes LHB reactive tendinopathy?

LHB Anatomy & function

  • What activities does LHB help with?
  • Long head of biceps (LHB) anatomy
  • Variance in proximal biceps attachment and how traumatic LHB injuries impact different structures
  • How the LHB is stabilised anatomically in the bicipital groove
  • Does the transverse ligament exist?

Patient features that help your diagnosis

  • Which patients are likely to present with LHB pain?
  • Which structures are more likely to be affected with traumatic shoulder injuries in younger vs older patients?
  • Why do young patients with LHB instability develop pain?

Subjective history features that help your diagnosis

  • Where do patients with LHB tendinopathy experience pain?
  • Which movements are likely to be painful in LHB tendinopathy patients?

Objective testing & diagnosis

  • Which tests or combinations of tests help diagnose LHB pain?
  • Which special tests help your diagnosis?
  • Does palpation have any value in LHB diagnosis?
  • How can you exclude intra-articular pathology with your testing?
  • How can you rule in or rule out rotator cuff pathology?

Rotator cuff tears & involvement in LHB

  • How does LHB muscle activity vary in painful vs painfree massive rotator cuff tear patients?
  • How do traumatic rotator cuff tears, particularly subscapularis, impact LHB?
  • If patients have rotator cuff surgery, what details in the operation notes will help you identify if they are at risk of persistent post-op pain and stiffness?
  • Why do subscapularis tears cause LHB pain?

Imaging

  • What information does imaging of LHB provide?
  • What imaging can you use if your patient is not progressing?
  • MRI vs MRA vs US for different pain & injuries

How to treat LHB

  • What is the best way to treat LHB tendon pain?
  • Are isometrics helpful with LHB, and how do these help?
  • What surgery is used for LHB pain?

Additional questions covered

  • How are results after rotator cuff tears impacted by the rotator interval?

Download and subscribe to the podcast on iTunes
Improve your diagnosis of acute shoulder pain with 3 free videos with Jo Gibson
Improve your confidence and clinical reasoning with a free trial Clinical Edge membership
Let David know what you liked about this podcast on Twitter
Review the podcast on iTunes
Like the podcast on Facebook
Infographics by Clinical Edge
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