Saturday, April 19, 2014

A Plea for “Real” Knee Exercise Models

Are you also tired of seeing models that look like this demonstrating the proper exercises to rehabilitate your bad knees? (The headline for this article: Knee Pain? Start Doing These Exercises ASAP)

And of course demonstrating “these exercises” are a number of women who are very toned, with pleasant faces, wearing that kind of tight-fitting workout clothing that you don’t put on (if you’re smart) unless you have sub 6 percent body fat.

What do you think is the chance that the models shown here are actually battling the kind of chronic knee pain that causes them to dissolve into tears and wonder if their lives will ever be normal again?

Yup, I’d say one in a million sounds about right.

So I’d like to advocate for “real” knee exercise models. Models we can believe in. Models we can look at and silently cheer, “Yes, you can beat this thing, hang in there!”

Instead we get these cheery fitness freaks whose barely suppressed smiles seem to be saying, “God, if you only knew how pathetically easy this exercise is for me!”

You’ll see there are a lot of recommendations here, a full page. And all of the “knee pain” models handle the exercises with ease. But if you’ve got delicate knees and bad pain, I wouldn’t recommend doing a number of these unless you want to wind up with even worse pain.

Saturday, April 12, 2014

The Drumbeat of Studies Disparaging Glucosamine Keeps Getting Louder

I know, I know, I’ve written A LOT about the (probable) uselessness of glucosamine (unless you’re susceptible to the placebo effect)

Then along comes yet a new study slamming the supplement. The L.A. Times did a nice write-up here.

Below are the three most interesting things about the study, in my opinion. But first the study, in bare bones form, looked like this:

The 201 subjects were 35 to 65 years old and complained of knee pain. For six months, about half of them consumed a daily lemonade drink that contained glucosamine hydrochloride (which the study’s lead author notes doesn’t differ pharmacologically from the more common glucosamine sulfate). The others drank the lemonade but without the added glucosamine.

Drinking glucosamine-laced lemonade “failed to prevent deterioration of knee cartilage, reduce bone bruises or ease knee pain.”

Now on to my personal “three most interesting things.”

#1 "Roughly 10% of the U.S. population uses the supplement, study authors said."

Did not see that one coming. The U.S. population is, what, 310 million? So about 31 million people take glucosamine.

Hey, that gives me an idea. :) This is directed to those 31 million people spending $10 monthly on glucosamine pills:

You all need to buy this book, Saving My Knees (link on upper right). It will tell you why you shouldn’t bother taking glucosamine. You’ll recoup the cost of the book in one month and have a net savings of $110 the first year (and I’ll finally be a multi-millionaire, cough, cough).

#2 "The urine was tested for levels of C-terminal cross-linking telopeptide of type II collagen (CTX-II), a molecular marker for cartilage tissue degradation."

This is the first glucosamine study I’m aware of that analyzed urine samples to look at whether cartilage rates of deterioration had slowed. Why does that matter?

Well, it shows that attempts to ascertain whether glucosamine has any salutary effect are getting more sophisticated. And, whatever they look at, they’re still not finding a benefit.

#3 "Study authors said theirs was the first to use MRIs to evaluate glucosamine's effects on cartilage and bone marrow lesions."

So this study is the first, the authors claim, to use MRIs to peek directly at the condition of the cartilage and bone. And, using this more advanced technology, researchers still found no glucosamine-related improvement.

Saturday, April 5, 2014

Beware of People Bearing Slick Stories

This happened to me very recently:

I was sitting in a Dunkin’ Donuts, enjoying a guilty pleasure (actually two, both frosting-covered). I had planned to finish my food quickly, when I picked up the frequency of a rather interesting conversation behind me. Two young men were talking -- or actually, one was doing most of the talking. He seemed to be telling a long story in a patient, smooth way. I recognized the patter as a well-practiced sales pitch, so I waited to see what the payoff would be. His listener appeared to be Hispanic, maybe a manual laborer, kind of quiet -- the sort of guy used to taking orders, and maybe not too sharp.

Mr. Salesman was saying how it would be great to work for yourself, then I recall him mentioning how much Elvis and Tupac made last year -- north of $10 million -- and they were dead guys, dead, and his listener kind of chuckled, because the implication was: “Hey, you can make more than a couple of dead guys.” And then the story shifted focus to a couple of men who became successful selling a product that was recession-proof -- soap -- because no matter how poor you are, you’re still going to bathe, right? And his listener had to agree this was true.

The mostly one-sided conversation was ongoing when I left. But I stayed long enough to hear one word that explained where all this was leading: Amway.

Amway, which has been likened to a pyramid scheme, is a multi-level marking system. As I understand it, Amway has a kind of pyramidal structure, where salespeople earn a certain percentage of sales they make, and a fraction of the sales by people who they brought into the selling network, and a fraction of the sales by people those people brought in, and so on. So if you were among the first generation of say five Amway salesmen, who then each brought in five people, each of whom brought in five, each of whom brought in five ... well, you get the idea. All of a sudden you’re making thousands a month (assuming your salespeople are good) without having to lift a finger!

Wow -- it seems. Actually there are a number of problems with this sales model, which I won’t get into, because that’s not the point of this blog.

My point is there are lots of smooth stories out there, promising suspiciously high returns for low investment.

In the world of knee pain, the biggest slick story I would be wary of is that of glucosamine. A pill a day chases the knee pain away! Could it be that simple?

Actually, no, as I’ve noted here, here and here for starters. Glucosamine’s story is appealing -- the supplement supposedly helps rebuild lost cartilage -- but the latest studies are suggesting that it’s a dud.

(Next week: I review the most recent glucosamine-doesn’t-work study.)

So beware slick sales pitches for knee pain relief. Hope is good, but make sure it’s informed hope.

Saturday, March 22, 2014

What Do Success Stories Have in Common?

For that subset of people who manage to beat knee pain, what are the common threads that run through their stories?

Of course I don’t know all the success stories out there, and I hate to generalize, but let me make some observations based on my experience (and that of a few others). I’m quite interested in success stories.

Here’s one (edited for length) that Larry Terbell recounted on Yahoo’s chondromalacia forum:
I had left knee cap pain that was getting worse. Resting my knee was not making it better, only weaker. Exercise aggravated my knee. I read articles by Doug Kelsey. His philosophy about joint motion interested me. I eventually went to Austin to have an appointment with Christine at Sports Center.

I started with 15 minutes of stationary bike, quad flex and one-legged leg presses on a Total Gym or Cybex Squat Machine (maybe about three sets of  15). After my appointment with Christine, I added the squat-hold exercise, hip exercise, and core exercises.

The first few months was the most difficult part. Too much load will set you back and too little load will not be helpful. I had to deal with the Goldilocks window also. I decided to try to stay in the pain-free zone. I began with a very light resistance and increased it very slowly. I only worked out about three days per week and often experienced delayed pain. I would simply lower the intensity or delay the next workout for a day or two. I avoided climbing up or down stairs. Doing a step-up on an 8-inch stair would cause pain. Jogging 10 feet was painful also, so I avoided activities such as these at first.

After about three months of low-resistance training, I was able to do a step-up with no pain. After about four months I could do the squat-hold exercise holding two 20-pound weights. After another month, I was doing step-ups while holding weights. The step-up turned out to be one of the best strength building exercises for me once my knee had enough strength. I found it  helpful to keep a workout log in which I monitored my exercises and how my knee felt.

Eventually I was able to resume full activities. Now I still do exercises to maintain my quad and hip strength.
So, based on Larry’s story and others, what are some recurring themes?

#1 It helps being methodical and detail-oriented.

One thing about Larry’s story that impresses me (and you have to kind of read between the lines) is that he sounds very much aware of the process he went through. He recalls precise details, and I sense he was quite deliberate in setting up his program -- everything from the amount of weight he used for squats to the height of the stair he stepped up on. Importantly, he had a plan. And it seems to me, he always had a good sense of where he was within that plan.

#2 It helps being very attuned to feedback your body is giving you.
I sense that Larry struggled the first few months (as did I), trying to figure out the right “baseline” of movement. As he says, too much load sets you back, and too little doesn’t keep you moving forward. Finding the right amount is very hard. God doesn’t toss you a manual that says, “For your particular bad knees, do x repetitions of y each day, then increase by z repetitions every two weeks.” You must figure this out (ideally with the aid of a physical therapist who is actually equipped to measure how much load your bad knees can tolerate).

If you don’t have that good physical therapist working with you, you’ll have to determine your baseline by yourself. Doing so will require being well attuned to the pain/discomfort signals your bad joint is throwing off.

#3 It helps being patient and accepting.

At first I just wrote “patient.”

But “accepting” is important too. Learning acceptance can be the result of a sort of “come to Jesus” moment. For example, your knees bother you after a seemingly innocuous activity and you have this epiphany: “Crap! My joints are really, really weak.”

Once you accept that, you can radically dial back on your program (if you recall from Saving My Knees, I spent weeks just walking slowly around a swimming pool every 10 minutes). “Accepting” means not fighting the fact that your knees are in bad shape; don’t pretend you feel okay after two weeks and go running a couple of miles.

And, if you’re patient enough, good changes should come!

One last thing: I was pleased to see Larry also kept a sort of “knee journal.” I thought mine was quite useful in helping me figure out where I should be going and keeping track of where I’d been.

Saturday, March 15, 2014

The One Thing I Hope We All Can Agree On

Anyone who’s been reading this blog for a while knows that I have a lot of, er, unconventional opinions.

Even those who largely agree with me probably draw a line somewhere: “I like his message about hope, and the ability of cartilage to heal, but his skepticism about stretching? Eh, I don’t know about that.” Or maybe you agree with me about stretching, but not about glucosamine most probably being a dud.

I hope there’s one thing -- or actually four things -- that we all can agree on. I made them into one short chapter in Saving My Knees. And, since the book’s publication three years ago, my conviction that these four matter hugely for those trying to heal bad knees has only increased.

These four things I mentioned in my “golden rules for fixing bad knees” chapter. To me they are almost like “Thou shalt” commandments. Of course you’d be hard pressed to find anyone sensible who disagrees with any of them, except I doubt you’ll find many people who believe in them with the same fervor I do.

#1 Use it or lose it.

In the immediate aftermath of a traumatic injury, when your knee has swollen to the size of a soccer ball, moving it admittedly isn’t a good idea. But when you have a more persistent, achy, low-grade knee pain, it seems to me that motion must be at the centerpiece of any plan to heal.

It has to be the proper amount of appropriate motion, for sure. But without movement, joints decay. Trying to avoid using your bad knees will only make them weaker, not stronger.

#2  Lose weight.

This is the easiest no brainer in the world of knee pain.

Don’t misunderstand me. I’m not saying losing weight is easy. It certainly isn’t.

What I’m saying: This is the one bit of advice no one disputes and there is no ambiguity about how to execute on this recommendation either.

For example, the advice to “strengthen your quads” is almost universally advocated (not by me, but by most everyone else). Still, there is considerable ambiguity about how to do this. What kinds of exercises? How often? When do you increase the intensity?

Taking glucosamine, on the other hand, doesn’t really involve ambiguity on the “how to execute” part -- you just take the required dose each day. With glucosamine, the problem differs; it’s that plenty of people dispute the supplement’s efficacy.

For losing weight, on these two points, there’s no dispute and no ambiguity. Many studies have shown that shedding pounds helps lessen knee pain and improve functioning of the joint. And losing weight is about as unambiguous a concept as they come. If you weigh 190 lbs. this week and 189 next week, you’re losing weight. If you still weigh 190 next week (or say 191), you’re not.

#3 Get on cartilage time (or however you prefer to express this).

In other words: Healing bad knees takes a long time (longer than doctors and physical therapists currently prepare you for, in my opinion). Make your peace with that upfront or you’re going to have a lot of frustration.

I still like the simple example I used in the book of hard-boiling an egg. Suppose you set out to discover whether such a thing is possible -- but you remove the egg from the boiling water after two minutes. Now, if you repeat the experiment 100 times, failing each time, should you conclude, “I’ve just proved it’s impossible to hard-boil an egg”?

Clearly, of course not. You’re judging success on the wrong time scale. Similarly, when trying to come to a fair judgment on whether bad knees can heal, you need to use the right time scale -- which my experience anyway showed is much longer than most people think.

#4 Listen to your knees.

I hope everyone who read my book at least came away with the message that “Listen to your knees” means much more than “If an activity hurts, don’t do it.” I think that often you may be further damaging your knees and setting back your efforts to heal even before you feel pain during an activity.

Sunday, March 9, 2014

Cherry Juice, Sesame Seeds for Knee Pain?

As many of you know, I get daily Google alerts related to knee pain. They do a decent job of capturing what’s being said on the Internet, from the latest knee pain studies to random knee chatter in various forums.

Here’s the type of thing I get links to periodically that I usually delete without a second thought:
Q: I am 55 years old and suffer from arthritis in my knees. One day I decided to try some unflavored gelatin with tart cherry juice because my nails were not growing as well as they used to, and gelatin is said to be a good anti-inflammatory. Much to my surprise, the pain in my knees subsided substantially within a week!
Then, recently, I thought: Why not? Why not write about whether tart cherry juice, or sesame seeds, blunt knee pain? Heck, I’ve written ad nauseam about glucosamine.

Now, if this were a different time in my life -- a time when I could take three or four hours to leisurely read studies and conduct research -- I’d probably do a different (and longer) blog post on this subject. But these days, I have an 8-month-old and a 4-year-old, both of whom want to be held or played with about 10 hours a day. So I’ll leave it to all of you (if you’re so inclined), to uncover the double-blind medical trials. :) I’m going to approach this from a different perspective: strictly my own.

While living in Hong Kong, trying to heal my knees, I tried a LOT of things. Remember, healing my knees was my full-time job for a year (I quit my regular job). So I tried to leave no stone unturned.

I did try natural anti-inflammatories. My main choice: garlic. I had read great things about this bulbous plant and its powers to suppress inflammation.

So I began garlic-bombing my dinners. Seriously. However much garlic you’re supposed to add to a meal, I must’ve thrown in 5, 10, 20 times that amount. I have memories of sitting on a chocolate-brown couch, slicing up garlic cloves by the pouch. My wife (at the time my fiancee) fortunately had no strong aversion to men who smelled like garlic, or I’d probably still be single.

After eating a lot of garlic, and monitoring how my knees felt before and after consuming it, how much do I think garlic was responsible for reducing my knee pain? In all honesty: I never detected any benefit related to a high garlic intake. Maybe there was a benefit, but it was so slight I just never noticed it.

In any case, my skepticism about garlic/tart cherry juice/sesame seeds stems mainly from this experience. During my travails, I was pretty sure that garlic was the knockout anti-inflammatory, and it just didn’t work for me.

To be fair, maybe garlic’s failure had something to do with my physiology. Or something to do with the nature of my burning pain. Or, then again, maybe garlic actually doesn’t do much, but other substances (cherry juice, sesame seeds) really do.

I’m not completely sure. And it’s always good to keep an open mind. So if you’re feeling relief from any of the above, or something else, and it’s not turning your face green or your skin blotchy or ... well, whatever ... you might as well keep taking it.

Saturday, March 1, 2014

Making Cartilage From a Printer

Anyone see this story?
Amazing advancements in the technology of 3D printing have been made at Scripps Clinic in La Jolla. Dr. Darryl D’Lima along with his colleagues report they have discovered a process to “bioprint” cartilage tissue ... Adapted from a Hewlett-Packard inkjet printer, the bioprinter spews out both cartilage progenitor cells and a biocompatible liquid that will congeal in the presence of ultraviolet light. In addition, the device can print bone cells necessary to deposit where cartilage attaches to bone.
(A less breathless take on the news is here.)

I especially loved the phrase “adapted from a Hewlett-Packard inkjet printer,” which has a certain mad-scientist-in-the-garage feel to it. The printed droplets are about one picoliter, or one billionth of a liter, and so are tiny enough to fill microscopic defects in cartilage or bone.

My prediction is we’ll see lots of new cartilage regeneration technologies in the 21st century. Great news, right?

Actually, it leaves me kind of depressed.

Why?

Because I think the fancy, high-tech solutions to regenerating cartilage -- maybe one day doctors will spray it out of a can? -- overlook the validity of natural solutions. That’s partly because of the following statement, which I believe to be wrong:
This tough, slippery tissue functions as a cushion between joints, but it does not often regenerate.
I think that’s false, and that cartilage does often regenerate. What’s more, it’s been shown that, after an injury to the tissue, the cartilage-making cells known as chrondrocytes kick into high gear. So your body tries to do the right thing, and heal itself.

But the real reason I believe cartilage often regenerates is because that’s what at least two clinical studies have shown. In at least one subject, a place where bone was exposed was later found to be covered with cartilage of almost full thickness. From my earlier linked post:
Here are some interesting numbers from a report published in Rheumatology magazine in 2006 entitled "Factors Affecting Progression of Knee Cartilage Defects in Normal Subjects Over Two Years."

Initially, there were 14 locations at Grade 3 (less than 50 percent thickness) in the subjects' knees. Three remained the same and five went to bare bone -- that's the bad news. However the good news is that almost half of them improved: four became Grade 2 and two Grade 1, which is nearly normal!

There were five sites at Grade 4, or bare bone. Now you'd expect at the end of two years, those five sites would still be at Grade 4, absent surgical intervention (such as a microfracture). But one ended up Grade 3, two were Grade 2, and one even healed all the way to Grade 1!
Now the initial durability of that fill-in cartilage can be questioned. Maybe it’s more fibrocartilage at first, but after microfractures, the fibrocartilage after a while begins to take on the appearance of normal articular cartilage.

So here’s why I’m depressed, in a nutshell:

No doubt, billions of dollars will be spent on finding ever-more clever ways to grow cartilage and insert it into human knee joints. We should expect no less, considering the state of medical technology, our relentless quest for progress and, not insignificantly, the potential profits to be made by someone.

What saddens me is there won’t be a commensurately well-funded effort to figure out how to encourage cartilage to regrow naturally. That’s a real shame. You wouldn’t need billions of dollars to conduct such a study, just some time, some willing subjects, and a healthy amount of skepticism that bio-engineering isn’t the only solution for this problem.