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.

Sunday, June 22, 2014

Comment Corner: ‘To Heal My Knees, How Often Should I Increase Light Activity?’

We get mail. (Well, sort of.)

Recently someone left this comment:
I have been scrolling through your entire blog for the day and reading all of your posts. I even bought your book! I'm a 20 year old female who led a VERY active life. I underwent a bilateral knee athroscopy to obtain a final diagnosis of my knee problems AND fix any issues that are able to be fixed.

The surgeon removed a medial plica, a piece of cartilage the size of a pinkie nail that was floating around the knee joint and another piece of cartilage that was flapping around inside the knee joint from my left knee. However, I was diagnosed with softening of the articular cartilage behind my RIGHT kneecap (chondromalacia patella).

My father (who is a GP) told me it will get better if I do light exercise (e.g. walking to the toilet) at regular intervals throughout the day (e.g. every 30 minutes). I had also undergone physio for several months but this exacerbated the problem. After reading your blog, it has given me new hope in healing the cartilage in my right knee.

The only thing that I'm unsure of, is how do you know when and how much to increase light activity. I understand there is no magic answer, everyone is different. But did you increase your activity slightly when the pain had remained relatively stable or did you slightly increase your activity when the pain had improved slightly? After you had increased your activity slightly, would there be a few days where you experienced a little more pain than usual and persisted for a few days before determining whether to decrease or maintain the new level of activity.
First, note that physical therapy made her knee worse. No surprise there. When misguided physical therapy (strengthen muscles! strengthen muscles!) meets very weak knees, it’s about what should be expected. I know that all too well from my own experience.

Now on to the questions. And they’re the hard questions, make no mistake about it. If they were easy, I daresay there would be many fewer cases of knee pain. I've already tried to answer such questions before (based on my experience), but they’re well worth revisiting.

First, she’s right of course. There is no magic answer. I wish it were as easy as saying, “Do x repetitions of exercise y for 2 weeks, then add 5 repetitions every week.” But you have to figure out exactly what works best for your knees.

However, here are three guidelines that worked for me:

(1) If possible, try to enlarge pain-free, or relatively pain-free, windows. So try to find a place of no pain/little pain, and go from there. This may require a radical readjustment: your knees may be too weak to do much more than walk around your apartment (or house) for short bursts at regular intervals. That then becomes your baseline.

Between the choice of (a) “increase activity when pain was stable” and (b) “increase activity when pain had improved slightly,” I guess -- if I had to choose -- I’d take (b) in most cases, as that’s the least-pain route.

(2) I had success operating on a weekly schedule. Each week I decided on my plan for the following week (based on how the current week had gone). And I tried to stick to the same regimen for at least one week.

Why weekly, not daily?

For me, it reinforced my belief that I had to go slow and get on cartilage time, where progress would be measured in weeks and months, not days. Also though, I found it easier to isolate cause and effect, when troubleshooting little issues with my knees, when I kept my program fairly constant.

(3) Err on the “go slow” side.

Say you’ve spent four weeks doing 2 one-mile walks each day. Your knees feel a little better, but not much, and could the “improvement” be just your imagination? Now you’re thinking: “Week 5. Time to step it up (so to speak)! I need to dial up the intensity. So I’ll start walking 1 1/2 miles twice a day!”

Time out. There’s no rush. If in doubt on increasing activity, I would give that stage of the program (assuming you are active, which is important), another week or two, or month even.

My hunch is that, while you’re going slow and thinking “I really ought to be doing more,” you’re actually building a nice “motion groove” for your knee that will help ensure success when you do step up to the next level.

(Oh, the commenter also asked if, after I increased the level of activity, were there a few days of increased pain? Honestly: not really. I tried to stay at a given level long enough, and increase intensity so gradually, that the transition was fairly uneventful.)