No Plateau Podcast

In this episode of the No Plateau Podcast, host Henry Hoffman sits down with Dr. Clay Guynn, a board-certified PM&R physician with fellowship training in sports medicine, to tackle one of the most common and frustrating complications after stroke: hemiplegic shoulder pain.

Dr. Guynn breaks down why shoulder pain after stroke is rarely a single diagnosis; it can arise from spasticity, musculoskeletal issues, neuropathic pain, or any combination of the three. He explains his "onion" approach to evaluation, where each layer of pain must be identified and addressed individually. The conversation covers diagnostic workups, the role of ultrasound-guided procedures, and how interventions like hydrodilation, diagnostic nerve blocks, Botox, and cryoneurolysis fit into the treatment puzzle.

Henry and Dr. Guynn also explore why early physiatry involvement matters, the critical role of therapists in both identifying pain generators and maximizing the benefits of medical interventions, and why communication between providers is the single most important factor in successful outcomes.

Dr. Guynn shares practical insights from his practice, from performing suprascapular nerve blocks to using hydrodilation for frozen shoulder to leveraging cryoneurolysis for longer-lasting spasticity relief. The episode underscores that hemiplegic shoulder pain isn't just about treating pain; it's about enabling patients to engage their impaired side, which directly impacts neuroplasticity and long-term recovery.

Listen to the full episode to learn how a multidisciplinary, layered approach can transform the way we understand and treat post-stroke shoulder pain.

In This Episode

Our Guest

Clay Guynn, DO 

Dr. Clay Guynn is a triple board-certified PM&R physician and osteopathic physician fellowship-trained in sports medicine, currently practicing in Atlanta, Georgia. He completed his PM&R residency at the University of Kentucky and a sports and spine fellowship in Florida. His clinical practice spans the full spectrum of physiatry, from spinal cord injury, stroke, and cerebral palsy patients to elite athletes, he serves as head team doctor for USA Blind Soccer (traveling with the team through the 2028 Games) and cares for athletes at four high schools and a college. His interventional toolbox includes diagnostic nerve blocks, joint and soft tissue injections, botulinum toxin, radiofrequency procedures, and cryoneurolysis, which he has used for spasticity management for the past four years with strong results. 

Resources & Links

In this episode of the No Plateau podcast, host Henry Hoffman sits down with physiatrist and researcher Dr. Paul Winston to talk about cryoneurolysis, an emerging treatment that is gaining attention in neurorehabilitation.

Dr. Winston breaks down how this minimally invasive technique works and why it is generating excitement among clinicians treating spasticity. Using a probe that delivers extremely cold temperatures, around −88°C, through gases like nitrous oxide, clinicians create a small “ice ball” around targeted peripheral nerves. This controlled freezing temporarily interrupts the nerve signals that drive muscle overactivity. The key advantage is that the nerve’s structure stays intact, allowing it to regenerate over time and creating a valuable window for rehabilitation and functional recovery.

Henry and Dr. Winston also explore how cryoneurolysis compares with more familiar treatments like botulinum toxin injections, nerve blocks, and surgical approaches. While some treatments chemically block or damage nerve signaling, cryoneurolysis uses a physical process that allows nerves to recover gradually.

Dr. Winston shares stories that will stick with you, the husband grasping his wife's hand for the first time in years, the 12-year-old boy applying his own deodorant, the patient who threw away his AFO and now runs through the neighborhood. These aren't just clinical successes; they're reminders of why we do this work. The conversation also highlights how collaboration between physicians, occupational therapists, and physical therapists can help patients make the most of this recovery window.

Listen to the full episode to learn how cryoneurolysis may reshape the future of spasticity treatment and what it could mean for your clinical practice or rehabilitation journey.

In This Episode

Podcast disclaimer (00:09)

Introduction to Dr. Paul Winston (01:21)

From dance to rehab (02:44)

How cryoneurolysis differs from cryotherapy (05:35)

How cryoneurolysis became part of Dr. Winston’s practice (09:11)

The first cryoneurolysis patient: eureka moment that changed everything (13:13)

Anatomy of a nerve: what actually happens during cryo (16:28)

Using ultrasound and electrical stimulation to target nerves (23:30)

Sensory vs motor nerves in cryoneurolysis treatment (25:58)

What spasticity really is beyond textbook definitions (30:02)

Comparing common spasticity interventions: Botox, phenol, and cryoneurolysis (33:44)

Choosing cryo vs Botox (38:35)

Toxin vs cryo: comparing mechanisms and applications (39:26)

How Botox works (41:33)

Contraindications and potential side effects of cryoneurolysis (43:21)

How therapists should use cryoneurolysis in rehab (50:01)

Real patient outcomes and functional improvements (56:01)

The future of cryoneurolysis in rehabilitation (01:00:53)

Understanding reducible deformity vs contracture (01:05:38)

Where clinicians can learn more about cryoneurolysis (01:07:56)

Our Guest

Dr. Paul Winston, MD

Dr. Paul Winston is a Canadian physiatrist and Clinical Associate Professor at the University of British Columbia specializing in neurological rehabilitation and spasticity management. Originally trained as a dancer at Canada’s National Ballet School, he brings a unique perspective on movement to rehabilitation medicine. He is widely recognized for advancing cryoneurolysis and is a co-founder of the Canadian Advances in Neuro Orthopedics for Spasticity Consortium. His work focuses on improving movement and quality of life for people living with neurological disabilities.

Resources & Links

Dr. Paul Winston on LinkedIn

Henry Hoffman on LinkedIn

Saebo

On YouTube

On Instagram

On LinkedIn

In this episode of the No Plateau Podcast, host Henry Hoffman dives deep into one of the most misunderstood and impactful challenges in neurorehabilitation: spasticity. Joined by nationally recognized physiatrist and researcher Dr. Monica Verduzco-Gutierrez, the conversation goes far beyond definitions to explore how spasticity truly affects function, quality of life, access to care, and long-term outcomes for stroke and brain injury survivors.

Dr. Verduzco-Gutierrez breaks down why the classic, textbook definition of spasticity falls short in real-world practice and explains how clinicians should think about spasticity as part of a broader upper motor neuron syndrome. Together, they unpack how spasticity actually presents in daily life, how to explain it clearly to patients and caregivers, and why functional assessment matters more than a number on a scale.

The discussion walks through the full spectrum of spasticity management, from therapy and home exercise to oral medications, botulinum toxin injections, neurolysis options like phenol, alcohol, and emerging cryoneurolysis, and when surgical interventions may be appropriate. Henry and Monica also explore why spasticity treatment must be goal-driven, revisited over time, and always paired with rehabilitation rather than viewed as a one-time fix.

The episode closes with an eye-opening look at disparities in access to spasticity care, cost-effectiveness research, and why treating spasticity early and appropriately can reduce hospitalizations, complications, and overall healthcare costs. This is a must-listen for clinicians, caregivers, and survivors who want a clearer, more practical roadmap for managing spasticity well.

In This Episode

Introduction to the No Plateau Podcast (00:00)

Meet Dr. Monica Verdusco Gutierrez (00:59)

Understanding spasticity: Definitions and misconceptions (02:59)

Assessing spasticity: Tools and techniques (08:35)

Treatment options for spasticity (12:38)

Neurolysis: Phenol, alcohol, and cryo (16:23)

The importance of functional goals in spasticity management (22:43)

Introducing the AAPM&R consensus guidance (24:39)

Getting feedback from patients and therapists (28:37)

Botox and other toxin treatments (29:07)

Exploring cryotherapy for spasticity (29:57)

Disparities in access to spasticity care (31:10)

Cost efficiency in spasticity management (36:56)

Caregiver challenges in managing spasticity (42:14)

Communication between therapists and physicians (44:47)

Future directions in spasticity management (51:20)

Conclusion and final thoughts (54:51)

Our Guest

Monica Verduzco-Gutierrez, MD

Dr. Monica Verduzco-Gutierrez is a board-certified physiatrist specializing in neurorehabilitation and spasticity management. She is a Professor and Distinguished Chair of Rehabilitation Medicine at UT Health San Antonio, Medical Director of Neurorehabilitation at Warm Springs Rehabilitation Hospital, and lead author of the AAPM&R Consensus Guidance on Spasticity Assessment and Management. Dr. Verduzco-Gutierrez is widely published on spasticity, health equity, and cost-effectiveness in rehabilitation medicine.

Resources & Links

AAPM&R Consensus Guidance on Spasticity Assessment and Management (2024)

UT Health San Antonio – Department of Rehabilitation Medicine

Monica Verduzco-Gutierrez on LinkedIn

Monica Verduzco-Gutierrez UT Health

Henry Hoffman on LinkedIn

Saebo

On YouTube

On Instagram

On LinkedIn

Saebo’s Stroke Caregiver Support Group

Saebo’s Stroke Survivor Support Group

Stroke Guidelines 2023

In this episode of the No Plateau Podcast, host Henry Hoffman sits down with occupational therapist, researcher, and educator Annie McCluskey to unpack the neurorehab lessons she wishes she had known as a new grad. With over 30 years of experience in stroke and brain injury rehabilitation, Annie brings a refreshingly honest perspective on how practice has evolved and where clinicians still get stuck.

They dive into big topics like becoming a true movement scientist early on, why repetition, intensity, and high dose practice matter from day one, and how fear once held therapists back from pushing patients hard enough. Why were we so cautious for so long? And what does the evidence actually say now? Annie challenges outdated habits like excessive hands on facilitation, routine splinting, and low rep sessions, advocating instead for task specific, meaningful practice that patients can carry beyond therapy hours.

The conversation also explores courage, having the confidence to question tradition, de implement ineffective treatments, and speak up in clinical settings. What should new grads stop doing immediately? And how can they collaborate more deeply with stroke survivors rather than prescribing one size fits all programs?

This episode is a must listen for students, new grads, and seasoned clinicians ready to rethink how neurorehab is delivered and how much better it could be.

In This Episode

Introduction to Annie McCluskey (00:00)

The Birth of Stroke Ed (03:03)

Lesson 1: Becoming a Movement Scientist (06:12)

Lesson 2: Repetition, Intensity, and High Dose Practice (12:42)

Lesson 3: Being Courageous in Clinical Decisions (25:34)

Introduction to Bo Bath Therapy (27:57)

Task-Specific Training vs. Bo Bath (28:49)

Challenges in Therapy Approaches (29:48)

The Evolution of Strength Training (31:05)

Hands-On Therapy and Its Limitations (34:46)

The Importance of Hand Function (36:51)

Collaborative Rehabilitation Planning (40:38)

Advice for New OT Graduates (44:23)

Resources and Courses for Therapists (49:01)

Conclusion and Final Thoughts (51:27)

Our Guest

Annie McCluskey, OT, PhD

Annie McCluskey is an occupational therapist, researcher, and educator with over 30 years of experience in stroke and brain injury rehabilitation across Australia, the UK, and internationally. She has published more than 70 peer-reviewed journal articles, contributed to multiple book chapters, and secured over $4 million in competitive research funding. Annie is the co-developer and director of StrokeEd, an education platform dedicated to translating evidence-based neurorehabilitation research into everyday clinical practice.

Resources & Links

StrokeEd Website

StrokeEd Free Lecture Series

StrokeEd Online Workshops & MOOCs

Annie McCluskey on LinkedIn

Henry Hoffman on LinkedIn

Saebo

On YouTube

On Instagram

On LinkedIn

Saebo’s Stroke Caregiver Support Group

Saebo’s Stroke Survivor Support Group

Stroke Guidelines 2023

In this episode of the No Plateau Podcast, Henry Hoffman sits down with Amber Walter, Clinical Science Director, and Caitlin Wright, Occupational Therapy Advisor at Sheltering Arms Institute, to dig into one of the biggest debates in stroke rehab: should therapy focus on restoring movement, or teaching patients to adapt with compensatory strategies? But on the other hand, if therapy leans too much on compensation, are we robbing the brain of its chance to truly recover?

Amber and Caitlin share how Sheltering Arms has taken a bold stance by committing to a neuro-restorative model of care, one built on intensity, technology, and outcome-driven practice. They talk about the science of neuroplasticity, the dangers of defaulting to one-handed strategies, and why therapists need to start planting seeds of recovery early, even for patients with the most severe deficits.

Throughout the conversation, you’ll hear why high-repetition, evidence-based therapy matters, how technology extends what therapists can do, and why the future of stroke rehab depends on longer, more intensive sessions that focus on restoration, not just adaptation.

In This Episode

Introduction to Caitlin Wright and Amber Walter (00:00)

The Importance of Neuroplasticity in Stroke Recovery (05:23)

Challenges in Current Stroke Rehabilitation Practices (07:25)

Sheltering Arms Institute: A New Approach (12:46)

Implementing Restorative Therapy at Sheltering Arms (15:05)

Technology and Evidence-Based Practices in Therapy (20:30)

Evaluating and Treating Stroke Patients (24:13)

Therapist Fatigue and Technology in Patient Recovery (31:44)

Critical Components for Severe Impairment Recovery (32:34)

Balancing ADLs and Intensive Therapy (35:31)

Historical Perspective on Rehabilitation (37:25)

Innovative Approaches in Modern Rehabilitation (38:35)

Case Study: Remarkable Patient Recovery (44:18)

Implementing Evidence-Based Practices (55:38)

Closing Thoughts and Recommendations (56:04)

Our Guests

Amber Walter, PT, DPT, NCS, is the Clinical Science Director at Sheltering Arms Institute in Richmond, VA. She oversees multiple therapy disciplines and specializes in translating research into everyday practice to improve outcomes for stroke and brain injury survivors.

Caitlin Wright, MOT, OTR/L, is an Occupational Therapy Advisor at Sheltering Arms Institute. She is board-certified in physical rehabilitation and a certified brain injury specialist, with expertise in implementing neuro-restorative strategies to maximize recovery potential.

Resources & Links

Sheltering Arms Institute Website

Amber Walter on LinkedIn

Caitlin Wright on LinkedIn

Henry Hoffman on LinkedIn

Saebo

On YouTube

On Instagram

On LinkedIn

Saebo’s Stroke Caregiver Support Group

Saebo’s Stroke Survivor Support Group

Stroke Guidelines 2023

In this episode of the No Plateau Podcast, host Henry Hoffman is joined by Amanda Saylor, an occupational therapist specializing in neurological rehabilitation, to discuss Vivistim Therapy, a groundbreaking treatment for chronic stroke survivors with upper limb deficits. Vivistim combines vagus nerve stimulation (VNS) with intensive therapy to enhance neuroplasticity and improve arm and hand function. Amanda shares her experience implementing Vivistim in her clinic, the science behind the treatment, and how it can be integrated into stroke rehabilitation.

"Vivistim is basically vagus nerve stimulation paired with therapy. It has to be—it cannot be one without the other."– Amanda Saylor

This episode highlights the importance of combining innovative technology like Vivistim with evidence-based practices to push the boundaries of stroke recovery. For therapists and patients alike, Vivistim offers a new avenue for hope and progress in the journey toward recovery.

"The success of Vivistim is only as good as the therapist that's going to be doing it. It’s the tool, but it’s the person behind the tool that makes the difference."

– Henry Hoffman

As Amanda and Henry discuss, the future of stroke rehabilitation lies in longer, more intensive therapy sessions and the integration of neurotechnology to enhance neuroplasticity.

"Patients need more time in therapy. We know they need more repetitions, and they can't always get those on their own."

– Amanda Saylor

In This Episode

Our Guest

Amanda Saylor, MOT, OTR/L, is an occupational therapist with over eight years of experience specializing in neurological and orthopedic rehabilitation. She works at AdventHealth in Orlando, Florida, and is a consultant for MicroTransponder, the company behind Vivistim. Amanda is passionate about stroke rehabilitation and shares treatment ideas and tips on her Instagram page, @neuro_ots, with her colleague Becca Carr.

Resources & Links

• Saebo’s Stroke Caregiver Support Group

• Saebo’s Stroke Survivor Support Group

• Stroke Guidelines 2023

Are you or someone you know working towards recovery and looking for effective ways to break through barriers? In the world of rehabilitation, evidence-based practices are making a significant impact, especially within the field of occupational therapy.

"We really have to take the time as educators to be willing to modify our courses, stay up to date on evidence, and make sure that we're using the best resources that are the most up to date." (17:45) - Jessica

In today’s episode of the No Plateau Podcast, we delve into the integration of evidence-based practice in occupational therapy education and clinical settings from our own perspectives. We tackle the challenges of translating research into practice, including the delay between discovery and implementation and the hurdles we clinicians encounter in keeping abreast of new information. We cover the initiatives we're taking at Concordia University to improve evidence translation, the significance of clinical practice guidelines, and the role we play as fieldwork educators. We also engage in the debate over whether to focus on ADLs or neuroplasticity post-stroke and discuss the use of assessments like the Fugl-Meyer. We recommend the ViaTherapy app as a tool for evidence-based stroke rehabilitation, sharing our insights and experiences with it.

"You can't get your arm and hand back if it's seven months, nine months, two years later; you missed a window. So focus on what matters the most, which is neuroplasticity." (24:25) - Henry

In This Episode

Our Guest

Jessica Schmidt, OTR/L is an assistant professor of occupational therapy at Concordia University of Wisconsin. She earned her master's from the University of Wisconsin-Milwaukee, and her post-professional doctorate in occupational therapy from Rocky Mountain University School of Health Professions. She is a member of ACRM, AOTA, and WOTA. In clinical practice, Jessica specialized in treating adult neurological patients in acute care and inpatient rehabilitation settings. She is passionate about evidence-based practice, helping translate research into the clinic, and preventing healthcare worker burnout.

Resources & Links

• Saebo’s Stroke Caregiver Support Group

• Saebo’s Stroke Survivor Support Group

What steps are necessary to establish a program for managing shoulder subluxations in a healthcare facility?

In today’s episode, we dive into the topic of creating a stroke shoulder subluxation program in acute and subacute settings. This is a topic of interest for many therapists, yet it's often overlooked in most facilities. To shed more light on this topic, we are joined by Jenna Barber, who has successfully created a subluxation program at her facility.

“Most facilities are not preemptively addressing this issue. Why pass the buck to outpatient when you have the opportunity to attack it now?"

During our discussion with Jenna, we debunk the effectiveness of slings and taping in reducing or preventing subluxation. Instead, we emphasize that strengthening exercises, particularly for patients with volitional movement, are the most effective approach. We also highlight the importance of proper electrode placement during electrical stimulation (e-stim) therapy, focusing on the posterior deltoid rather than the supra. We stress the importance of evidence-based practice and the need for therapists to be trained and competent in using e-stim therapy.

"I don't know if I would change the program to maybe like shoulder e-stim program. I'm still debating on this one, but I really stressed in the beginning that it's not just shoulder subluxation, it's for those who don't have one yet to prevent one from happening."

Jenna explains the implementation process of the subluxation program for stroke survivors at Froedtert. Patients are evaluated on day one or two after a stroke to determine if they would benefit from the program. Regardless of whether the patient currently has shoulder subluxation or not, they start them on the program to prevent it from happening. 

In This Episode

Our Guest

Jenna Barber, MOT OTR/L, is an accomplished occupational therapist with a Bachelor's in Kinesiology from UW-Eau Claire and a Master's in Occupational Therapy from Concordia University Wisconsin. She excels at Froedtert & MCW, specializing in neuro and orthopedic conditions. Jenna is also an adjunct faculty member, recognized for exceptional patient care, and enjoys family time with her husband and two daughters. 

Resources & Links

• Henry Hoffman on LinkedIn

This week, we are talking about activity-based training, what it is, what the benefits are, and how this practice's guidelines and progress compares against stroke therapy and patients. Darci Pernoud is an OT going on 18 years and has immense experience working with spinal cord injury patients in her very own gym. This week on the No Plateau Podcast, she speaks with Henry about ABT, patient recovery, and current state of spinal injury treatment and technology.

“A great deal has changed from where we are today than where we were 20, 30, 40 years ago. There is much more incomplete injuries, more people walking. I think it has a lot to do with continued research, continued thought process, how to push people hard. It's a very hot topic. I feel like right now in the rehab world is higher intensity pushing people harder to help create that change and drive home that neuroplasticity.”

Darci wastes no time in emphasizing the importance of activity based training also known as ABT. The benefits of this therapy are numerous and the impact on patient recovery and healing is immense.

“And so, by applying activity based therapy principles, that includes our health and wellness exercise measures, it's getting our bone density where it needs to be. It's getting our cardiovascular training where it is, it's getting our muscles stronger for resistance training, which is going to help with posture. So, it's going to help people look better. The benefits of exercise, getting circulation, getting all the right hormones, the growth factors, everything on a cellular level is going to be improved. So people are going to feel better, Their mental health is going to be better. That's going to affect their quality of life.”

In This Episode 

Our Guest

Darci Pernoud has been an OT for over 18 years. She started out as a dual diagnosis therapist working in-patient rehab, and eventually went through a day program, an out-patient program, post-op work and upper extremity limb data collection work. She started networking with an activity based therapy gym which closed during Covid, prompting her to become a gym owner, trying to help the community’s experience of neurodiagnosis, assisting them in their recovery journey.

Resources & Links

• Henry Hoffman on LinkedIn

In this episode, we delve into the critical nature of the first few weeks following a stroke and how the type of care and approach can greatly impact the outcome of a patient's recovery. Our guest, occupational therapist Cortney Jessee, provides a detailed overview of the inpatient rehab process, offering useful insights and tips for therapists, caregivers, and patients alike.

“The problem is that I think the whole purpose for this podcast being the no plateau podcast is again if we don’t start at those basics, we can’t get to our task specific training so how much are we being true proponents of the plateau. I think that’s the true plateau, not the myth of your first three months is where you are going to get the most outcome.”

Cortney stresses the importance of specific care within the first 72 hours post-stroke and the severity of subluxation in inpatient rehab. Drawing on her experience, Cortney elaborates on the need for proper positioning and understanding of anatomy to ensure optimal success for patients. 

“If we know our anatomy and if we can show our caregivers and our patients what we are looking for in positioning and help them feel like they are not going to mess it up in what to look for; the outcomes are significantly more impactful. It also makes our jobs a lot more fun.”

Courtney highlights the impact of small things and offers practical tips for therapists to empower patients and caregivers. She also offers passionate words of encouragement for occupational therapists to embrace their impact on patients' lives and stresses the importance of consistency in a patient's recovery process.

“I just want to encourage any OT’s out there who are either starting their time in neuro or been doing it for a while that your jobs are impactful, no matter what part of recovery you are in someone’s stroke. And the little things matter. Going back to that 60-to-90-day mark, that’s wonderful. But how great would it be from days 0 to 30, to be a part of your patient’s foundation for optimal success. And I want therapists to feel empowered to do those small things for consistency in a patient's life and to give our caregivers and patients hope.”

In This Episode 

Our Guest

Cortney Jessee is an experienced occupational therapist with over 6 years of specialized practice in inpatient rehab at Novant Health in North Carolina. Although she recently transitioned to outpatient neuro-rehab, she maintains a deep attachment to inpatient care and values the unique challenges and rewards it offers.

Resources & Links

• Henry Hoffman on LinkedIn