Saturday, October 25, 2014

Clarification Corner: On Muscle Strength and Anti-Inflammatories

Recently I read some criticism of my book that had me grinding my teeth because it was just so wrong.

So let me clarify a few things for the record.

Saving My Knees is my story. It’s what I did to save my knees. What you should do may be exactly the same. Or, most likely, what’s best for you will differ in some ways. In the book, I simply tried to expose some of the wrong thinking that held me back while giving credit to some of the right thinking that helped me overcome my condition.

To quote from my own introduction:
I don’t include twenty pages of illustrated exercises . . . My preference would be to call Saving My Knees broadly prescriptive. I lay out what I tried, how I succeeded, and what I learned. My goal is to show how knee pain sufferers have to start thinking about their knees and what’s important for those ailing joints to heal.
Another thing:

I am not against strong legs to support weak knees. Strong muscles supporting the knee joint are wonderful. If you have bad knees, and you can do quad-strengthening exercises -- squats, straight leg raises, whatever -- without worsening your symptoms, do them, by all means.

But I couldn’t.

And when I finally recovered from knee pain, I found Doug Kelsey (he of Sports Center, who is the smartest guy I know of when it comes to rehabbing bad knees) nailed it with this observation:
Having stronger muscles is helpful but weak muscles are not the primary problem.
The strength of that knee joint is the main problem, I realized, and so I focused on that through a program of movement. My legs in fact got weaker as my knees got better.

And finally:

You may decide to take nonsteroidal anti-inflammatory drugs. That’s fine. They didn’t work out well for me. Here are four things to consider if you are thinking of taking NSAIDs.

(1) Anti-inflammatories can mute constructive pain signals that are telling you “don’t do that; it hurts.” For example, as I describe in the book, I took an arthritis drug that helped me get through an afternoon sitting at work, but the next morning my knees felt worse because they really weren’t strong enough for prolonged bouts of bent-leg sitting.

So the upshot was I could take a drug to make the discomfort go away, but underneath it all, my knees were still too weak to do what I was making them do. Fixing that weakness was my main challenge.

(2) NSAIDs can have unpleasant side effects that, for example, affect the cardiac and digestive systems. This shouldn’t be a problem for most people for short-term usage, but the more you take, and the longer you take them, the more it becomes an issue.

(3) If you take two aspirin -- or Advil or whatever -- twice a day now to manage the pain, then a year from now, you may be swallowing three aspirin four times a day. Often, the drugs lose efficacy with constant, repeated use, necessitating higher doses -- which boosts the likelihood of those unpleasant side effects.

Now for #4, which is the real kicker.

(4) I asked my doctors if anti-inflammatories would slow the progress of cartilage loss or fundamentally improve my underlying condition. I was told they would not. This is the common thinking among doctors and medical professionals. Here is one site weighing in; I could find a dozen others saying essentially the same thing:
Anti-inflammatories do not alter the course of painful conditions such as arthritis. They just ease symptoms of pain and stiffness.
I’m not denigrating the benefit of easing symptoms. Still, ultimately, what matters most is fixing what’s causing the symptoms. And when it comes to mending what ails you, anti-inflammatories appear to have no effect.

To be fair, I’ve had some exchanges with a blog reader on whether just suppressing inflammation should be beneficial, by slowing the degradation of cartilage. There seems to be a logic to that, but I’m not sure if NSAIDs significantly affect cellular processes or just mainly calm nerves. I do think that if they had clinically proven powers to stop or slow disease, drugmakers would be boasting about this is 30-foot-high advertisements -- which they’re not. (An aside: I’m talking about NSAIDs here and not the more powerful DMARDs used for treating rheumatoid arthritis.)

If in the future NSAIDs are found to help beat arthritis -- not just mute the symptoms -- I’ll be sure to share that on this blog.

However, even if they do, you still have to wonder if the negative effect from NSAIDs blunting pain signals would outweigh what may be a small benefit that the drugs would have in preserving cartilage.

So there you have my clarifications. I hope that's clear now. :)

Sunday, October 12, 2014

Time for Another Personal Note

Some of you may have noticed that I have been posting less frequently.

Well, in April of this year -- for the first time in my life -- I became a homeowner. My family now lives on Long Island’s north shore. Our community boasts its share of the affluent; I like to joke that we’re the poorest people in town. The major attractions included the excellent schools and low crime and short distance to beaches and water. Our house -- as befits a house belonging to people who aren’t among the nouveau riche or the nouveau near riche or anything like that -- has its share of problems. Windows that won’t open (normally). Leaking tubes in toilet tanks. A broken air conditioner in the basement. Etc.

So now, along with having two kids who constantly clamor, in their own ways, “Play with me!” I have an equally insistent house clamoring “Work on me!” So I’ve repainted a room, replaced door locks and fixed leaks in a toilet tank. When your home was built on the cusp of the Great Depression, in 1928, there’s never a shortage of things to do.

However, I’m still actively monitoring the blog, even on weeks when I don’t put up anything new. Recently a post attracted 36 comments! While that had more to do with people talking amongst themselves than the actual post, I think it’s great that a small community of (pretty smart) knee pain sufferers has cohered around this blog.

As for my future plans:

I’d like to get out a second edition of Saving My Knees in 2016. Why?

Among other things, I want to update readers on how my knees have been since I published Saving My Knees (basically, great). Partly I want to do this because I still get e-mails from well wishers that contain lines like, “I hope your knees are feeling better.” Also I want to talk about what I’ve learned since that publication day, back in January of 2011. And I want to address frustrated readers who complained that they couldn’t figure out how I healed my knees from the book (it isn’t all that exciting, as I’ve said before on this blog, but I never meant to leave this as a mystery).

Because I think Saving My Knees is about 10 to 20 years ahead of its time (in the rejection of structuralist tenets and in the level of justifiable optimism in cartilage healing, or at least improving substantially), I think the message on its pages will continue to be fresh for another couple of decades. We’ll see.

In closing, there’s one other cool thing I wanted to mention: Sometime recently, while I wasn’t paying attention, this post of mine became the most read on this blog:

Here Are My “Radical Beliefs” About Healing Bad Knees

I love it. This short post shows the reader, largely using common sense, that what I believe about healing bad knees isn’t crazy. What’s really crazy is the traditional treatment protocol (and underpinning beliefs) that doctors and physical therapists advocate.

Saturday, October 4, 2014

How You Feel Affects How You Heal

Here’s a study that tells us something rather intuitive.
People who tend to blame others for their suffering and think setbacks in their lives are irreparable tend to report more pain after knee replacement surgery, according to a new study.
Ordinarily, I’d deride this sort of finding as one for the annals of Captain Obvious. Nothing surprising here.

But the larger point is worth underscoring.

People who are gloomy fault finders, looking to blame others for their misfortune, are most likely going to do worse at everything from healing and managing pain to standing in a long line for pizza without exploding. When it comes to one’s health, there is such a thing as a “negativity tax.” I’m convinced of that.

Attitude matters. If yours is, “Okay, I’m going to try X to heal my knees, but nothing else has worked and this probably won’t either,” then guess what? It probably won’t. Because you’ll undertake the program half-heartedly, with the built-in expectation of failure. How many people do you know who have achieved a difficult goal have an approach of “Oh well, let’s see what happens, but I’m really pessimistic?”

Now, for those interested, some details on the study:

A group of 116 men and women (age 50 to 85) who were scheduled for knee surgery took part. Before the surgery, they filled out questionnaires that assessed “perceived injustice, how much they think about or worry about pain and their fear of movement or re-injury.” A year after surgery, they were surveyed again. Those who (before surgery) felt helpless because of their pain and judged life as unfair did worse after the operation, even after controlling for such factors as age, sex, and prior pain levels.

To be fair, there is a wrinkle here:
Researchers don’t yet know if people with more negative outlooks only perceive their pain as worse than others or if their psychological state affects the physiology of healing and actually leads to more pain.
Still, pain is pain, and I’m not sure it’s much different to have level 5 pain and think it’s level 9 than to have level 9 pain in the first place.

Sunday, September 21, 2014

Is Water Therapy Good for Your Knees?

I recently came across the question above in the comment section.

My answer is scattered all over this blog, but I don’t think I’ve dedicated an entire post to the subject.

So here’s my opinion:

Absolutely.

In fact, if I were to suggest a “Holy Trinity” of the most excellent knee exercises -- those where you can get in lots of nourishing high repetition movement with little strain on the joint -- it would look like this (in no particular order):

(1) easy walking (initially stay on flats, take breaks every 20 minutes or so, and don’t let your legs slam down -- ever)

(2) easy cycling (a stationary bike though more boring is better as it’s easier to control the force you exert; cycle backwards if your knees are really weak)

(3) easy water movement (careful -- swimming may be a very bad idea if you’re kicking vigorously with your legs; you’ll need exercises designed for people with tender knee joints)

The right kind of water exercises can be a great way to heal bad knees. Water provides gentle resistance and support when you're moving about. Of course just jumping in and doing the overhead crawl from one end of the pool to the other usually won’t be a smart idea.

Where do you find good exercises?

Heal Your Knees is a book that contains many water exercises designed for those with hurt knees. A frequent commenter here likes The Complete Waterpower Workout Book (both books share an author, who evidently has made water therapy a key part of her physical therapy treatments).

My biggest reservation about telling people to try to heal through water therapy:

Most of us simply aren’t close enough to pools, or can’t afford pool memberships, or can’t align our schedules with pool hours, to make this a really practical option. A nice thing about a walking regimen is that walking can be done anywhere, anytime.

The other thing to note: Water therapy may not be the best treatment plan for you, regardless of whether there's a convenient pool nearby. I did try it for a while and had some good results. But then I had a setback and found I wasn’t getting the same benefits as before, so I changed to a walking-centered program.

Sunday, September 7, 2014

More From Last Week's Success Story

Last week, I posted a great story of recovery from knee pain, as told by “Luis” about his wife. The story was so long (even after being edited for length) that I decided to dispense with any of my own comments. Also, I trimmed out a couple of sections.

This week I wanted to quickly comment on a few things, then include the sections I omitted last time.

One thing that struck me as interesting about his wife’s pain early on:

The doctors found nothing wrong.

MRI fine. Bloodwork fine. Alignment fine.

This, I imagine, is very common. It was my situation as well.

So what did doctors diagnose her with?

That terrible, kitchen sink, pseudo-diagnosis of “patellofemoral pain syndrome”.

I wish more patients who were told they had PFPS would gently challenge their doctors by saying, “Right, but what’s causing my knee pain?” Because the PFPS “diagnosis” neatly evades that answer.

Here’s another thing that resonated about his wife’s story: she noticed that walking uphill was okay, but downhill was painful.

When I was engaged in my recovery, I remember striding uphill, but descending very, very gingerly. Uphill is good for you, downhill is poison. Going uphill, your legs are working hard and gravity is slowing you and minimizing the pounding your knees are taking. Downhill, just the opposite: no muscle benefit and a lot of joint abuse.

Now back to Luis.

In the original telling of his story, he described how he developed a classification system to identify where his wife was in her recovery. When I saw this, and the level of detail, I knew Luis and I were kindred spirits. :) Anyway, I include it here because it shows that to heal from knee pain, you often have to really get involved in your own treatment and it helps to be a bit analytical and even anal (the first four letters of “analytical” -- hmmm, coincidence?)
We tried to identified the percentage of recovery.
    STAGE 1. 0-20% - When she couldn't even walk a couple of steps on flat surfaces.
    STAGE 2. 20-40% When she was able to walk continuously for at least 50-100 m without starting to feel pain, on flat surfaces.
    STAGE 3. 40-60% When she was able to walk continuously with discomfort, but no more than 300 m (600 steps), on flat surfaces.
    STAGE 4. 60-80% When she was able to walk continuously with a bit of discomfort on uneven surfaces for 2-2.5 km (4000-5000 steps) (avoiding downhills or with assistance going down)
    STAGE 5. 80-90% When she was able to walk continuously without discomfort on uneven surfaces for 4-5 km (8000-10,000 steps) (avoiding downhills or with assistance going down)
    STAGE 6. 90-95% When she was able to walk continuously pain free on uneven surfaces for 5-8 km (10,000-16,000 steps) (avoiding downhills or with assistance going down)
    STAGE 7. > 95% When she was able to walk continuously pain free on uneven surfaces for 8 to "X" km (till her body started to feel tired instead of her knees)
Last, here is the advice that Luis gave to others.
    1) Read to understand, not to find a magical cure.
    2) Develop an achievable plan depending on your observations, reward yourself and feel proud about it.
    3) If you are overweight, there are no excuses nowadays not to reach an ideal weight. Just go for it with a balanced diet.
    4) Walk every day. If you were able to walk before, is there a reason why you can’t do it now?
    5) Find the cause. In the case of my wife, she spent 2 years almost doing nothing. The biggest impact was when we returned from the mountain that we jogged-hiked in June 2012. If we have known that this could have happened, we should have focused on a minimum of 6 months covering 10,000 steps per day before even starting running.
    6) Use shoes that suit you and don't use different shoes when walking, stick to the ones that suit you.
    7) At the beginning if you have to use braces, but once you get into a more comfortable point try not to.
    8) Does this only help for PFS? I'll say that it can work with any other knee problem, just like for me it worked as well.
    9) Don't let anyone tell you that there is no hope, because there is.
    10) Listen to your knees and avoid what they don't like. Do not jump, do not run, go slowly when going down stairs. If there is a handrail, use it and put most of your weight on it. Plan your walking routes and walk only flat and slightly uphill, avoid stiff hills, do not fully stretch your quads until STAGE 3.

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.