Laurie's Blog

04 Jun 2017

The Princess of Placebo

 Princess of Placebo

The placebo effect of physical therapy gets talked about frequently in various physio-circles.  We know that in research “the placebo effect” can account for 30% of a patient’s reported improvement.  As best I can recall, I was trained to think that simply getting a placebo effect was bad.  We wanted better than that!  We (as practitioners) wanted to believe with all of our hearts that the therapies we were choosing were making big differences based on their properties, and not placebo.


Here’s the thing.  Getting a placebo effect isn’t bad!  It’s real!  It makes a difference for those who experience it! 


 Firstly, we know that PAIN is in the BRAIN.  Meaning that, whether or not your body experiences pain is determined by whether or not the brain decides to register the ‘neural signal’ from a particular body part as pain or not.  And we can control the brain.  We can condition the brain.  It’s a darn powerful tool, if we can tap into it!


Secondly, we know that emotions and ‘psychosocial’ factors can have an impact on pain, health, and wellbeing.  We encourage chronic pain patients to get out, socialize, interact, and enjoy life.  Enjoy experiences.  Enjoy other people.  These things impact our health in more ways that we know.


Thirdly, we are all touch deprived!  Look at monkeys!  (And we’re just evolved monkeys, sharing 96% of our DNA with these furry cousins.)  Monkeys are constantly touching one another… picking bugs and ‘who knows what’ off of each other.  It’s called ‘social grooming’.  And we’ve gotten out of that habit as humans!  (Which is okay to a certain extent, because I don’t want to feel obligated to pick grubs off of any of you if or when I see you next at a conference!)  However, because we’ve progressed in our social proprieties, we receive very little physical touch anymore… and with physical touch comes oxytocin, and serotonin.  These two ‘happiness hormones’ can impact your mood, health, and pain status tremendously!


So, let’s take it to the dogs.  We might not be able to use a placebo effect (i.e. Tell the dog she’ll feel better if I apply the TENS machine to his arthritic hip and convince her of this!) as it’s traditionally thought about.  However, in the case of a geriatric dog for example, having an outing to the Doggie Physio Clinic to see “Auntie Laurie” might satisfy a psychosocial component for the dog’s well-being.  Even better then, is if Auntie Laurie touches the dog.  Maybe some mobilizations, some massage, some myofascial therapy, and some pre- and post-session belly rubs or butt scratches would help little “MuffinTop” to have a nice shot of oxytocin and serotonin. Then, if along with any in-clinic exercises or therapies “MuffinTop” was doing, she received cookies and praise, and she was moving while having positive experiences, she might just find that the brain stopped focusing on the pain.  Enough repetition of this cycle could rewire the brain to reduce its interpretation of the neural signals from the hip as being very painful at all!  And all of that happened to help with health, wellbeing, and pain without even talking about the direct effects of the modalities, manual therapies, and exercises.


If all of that placebo effect makes my patients better, happier, healthier and be less painful, then I will be the Princess of Placebo!  I love my manual therapies and my tools, but I also know that I have dogs that simply LOVE coming to see Auntie Laurie, and I fuss over them and tell them they’re wonderful… and if that makes my patients 30% better than somebody else’s patients, then I’ll take it!  That how I choose to look at it anyways – as if I’m adding 30% to my effectiveness as a therapist. 


Okay, so feel free to placebo effect the heck out of your patients!


Until next time!  Cheers!  Laurie


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28 May 2017

Post-Op ACL - Quads versus Hams Ratio

Quads-Hams Ratio

This blog was inspired by a Mike Reinold Podcast:  

BTW his stuff is great!  Yes, it’s all ‘human’, but the veterinary / animal rehab side of things has so much to learn from the human side.  Anyways, the discussion was about ‘the optimal’ quads-hams ratio that you would aim for in ACL rehabilitation.


Firstly, what is interesting to note, is that PTs / Physios will tend to default back to what they learned first… and if that isn’t altered with new or up and coming research, then we tend to get stuck in our ways.  (All professionals do it!  That’s why continuing education is so important!)  Okay, so back when I was a newer graduate, I was taught that hamstrings were so important.  They were the protectors of the cruciate.  They assisted in preventing anterior translation of the tibia.  We were also taught to be careful with the quads… they caused anterior translation of the tibia.  Biomechanics… right?  Not so simple.


What do we know?  We know that the Quads are big power muscles.  You will never get hamstrings to be stronger than quads (as least not in people, and not in most dogs either… maybe you could in a racing greyhound! Bazinga! Now THEY have hamstrings!!!)  We also know that quadriceps strength is inhibited with knee pain / knee swelling.  So, we’d be fools to not try to gain quad strength!


In current human PT practice, we are looking to engage the quads early on in rehab. But once we get into advance stages of rehab, then we need to engage ‘the posterior chain’ and engage the hamstrings (and glutes) to optimize the ratio.  What should the ratio be?  We don’t really know!  We just know that the quads will always be stronger.  They’ll never be equal!  And… just when it is starting to sound simple (Quads first, Hams second…), we’ll go back around to saying that those quads need to be super strong, and super strong eccentrically when the patient is ready to be discharged from rehab.   


Additionally, it’s also helpful to know that from a ‘preventative’ standpoint, PTs and Athletic Trainers are trying to coach athletes to land in a more flexed-knee forward-lean posture, so that hamstrings are better engaged and protecting the ACL.  Is there a way to prevent cruciate tears in dogs?  Possibly!  They need lots of coordination & proprioceptive training – some stable, and some dynamic.  We can work on hamstrings using backwards walking on a treadmill (my favourite), I also like tug of war (especially if you let the dog pull you and ‘win’ the war a little bit).  As well, we mustn’t forget about the glutes!  Glutes stabilize the hip which allows the knee to be stabilized as well.


Okay, so this blog was primarily concept based, not ‘how to’… but as I like to do in my ‘live’ teaching, I want to teach you how to think, how to problem solve, and not just follow a recipe!


There you go!  Happy Quad & Hamming!  

Cheers!  Laurie


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