Saturday, August 12, 2017

Low Dose Naltrexone for Damping Inflammation?

Sometime visitor “Racer R-X” (that’s his full handle, if I recall correctly) occasionally drops a comment below one of my posts.

I’ve maintained for a while that I get the smart readers in the world of knee pain – thoughtful, analytical people who are in full-on search mode for ways to get better. Every time I hear from Racer R-X, I’m reminded of this.

He’s pretty much beaten his knee pain and is back on his bike, powering up mountains. It took him a while to reach that point, he learned a lot, and I’d love for him to tell his complete story here at some point. (There are bits and pieces in the comments he’s left, scattered over a number of posts.)

Anyway, he dropped in a link to an article, "The use of low-dose naltrexone as a novel anti-inflammatory treatment for chronic pain."

First, people with stubborn knee pain usually suffer from the bad kind of inflammation: chronic inflammation that has a harmful effect on their joints. Getting inflammation under control is important to getting better.

This article suggests that low doses of naltrexone may be helpful for certain people:
Low-dose naltrexone (LDN) has been demonstrated to reduce symptom severity in conditions such as fibromyalgia, Crohn’s disease, multiple sclerosis, and complex regional pain syndrome. We review the evidence that LDN may operate as a novel anti-inflammatory agent in the central nervous system, via action on microglial cells.
Yes, no overt mention of knees, but complex regional pain syndrome may be a factor in some cases of knee pain, according to one reader of this blog who has researched this extensively.

Naltrexone apparently is used mainly to treat dependence on alcohol or opioids. It’s sold under the trade names Revia and Vivitrol, for example. If you’re having trouble with subduing inflammation, I encourage you to take a look.

Advantages of taking naltrexone include its moderate price (less than a dollar a day) and infrequent side effects.

Disadvantages are worth pointing out too: It’s unclear how to determine the best dose for particular individuals, and the default dose commonly used (4.5 mg) isn’t a size that tablets are now created in. Also the authors note: “Even though naltrexone has a long history of safe use with a wide range of large dosages, we know very little about the long-term safety of the drug when used chronically in low dosages.”

As usual, my standard disclaimer applies: This is not in any way my endorsement of this drug. I’ve never tried it myself; I don’t know anyone who has either. But when I was dealing with knee pain all the time, I eagerly read about anything and everything that might help me. So consider the above link in that spirit.

Saturday, July 29, 2017

The Latest Reason to Skip That Steroid Shot for Knee Pain

If you’re trying to fight inflammation in a bad knee by using drugs, opt for the milder, non-steroidal stuff.

That’s the takeaway from a study published this year in JAMA.

There were 140 subjects, average age 58. They had pain and inflammation because of knee osteoarthritis. For every three months over two years, the subjects received knee injections that consisted of either the corticosteroid triamcinolone or a placebo.

What researchers then found was rather surprising.

Knee pain declined slightly in both groups, but by about the same amount – so the steroid didn’t even outperform a saline placebo. However, those who got the corticosteroid injections had “significantly greater cartilage volume loss.”

The researchers’ conclusion doesn’t mince words: These findings do not support this treatment for patients with symptomatic knee osteoarthritis.

Controlling inflammation is good, but it’s probably a good idea to take a pass on steroids.

Saturday, July 15, 2017

What Jane Brody Wishes She Had Known About Her Knees

Check out “What I Wish I’d Known About My Knees” by Jane Brody of the New York Times. It’s a very good article, and you can feel her weary skepticism shining through. Jane Brody has been through a lot trying to get rid of knee pain. For instance, in the 1990s, she wrote a flattering column about the potential of glucosamine. But alas, in the end the supplements didn’t work. She tried a lot of other things that didn’t work too before finally undergoing a double knee replacement.
Many of the procedures people undergo to counter chronic knee pain in the hopes of avoiding a knee replacement have limited or no evidence to support them. Some enrich the pockets of medical practitioners while rarely benefiting patients for more than a few months. 
I wish I had known that before I had succumbed to wishful thinking and tried them all.
She tried arthroscopic surgery for a shredded meniscus. She mentions a systematic review of 12 trials and 13 observational studies that determined that arthroscopic surgery to improve knee arthritis and tears in the meniscus offered no lasting relief or improvement in function.

She also tried hyaluronic acid when she was told her knee arthritis was bone on bone. But, she reports:
The painful, costly injections were said to relieve knee pain in two-thirds of patients. Alas, I was in the third that didn’t benefit.
One of the best parts of the article wasn't even in the article. I fished it out of the comment section. Note the underlined sentences. This commenter, presumably an orthopedic surgeon, is fully aware of the profit motive at work behind all those needless arthroscopic procedures:
I started my orthopedic residency in 1995. We had a monthly journal club where we met at a fairly expensive restaurant (paid for by pharmaceutical or joint replacement companies!) to discuss the articles in the latest orthopedic journals. 
The article that generated the most buzz was a double blind study of patients with meniscal tears. Half the patients got the actual arthroscopic repair, the other half underwent the same general anesthesia and had the same surgical incisions but no actual arthroscopy. Double blind means neither the patients or the surgeons knew which patients were in which group. No difference was seen in the two groups. Some protested that the study was unethical by subjecting the placebo group to the risks of general anesthesia and infection. In retrospect the same could have justifiably been said about those getting the actual procedure. 
Two decades plus, nothing has changed. Arthroscopy is the bread and butter for orthopedic surgeons. A general orthopedist might do a handful of knee replacements in a week while they do twenty scopes. The latter can be scheduled like a factory line, each scope taking less than half an hour to perform. Doesn't pay like a knee replacement but it's far less grueling on the surgeon (and the patient!). Far less likelihood of complications. 
Nothing's changed in 2+ decades, don't hold your breath waiting for the ortho docs to give up their bread and butter!
Something to keep in mind if a surgeon suggests going into your joint to "clean it up a little"!

Saturday, July 1, 2017

Housekeeping Stuff: Second Edition of SMK, Spam Comments

I’m hoping to get a second edition of Saving My Knees out by the end of the summer, or early fall. The major reason for a new edition is to update a few things, such as how my knees have been since I wrote it (they generally feel great) and what I’ve learned since then (such as the envelope of function framework for understanding knee pain).

But not to worry: I’m not backing away from what’s contained in the heart of the book. I still think the program I followed made the most sense. I may have focused a bit too much on this idea of restoring my cartilage, but I will say: my cartilage was very crunchy before, and it isn’t any longer. So something apparently improved.

Now, on to the subject of what have become increasingly sophisticated spam comments:

I expect that the people who really need to read this won’t, because they don’t really read this blog. Rather, they’re like those people you see briefly in a neighborhood, stapling advertising fliers to a telephone pole, then moving on.

I realize there are ways of escalating against spam comments, such as (most severe) putting comments in a pen until a moderator (that would be me) can approve them. Then nothing that’s spammy gets in the comment section.

But honestly, I don’t think that’s good for people who want live back-and-forth discussions here, plus it’s not great for me either, having to constantly moderate. I’d rather jump in on my usual occasional basis and clean up the comments. So far it seems to be working.

What is a spam comment? This is a good question. As some of you may know, when my book first came out, I was accused of promoting it on the KneeGuru website and thrown out of their online community. In that case though, I was actively participating in the boards. I went on there and told my story and answered questions. Honestly, I strongly believed that I had a message that needed to be spread that I wasn't seeing anywhere else.

So back to the question: What constitutes a spam comment? What gets a comment deleted? Here are a few things I look for:

* Someone I’ve never seen on the site before, who posts once with a link, and that’s it. That's often a red flag.

* A comment that’s blandly approving (“This is a great post”) or that speaks in generalities but doesn’t really address the post above. Believe me, after a while, it gets easy to spot the spam comments where a person probably making $2.15 an hour in some Third World country is trying to engage superficially with the blog, all the time thinking, “Gotta get this link in.”

* A short comment that has a link, either embedded or at the end, to something like “orthopedic supplies.”

Basically, I apply the smell test to a lot of stuff. I hope I haven’t inadvertently deleted any legit comments. But I strongly suspect that if I have, the ratio is something like one good deleted for every 300 bad.

Anyway, that’s the end of the housekeeping stuff. A Happy Fourth to all!

Saturday, June 17, 2017

Fake News, Medical Edition

There is something that’s not quite fake news, but possibly more dangerous, in the world of medicine.

First, what would you think if you had chronic knee pain and came across this intriguing item?
High quality (pharmaceutical grade) chondroitin sulfate is as good as a widely prescribed non-steroidal anti-inflammatory drug (celecoxib) for the treatment of painful knee osteoarthritis, according to a British study published in the Annals of Rheumatic Diseases.
Your reaction might be something along the lines of “Sign me up for that!” Especially when, upon doing a little investigating, you discover that chondroitin sulfate is an over-the-counter supplement – much cheaper and easier to obtain than celecoxib. What’s more, it’s naturally found in cartilage.

The problem is, high-quality studies have found it’s basically useless, just like glucosamine.

So what’s going on with this new study? I was curious and tracked down the full write-up here. But I wasn’t looking for details such as the number of people who took part, the methodology, confidence intervals for the results, etc.

This time, I was looking for something different: a certain taint that is increasingly a problem with published clinical studies. It took me a lot of – I mean, a LOT of – scrolling to find it. But at the end, neatly dropped in like an insignificant afterthought, there it was:
The study was sponsored by IBSA Institut Biochimique SA, Pambio-Noranco, Switzerland, a pharmaceutical company marketing Chondroitin Sulfate. The manuscript was entirely written by the first Author (JYR) who received an editorial assistance from IBSA. However, IBSA has no influence on the content of the manuscript. The editorial assistance was limited to the final editing of the manuscript and the submission process through the ARD website.
Which raises a host of questions: (1) If the study happened to find that chondroitin sulfate was useless, or even worse, harmful in some way, would the results have just been quietly quashed? (2) How exactly was this study “sponsored”? How much money did the principal researchers receive? Are we to believe that the knowledge of who is writing their paychecks really has no influence on how this study is conducted and reported? (3) What exactly was the nature of this “editorial assistance” that was provided?

Upton Sinclair once wrote wisely: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

This study is not quite that kind of situation. But it’s a cousin to that kind of situation.

Saturday, June 3, 2017

Open Comment Forum, Dive In!

I started scrolling through recent months, and realized we haven’t done one of these in a while. They’re extremely popular, and probably more useful than the regular posts. :)

So I invite everyone to take over the comment section and say what’s on your mind (about your knees, or matters related to your knees).

A suggestion, in case anyone’s looking for a theme: What are you struggling with most right now? What’s the one big single thing? Tell us, and perhaps the wise commentariat (that is, the very knowledgeable people who frequent this blog) can help you find a solution!

Cheers, and hope everyone is having a good spring (or fall, if you’re in Australia).

Saturday, May 20, 2017

Those Noisy Knees: Crepitus Revisited

The medical community may be realizing that crepitus is significant after all.
A study of 3,500 subjects, led by a group of researchers from the Baylor College of Medicine in Houston, found that those with crepitus were more likely to develop knee pain.
The findings don’t surprise me at all. Back in December 2011 I wrote about crepitus (the medical term for creaky knees). The first paragraph of this excerpt from the post, below, references an arthritis website that describes the condition:
The site also declares, incorrectly I think, "If it occurs without any pain, it is unlikely to be caused by arthritis or any medical condition, and is usually meaningless." A popular "save your knees" book on the market also asserts that that noise from your knees, unaccompanied by pain, isn't significant. I think that's wrong thinking, and dangerous. 
What if you were a ship's captain and spotted a strong beam of light through the fog? If you continued on your way without incident, you might conclude that the light was meaningless. However, if you strayed too close to the light's source -- and wrecked your ship on the rocky shores that this lighthouse was trying to warn you of -- I think you'd argue the opposite: that the light was quite meaningful indeed.
My thinking about crepitus remains pretty much the same, more than five years later.

First, when you’ve got bad knees, don’t obsess about it. For a while, I kind of did (along with eighteen other variables related to my knees as I tried to figure out how to heal them). But it’s very tricky mapping the amount of crepitus you hear in your bad knees to how well they’re healing, or not healing.

In short: Once you’ve got bad knees, monitoring crepitus probably isn’t all that worthwhile.

But as an early-warning harbinger of trouble ahead, I believe the presence of crepitus is very useful. It doesn’t mean you’ll develop knee pain. For instance, when I was thinking of doing the grueling Mount Washington “Hill Climb” on my bike, I remember a forum full of riders who had done the race, and one guy who said his knees were very crunchy, but he was asymptomatic.

However: anytime the crepitus gets worse and worse, I think you are at much greater risk of eventual knee pain. I often wonder about that rider. It’s been about a decade since I read those comments he left. Is he still asymptomatic, or is he now among the legions of people with knee pain?