Saturday, August 30, 2014

Success Stories: A Plan, Determination and Unwavering Focus Go a Long Way

I found a great success story about beating knee pain that cited my book. Originally I wrote a post that had my comments interspersed. But the story is so long, and so good, that I’m just going to stand back and let the author (Luis) tell it. I’ll follow up later with some comments. (Note: I did some editing for length and because the author isn’t a native English speaker. The original version is here.)

Let me share my wife's experience. I always refer to her as a fighter. She is 35 at the moment, and in her youth, was a professional athlete who represented her country (Bolivia) in several Pan American games. She used to run 800 and 1,500m races.

Her problem in her knees started just after she recovered from a compression on her sciatic nerve that didn't allow her to walk more than 50m without feeling a sharp pain in one of her feet. She was starting to run again after 2 years of not being able to walk at all.

Her problems started when we decided to start doing hikes. In June 2012, we went on a really stiff hike (not just hiking, jogging). After two days, she started to feel some discomfort in her knees (the usual swelling under the kneecap). She didn't pay too much attention and kept training for the next month, until one day the pain was so sharp and strong that her knees started to lock with sharp pains.

We did all the medical checks. The results: blood tests fine, no deficiencies in vitamins. The MRIs showed everything was alright. Our chiropractor said there are no misalignments in the way she walks and how her body aligns, so doctors diagnosed her with PFS [patellofemoral syndrome -- also called patellofemoral pain syndrome]. Some doctors recommended surgery for a lateral release, but we didn’t follow that advice because it didn't make any sense.

The only procedure we tried was the PRP (platelet-rich plasma) shots, which from my perspective helped her a bit with her tendon because it was kind of torn. Every time she tried something like strengthening the quads, the results were just the same endless cycle of pain. So from July to December 2012 she didn't really improve much.

It was really sad hearing more than 10 doctors opine that she was not going to run again and always telling her to lie down for a couple of weeks in bed with painkillers until she stopped feeling sharp pain. After the first two weeks of taking painkillers and seeing that they didn't help, we realized they weren't the solution.

There was a physiotherapist that didn't have a degree, but his therapies were comfortable. He gave us really valuable advice. "Walk as much as you can everyday.”

After paying attention to when she was feeling more pain, she ended up using hiking boots. The boots provided more stabilization. Another thing that seemed to help at night was using a pillow below her knees. She realized her knees hurt while walking down stairs, but not up, so she started to be really careful when walking down stairs.

Before we went on our vacation trip at the end of the year, we bought some knee compression braces. She could walk for less than 250m before feeling her knees lock and sharp pain. At that time we were living in Mexico. We traveled at the end of the year to Bolivia for a three-week vacation, where her family lives. To get to the flights I was always asking for a wheelchair so we could make the connections.

We had a job opportunity to work in St. John's, Canada. We relocated in winter (snow everywhere). It was hard to enjoy walking outside so we signed up right away in a gym. We kept walking, but still had the idea that sooner or later we should be improving quad strength, so from February to April, we followed a gym routine of walking on a treadmill for 30 to 40 min, biking 10 min in the special stationary bike for knees and always focusing on strengthening the core.

I was always researching information. I used to always search on Google for exercises to help PFS, but one day I tried "save knees" and there was a book called "SAVING MY KNEES." My wife was of course skeptical because no one could find anything at this point and doctors couldn't find anything either. I read it the first time in 4 hours and was feeling more excited than ever!

Before we started to develop a plan based on his book, we still had the quad strengthening idea. In August, some friends from Mexico were going to visit us and we started to plan hiking routes. One month before, we decided to start doing leg extensions in the gym, and all of a sudden the work of 6 months started to vanish. She returned to the state that she was in in January, feeling a sharp pain just after walking 150m. She had a huge setback.

After her setback, we started to read his book over and over to see what we could come up with that could help on her recovery. We developed a plan based on walking. She couldn't walk much, but we started to do it every day, like 300 steps, and with stopping. Days passed; she started to feel better. It was funny because even though she was in pain at the beginning while walking, the next day she could feel the difference when trying to walk the same distance and felt progressively better. After 4 weeks we reached a point in which she was able to walk between 4,000 to 5,000 steps per day.

Our friends arrived in August and we started to go on hikes again, with the fear that she could have another setback (we did like 4-6km hikes), so we followed some golden rules:

1) Never go downhill unassisted or without a support that would help reduce the impact of her body being absorbed by her knees.
2) She decided not to wear the knee brace in order to be able to hear her knees.
3) Take breaks every 2km, no matter if she was feeling alright or not.

After focusing on her recovery, she has not had another setback since then. We had a great time in August and September doing short hikes and walks and were prepared for the next step. Since she was able to do 4,000 to 5,000 steps per day, our new target was 10,000 steps. Between September and December, we increased the amount of steps from 4,000 to 8,000 just progressively. At the same time we did tons of core exercises, stretching and short squats. At this point she started to feel pain free!!

Between December and January, we took 3 weeks of vacations. We went to Bolivia again and kept our religious daily walks that would get us the 8,000 steps. But for New Year, we went to Brazil for 5 days. We had no other option than to walk every day if we wanted to have fun. We walked 4 days an average of 22,000 steps per day, and every time, pain free.

Since we returned from those vacations, which were from January 2014 till today, we had been walking around 12,000 to 18,000 steps per day. But we've reached a time constraint -- it takes around one hour to cover 6,000 steps, so doing 18,000 consumes like three hours in a row. So now, we just bought some weight belts and are starting to walk with just a little bit more weight and do between 10,000 to 15,000.

In April 2014, we started to do moderate hikes with the club. At this time my wife is able to do them completely unassisted. She is really excited about running, but has learned from this experience that patience is your best ally, so she has started to jog distances between 200 to 300 meters, but just for fun. She is waiting till next year to start running long races again. She even ran with me last week 500m at a pace of 6:00min/km. And the best thing, completely pain free!!

If you want to e-mail me, for some additional advice or explanation of something that wasn’t clear, write me to ing_luisgonzalezrangel@hotmail.com

Luis

Next time: More from Luis, including his advice.

Saturday, August 23, 2014

Do You Really Want to “Freeze Away” Your Knee Pain?

Recently I spotted this: a short and not very detailed article about freezing nerves to quiet persistent knee pain.

The treatment, called Iovera, uses nitrous oxide canisters to freeze tiny needles to minus 126 degrees. Once injected into the skin, the needles freeze the nerves that are firing off pain signals. Apparently, instant relief follows.

I like that phrasing: “instant relief.” It sounds so uncomplicated. If only!

The problem is, nerves are generally useful, even when bearing bad news (i.e. tidings of pain in this case). The best thing is not to shoot the messenger, but rather work to change the message!

The downside of numbing nerves (whether using this method or taking pain pills or undergoing serious joint icing) is that you may not get some helpful pain signals that would prompt you to avoid activities that are simply bad for your particular joints. There’s a tradeoff, for sure.

But, to be fair, there are times when overactive nerves may be a problem in and of themselves. They may go renegade and start relaying sensations that are not consistent with any damage being done (or NOT being done for that matter).

All of which is my way of trying to strike a nuanced stance here: Freezing nerves doesn't have to be a bad thing. But I’d think it over long and hard first.

Sunday, August 10, 2014

Stay That Knife, Surgeon

Anyone else see this?
Over a third of the total knee replacements in the U.S. are inappropriate, according to researchers who found that many patients had pain and other symptoms that were too mild to justify having the surgery.
Actually, uh, it’s worse.

Along with the 34 percent of subjects for whom a total knee replacement was deemed inappropriate, there were 22 percent for whom the evidence was “inconclusive.” That leaves only 44 percent of the 175 subjects whose replacement surgery was definitely judged to be “appropriate.”

In other words, less than half.

Why that matters becomes clear when you see the statistics. More than 600,000 knee replacements are performed each year. That’s a big number, considering how extensive this operation is. What’s more, the number of the surgeries is on the rise.
In the past 15 years, the number of total knee replacements (TKR) has grown significantly, with studies showing an annual increase of nearly 100% in surgeries between 1991 and 2010. The number of Medicare-covered TKR surgeries grew by 162% annually over the same period.
It should go without saying that a total knee replacement should be considered a last resort. With biomechanical structures, even if they don’t work well, they’re still part of a dynamic, changing system that perhaps can heal. Once a surgeon starts sawing out a chunk of your femur to install a plastic-and-metal knee, that biological system is gone. The car-knee analogy then does become relevant. Your new knees will slowly start to wear out, just as a new car driven off the lot does. Plus, possible complications from surgery and the effectiveness of surgery are always two big unknowns.

Which all adds up to: There should be plenty of concern about unnecessary total knee replacements. In an editorial, Dr. Jeffery Katz, a professor at the Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital in Boston, expresses concern that “doctors were offering TKR surgeries to patients who had mild pain and little loss of function in their knees.” He further writes:
As a community of providers, we implore our patients and the public at large to engage in exercise and physical activity in order to delay functional decline and to preserve and augment functional status. We must consider whether it is advisable and affordable to use costly technology such as TKR in the same fashion.

Saturday, July 26, 2014

Is Hip Weakness Just Another Structuralist Bugbear?

A longtime reader who uses the moniker “Knee Pain” first got me thinking about weak hips and knee pain. Physical therapists were blaming weak hips for her pain. To me, that reasoning smelled a bit funny, right away.

My skepticism about “structuralism” immediately kicked in. In brief, my thinking about the structuralist tendency to blame imbalances and crookedness for knee pain goes like this:

1. At the extremes, structure definitely matters. If your right leg is two inches shorter than your left, you will have problems running a marathon for sure.

2. The majority of people, by definition, aren’t at the extremes, so structuralist explanations aren’t significant, or aren’t very significant, for most of us.

3. Structuralist reasoning doesn’t correctly explain the majority of knee pain problems.

Anyway, “Knee Pain” inspired me to write a couple of loooong posts more than a year ago that I think are among my best, which are here and here.

A big point in the first one: weak hips are probably not a cause of knee pain, but a result of it. Just because 30 knee pain patients happen to have weak hips does not allow you to conclude, “Ah hah, their weak hips caused their knee troubles!” In my corner of the world (financial markets), people like to quote a saying from the realm of statistics: “Correlation does not imply causation.” And pity the investing fool who doesn’t understand that elemental truth.

Anyhow, that’s a bit of a long windup to the introduction of a sort of meta-meta study done recently that supports what I suspected. It consisted of a review of 24 papers that looked at the relationship between hip strength and knee pain.
Michael Skovdal Rathleff, Ph.D., from the Department of Health Science and Technology at Aalborg University in Denmark, and his colleagues found “moderate-to-strong evidence from prospective studies indicates no association between isometric hip strength and risk of developing PFP [patellofemoral pain].”
As for why so many people with bad knees have weak hips ... well, that too is pretty much what I figured as well, according to Rathleff:
Hip weakness may not be the cause of knee pain — in fact, it is more likely to be a result.
Now, to be clear: Rathleff, who is quoted at some length in this article, isn’t saying hip strength doesn’t matter at all. In fact, he speculates that better hip strength, say, may allow a runner to withstand more loading on his or her knee joint before developing pain. This, to me, is the part of the structuralist perspective that does make some sense. Whatever you’re doing (running, walking, high jumping, etc.), a weakness in a muscle or tendon or other structure that is involved in that activity can affect your performance. Seems logical enough.

But it’s a long way from accepting that proposition to blaming those weak hips for your knee pain. It may make more sense to fault your knee pain for your weak hips instead.

Saturday, July 19, 2014

Six Things I Like About Doug Kelsey’s New Book

I first mentioned Doug Kelsey’s latest book, The 90 Day Knee Arthritis Remedy, here. Kelsey, as anyone who read Saving My Knees knows, is the person that I credit the most with helping me figure out how to fix my knee pain -- and giving me the hope that I could be successful.

I planned to write a book review but -- yawn -- those are so 20th century, right? :) Plus, I can’t pretend impartiality here; I clearly owe him a large debt.

So instead, I give you this list of what I liked most about the book.

(1) The writing includes many examples. I like this style for a few reasons:

It makes for smoother reading.

It helps reinforce a sense of authority -- he can cite so many relevant examples because he’s seen so many patients.

It’s effective when showing how conventional wisdom for treating bad knees falls short, as with “Sue,” whose condition doesn’t improve when Kelsey, early in his career, tries applying the standard muscle-strengthening approach to fix her pain.

(2) He attacks foolish myths and exalts logical truths. For example, he talks about how, many years ago, he was perplexed by the idea that cartilage is inert and just wears out and nothing can be done -- end of story. He realizes something: This makes no sense. And it makes no sense, understandably, because it’s simply not true.

(3) You want exercises? You got exercises.

The book has plenty, with photos and video links too. Kelsey even includes multiple exercises to choose from when you have a highly sensitive and easily overwhelmed knee joint.

(4) The writing is smartly footnoted.

So Kelsey’s not just saying, “Here’s what I think” but “Here’s what I think and here’s some hard evidence why I think that.”

(5) There’s a little something for everyone.

There are abundant exercises if you’re just interested in therapeutic movement. There’s an analysis of dietary supplements if that’s what you want to know about. There’s Kelsey’s easy-to-digest explanation of the biomechanics of the knee joint.

(6) Plus, something I really like at the end: Kelsey concludes by taking a long look at “stumbling blocks.” Why, after trying so hard, have you failed to get better? This is the section that emphasizes the importance of getting your head right. How do you deal with doubt, impatience, failure to focus, worry? For some people, this part will be even more important than the description of all the exercises.

Last thing: I saw that “TriAgain,” who’s made some great, interesting contributions to this blog, made some remarks about what he saw as flaws in the book. I just wanted to say that, to be fair, Kelsey’s not a professional writer and he most probably didn’t have a professional editor helping to shape his prose. I happen to like Kelsey’s style, but that’s just me.

Also, try not to be too hard on him if he doesn’t respond to questions (or suggests you may need a “consultation,” probably at some cost). :) I can tell you, as someone who wrote a what-to-do-about-bad-knees book, that even though I lack the expertise to advise anyone, readers have approached me about essentially becoming their coach and sounding board. I always try to decline with tact and modesty, because really, I’m not qualified. So I imagine someone like Kelsey -- who clearly is very qualified -- gets scores of questions and requests. It would be overwhelming, I’m sure, for him to try to engage with everyone who wants to.

Still, I’m sure Doug Kelsey is as open to comments as I am, so anyone wishing to express an opinion on The 90 Day Knee Arthritis Remedy, whether good or bad, feel free to leave your thoughts below.

Saturday, July 5, 2014

More Evidence That Running Doesn’t Destroy Your Knees

What group would you expect to suffer the worst repercussions from the relentless pound-pound-pound act of running?

What about marathoners -- and not only marathoners, but first-timers?

Surely, they must be asking for trouble, right?

Apparently not.

A study of five men and five women (yes, small sample size) showed that:
High-impact forces during long-distance running are well tolerated even in marathon beginners and do not lead to clinically relevant cartilage loss.
The researchers from Germany’s Freiburg University Hospital measured cartilage volume and thickness, using the very precise 3-D quantitative MRI, before the runner’s training began and immediately after the marathon. The small changes that were detected were not judged to be meaningful.

Incidentally, the subjects averaged 40 years of age, with a mean BMI of 25.9.

To be sure: running a marathon, especially if you’ve never done one before, can be disastrous for your knees. But the good news appears to be, with some sensible training, it doesn’t have to be. Running isn’t bad for your knees per se. Running dumb is what’s bad.

Saturday, June 28, 2014

Studies That Probably Didn’t Need to Be Done: Knee Pain Causes Activity Avoidance

Today, we’re on the lighter side.

This just in, from the annals of Captain Obvious:
Patients with early symptomatic osteoarthritis (OA) of the knee avoid performing normal daily physical activities because they are experiencing pain, findings of a large, longitudinal study suggest.
I found this amusing and will bite back on my natural inclination toward sarcasm. I do find rather intuitive the concept that if someone has been banged in the kneecaps with a lead pipe his appetite to weed the flowerbed or climb a set of stairs will rapidly diminish.

There were 828 subjects in the study aged 45 to 65 years (yes, it is somewhat of a shame that this huge sample size went to waste.)

You might say the study helps confirm the vicious cycle that when your knees hurt, you move them less and so your muscles weaken, which leads to your knees hurting more, so you move them even less and etc. You get the picture.

I will say, in this study’s defense, that one admirable thing about scientists is that they don’t take accepted wisdom for truth. Some studies reveal curious, unlikely things, but others simply look at something that we think should be true and confirm it.

In this case:
“The results support the validity of the avoidance model in persons with early symptomatic knee OA,” said study author Jasmijn Holla, from the Amsterdam Rehabilitation Research Center in Reade, the Netherlands.
True. But I’m just not convinced we needed a full-blown study to tell us that.