Saturday, December 16, 2017

Why I’m So Optimistic About Cartilage Healing

I figured I’d tackle this one straight-on today.

First things first: No, the holes in your cartilage don’t have to heal for your knees to feel better. This is absolutely not a prerequisite. There are many people walking about with cartilage defects and no knee pain. That’s not a bad club to be part of. After all, you just want to be rid of knee pain, right? Who cares if your cartilage is as smooth as a baby’s bum?

Second thing: I am occasionally asked if I have a follow-up MRI in my possession to prove that my cartilage did, indeed, heal. See my post here about why, no, I haven’t done this and why I don’t think it matters much anyway.

Another reason it doesn’t matter much: there appears to be much stronger evidence out there than a single MRI from yours truly. That takes us back to the original point: Why do I think cartilage can heal?

Take a good hard look at the table below. I copied it from a study, “Factors Affecting Progression of Knee Cartilage Defects in Normal Subjects Over Two Years.” The 86 people who participated had MRIs done of their knees at the start of the study, then two years later. (Yes, these were “healthy subjects,” but I’ve seen another study that includes knee pain sufferers that came to similar conclusions.)

The condition of each subject’s cartilage was graded for five different knee compartments. The scoring again goes like this:
Grade 0 = normal
Grade 1 = focal blistering
Grade 2 = irregular surface and loss of thickness of less than 50%
Grade 3 = deep ulceration with loss of thickness of more than 50%
Grade 4 = full-thickness wear of cartilage with bone exposed

Now look at that table. I’ve color-coded it in a way that I hope enhances readability. Let’s consider the the 14 defects that started out as Grade 3. If cartilage simply wears away, and that’s the end of story, you would expect their follow-up grade to be either 3 or 4.

But what actually happens? Yes, three of them stay at Grade 3, and five worsen to Grade 4. Yet four improve to Grade 2, and two of them – one in seven – improve all the way to Grade 1.

Yes, the sample sizes are small. Still, the pattern is repeated elsewhere (the extremes, at Grade 4 and Grade 0, suffer from the floor and ceiling effect, of course). Look at the 88 defects that started out as Grade 2. A full 31 percent of them, or almost a third, improve to Grade 1.

Yes, there are valid questions to raise. What is the nature of this new cartilage? Is it weaker fibrocartilage (actually, another researcher has found that though new cartilage starts out that way, over time it begins looking more like regular hyaline). Also, could there be misreading of results? (My take: yes, probably some, but I doubt on this extensive a scale.)

To me, this constitutes very interesting, and compelling, evidence that cartilage changes are a two-way street. Cartilage doesn’t just get worse. It’s always getting worse and getting better. And if it can get better, then why not try to enhance that ability? (Note: this was a “natural” study, meaning that some subjects saw positive changes in the tissue, and they weren't even on a special regimen!)

Saturday, December 2, 2017

Taking the Big Leap: It’s Not an Easy Call

Every so often I like to mix into this blog something both personal and current. How’s this: At the end of September, I got laid off in a restructuring.

It happens. If you’re a little older and experienced, it happens more often.

But, as readers of my book may realize, I take a perverse pleasure in proving wrong the people who underestimate me. Orthopedic doctors in Hong Kong didn’t think my knees would get better. After extensive (and obsessive) research, I found what I thought was lots of evidence that they were dead wrong.

It took me many months, with much detailed record-keeping and experimenting and patience, but in the end, I healed. My knees returned to normal. This became the greatest achievement of my life, and nothing else is really even close.

Today I wanted to revisit a hard decision I made, now that I find myself among the ranks of the unemployed again. Early in 2008, I made up my mind to quit my job in order to try to heal my knees. Sitting at work with bent legs was impeding my effort to heal, because my knees were constantly inflamed.

First, let me make something clear: I could never advise another knee pain sufferer to quit his or her job. That’s a very individual decision. It’s also a calculated gamble. Had I never managed to heal, I would have found myself unemployed, and maybe even unemployable.

But if you’ve got chronic knee pain, it may be worth considering. If you do, here are some questions worth asking yourself:

How much do activities that I must perform at work worsen my knee pain? Those “activities” can even be non-activities, such as sitting. Or maybe you’re roaming a warehouse eight hours a day, fulfilling Internet orders. Or maybe you’re dealing with a crushing amount of stress.

Do I have any evidence that my knees will improve if I devote myself to healing them? Do you have a good feel for what your knees like and don’t like, and what kind of program will provide the kind of nourshing motion that will enable them to get better?

If I leave my job, what support do I have? Financial support could be savings (and you’ll want to calculate how long it will last). Emotional support could be friends and family.

How hard will it be for me to rejoin the workforce in six months, or even a year? Clearly, some of this depends on factors beyond your control, such as the job market, but certain high-demand professionals may find it easier to transition back into full employment.

What are my goals, in terms of healing, before I rejoin the workforce? And, if things don’t go well, when do I give up and either live with the pain or turn to pain medication or surgery? It’s good to have goals before you set out on what could be a challenging journey.

Is there a way for me to keep working, but only part-time? If you recall, in Saving My Knees, I proposed an experiment, with my doctor's support, to try to rehabilitate my damaged knees. My employer agreed, but unfortunately, the experiment was too short. Still, it did prove to me that I was on the right track with my thinking.

Again, it’s a difficult, courageous leap to take, and not for the faint of heart. It may be worth it for you, or it may not be. I can’t decide that for you. Only you can.

Saturday, November 18, 2017

Inflammation and Knee Pain, One More Time

I’ve already touched on renegade inflammation and knee pain a few times, such as here and here.

But the subject of inflammation and knee pain is intriguing enough, and relevant enough (and what’s been found lately is also contrary enough) that it deserves plenty of space.

Take this article, now two years old:
Knee osteoarthritis should no longer be thought of as a "noninflammatory" condition, as inflammation associated with synovitis or effusion plays a bigger role in worsening pain than mechanical load, according to a new report from the Multicenter Osteoarthritis Study, published online November 10 in Arthritis & Rheumatology.
There were 1,111 people in the study, aged 50 to 79 years, who either had knee osteoarthritis or were at risk for it. Initially, 21 percent of the subjects reported frequent knee pain.

One of the doctors involved noted an unexpected result:
I was surprised that we found no relation of bone marrow lesions to pain sensitization because one of our hypotheses, based on animal models, is that mechanical and/or inflammatory lesions can lead to sensitization.
What was related to “sensitization” instead? Synovitis, or inflammation of the synovium.

Oh, another interesting finding that has grim implications:
The authors suspect that once sensitization has occurred, just cooling the inflammation might not be enough to correct it.
So what’s the takeaway? Trying to quell inflammation early may be smart, the researchers suggest:
[Their findings] do suggest that early targeting of inflammation might reduce sensitization ... Preventing the altered neurologic processing of nociceptive signals that usually occurs in OA might also prevent the progressive worsening of pain.

Saturday, November 4, 2017

Looking for a Bionic Knee Brace? Read on.

I saw this story last year and bookmarked it. It’s knee-related and kind of fun:
A pair of Nova Scotia researchers are close to producing a "bionic" knee brace that enhances ability and reduces fatigue, and have now landed a lucrative contract to produce a beefed-up version for the Canadian Armed Forces.
Production has indeed started on the “Levitation brace” (I found it selling online for $1,999). The device is a bit pricey, but knee braces are one decent option for bad knees:
The civilian product . . . is intended for athletes going through rehabilitation, workers needing to alleviate knee stress and fatigue and older people with worn-out knees.
It turns out the brace’s inventors know a little about suffering with knee pain:
Both men had knee issues. Garrish (Bob Garrish, the company’s chief tech officer) suffers from osteoarthritis in both knees, and Cowper-Smith (Chris Cowper-Smith, the company’s CEO) was suffering at the time from anterior knee pain, which is also known as runner's knee.
The military application is rather interesting. The brace would help soldiers who are often crouching and standing while wearing packs up to 120 lbs. Also, the company is looking at making a special version to absorb the high-impact stress when paratroopers drop out of planes.

I’m a big fan of devices/tricks to unload bad knees. Has anyone used a brace – probably not this one, but something simpler? How well did it work?

Saturday, October 21, 2017

Open Comment Forum: How Does Diet Affect Your Knee Pain?

Well, it’s about time again for an open comment forum. So, below in the comments section, please talk among yourselves. I’ll keep my piece short.

If you’re looking for a topic, here’s one: how have you found that diet affects your knee pain? This is something that interested me during my recovery. I read a lot about foods that supposedly help damp inflammation. Readers of my book know I ate a lot of garlic because of its reputation as a supercharged anti-inflammatory.

In the end, I’m not sure it did much, or anything. But that’s not to say diet was totally uncorrelated to my knee pain. I noticed a slight negative effect when I gorged on saturated-fat-heavy food, such as pizza.

So what’s your experience been? Please comment below. Or feel free to discuss whatever you want to, or just introduce yourself to everyone.

Happy Halloween!

Saturday, October 7, 2017

Karen’s Success Story: Cycling with a Twist

I recently fished a recovering-by-bicycle story out of the comment section. I love it because it shows how a little ingenuity can take you a long way, and Karen’s attitude is definitely that of a winner. Here it is below, with light editing:

"About two years ago I began experiencing pain in my knees going up and down stairs after workouts. It gradually got worse until I decided to see a doctor. I received X-rays, two cortisone shots and the knowledge that I don’t have arthritis. (I used to work out regularly three to four days a week.)

"I pouted around, got depressed, gained 20 pounds and about one year and a half later finally started seeing a trainer to help me get back in shape. It was very, very slow progress, but after about six months I was able to go up and down stairs without pain. However, the workouts began to get increasingly frustrating because the strength-training exercises pretty much all hurt. Squats were terrible. My trainer was really positive and kept trying to motivate me, but it seemed like everything he tried hurt.

"So I quit and started reading up on knees and ran across your blog.

"Last fall, my husband and I first saw pedal-assist electrical bikes all over Europe. I tried riding a bike when my knees were at their worst and couldn’t. But I tried a stationary bike again and this time had NO problem whatsoever! So my husband and I walked into the bike store and I walked out with a Trek Lift.

"Without sounding corny, it has changed my life. I ride my bike every day I can. I feel normal again. I feel like I’ve actually worked out. My husband and I used to ride together, but stopped due to my knees. Now I leave him in the dust! He loves it because I push him to ride harder and he sometimes even drafts off me. LOL!

"I’ve found that I use the motor the most on very steep hills, when I need to push off at a stop sign, or cross the road quickly. The bike feels best for me in the “ECO” mode in a middle gear. It has the smoothness of a stationary bike and I'm still working to pedal. Plus all the fun of riding outdoors. The best part is that my knees feel better than ever! (My knee problems stem mostly from pressure on the knees, for example: hopping up and down on my toes. But luckily, I’ve never had any problem walking.)

"I wanted to share my cycling SUCCESS story and maybe it will inspire someone else to give a pedal-assist bike a try. Thank you for sharing your success stories too!"

Thank you, Karen! Anyone else want to share a success story? Just drop it in the comment section. Success stories are always in vogue!

Saturday, September 23, 2017

The Great Lie in the U.S. Health Care Debate

I want to talk about something a little different today. If you're an American with bad knees, yes, it affects you – but it also touches the lives of many millions more than than that.

I want to talk about the great lie in the debate about U.S. health care.

First, this isn’t about Democrats, Republicans, Democans, Republicrats, whatever. Personally, I’m an Independent. I think both parties have become corrupted by money, but that’s a subject for another day, and another blog.

The great risible lie is this: U.S. health care is a free market that people choose or choose not to be part of, and like other free markets, the solution to our current woes – millions of uninsured, soaring drug prices, unaffordable insurance, etc. – can be found simply by unshackling market forces.

This is ludicrous.

Look, if I walk into a Honda dealership, and demand an Accord for free, the salesman (if he’s not laughing too hard) will point me to the door and tell me to get lost.

Sales of autos operate well within the free market model. There are competing dealerships; comparison-shopping isn’t hard to do; a Honda Accord buyer who doesn’t find the deal he wants can substitute a like product (a secondhand Accord, or another model from a different carmaker) to satisfy his need for private transportation. Also, we all agree no one has a “right” to a car.

But if I walk into a hospital emergency room, staggering and vomiting blood and without a penny to my name, the nurse on duty won’t point me to the door and tell me to get lost. That hospital has a legal obligation under the Emergency Medical and Treatment Labor Act (passed by Congress in 1986) to care for me. If I don’t have insurance, it doesn’t matter. What’s more, the law doesn’t let doctors half-treat me or dump me on another hospital for failure to pay.

And, at some point, most everyone will wind up in an emergency room. It happens, even to people who eat their kale every day and exercise vigorously and do a hundred other things right. We’re all going to need a health care “product” at some point – and we’ll need it for much more than emergency room visits -- whether we can pay or not. If we can’t pay, everyone else gets to pay for us that day when we land in the ER (see Note #6 below).

The alternative is stark: All those people without insurance, and without a means to pay, we let die.

Who wants that? Who thinks that even makes sense in the richest nation on earth, which spends so much on health care?

I know there are a lot of ideas on fixing the U.S. health care system: offering insurance across state lines (which will do very little), tort reform (which will do a little, but not nearly enough). But the first thing we have to face: every American is in this system together. We need a proposal that starts with that as the first principle. Everyone gets covered. Maybe that leads to single payer. Maybe that leads to Medicare for all. Or maybe there’s a different way.

But let’s be honest about who’s in the U.S. health care system.

We all are.

Some additional notes:

1. The U.S. pays two to three times as much per person as most other industrialized countries on health care. Despite this, the quality of our health care is ranked only 28th worldwide, below Slovenia’s. The U.K., which is ranked fifth, spends less than half what we do per capita. So it’s like we order filet mignon at Le Cirque, and in return get a turdburger in a styrofoam clamshell. Why isn’t everyone incensed about this? This isn’t a Republican issue, or a Democrat issue. It’s a people-opposed-to-stupid-spending issue.

2. On free-market “comparison shopping” for medical services: It’s practically impossible. Don’t believe me? Read this. The author says he should have been the perfect shopper for medical care: (1) he lives in Massachusetts, a state that passed price transparency laws to help patients shop for care (2) he’s a physician (3) the surgery at issue was minor and not urgent, giving him plenty of time to shop around (4) his research focuses on consumerism and price transparency. So it’s like the author of the Kelley Blue Book shopping for a used car. And how did the process go? Terribly. How’s this an efficient free market when price discovery is a nightmare?

3. Did you hear the story about Fin Mox? It’s an antibiotic for fish. But people were buying it for their loved ones – er, loved “fish” – because they couldn’t afford regular antibiotics. I’d link you to the Amazon page, with the hilarious comments from people whose “fish” didn’t have health insurance, and for whom Fin Mox was a blessing – but Amazon took the page down. The richest country in the world has poor people buying antibiotics for fish to get the medicine they need? That’s a disgrace.

4. Read this from emergency room physician Farzon Nahvi. He treated people – including a man with a brain bleed, whose life he saved – who later said, “Thanks, but I wish you hadn’t done that.” Because they didn’t have the money to pay the staggering emergency-room bills. Nahvi quotes Paul Ryan on health care: “You get it if you want it. That’s freedom.” Nahvi observes “Being given services without your consent, and then getting saddled with the cost, is nothing like freedom.” No, and let me complete the thought: it becomes closer to indentured servitude – or actually slavery, since indentured servants at least have to sign a contract.

5. One thing that puzzles me: if you believe in a free market in labor, you should definitely hate the current health care system. A full 56 percent of Americans get their health care through their employer. Many people are shackled to jobs at large companies, resistant to changing, because they don’t want to lose that precious insurance benefit. So think of all the people who could be innovators, or who could switch to a more productive job at a smaller company, benefiting the economy, but don’t because they need their gold-plated health insurance plan. So we squander the potential in our labor force. Why aren’t more conservatives upset about this?

6. A report last year showed one of five Americans visit the emergency room at least once a year. Separately, a study showed that a whopping 71 percent of these visits were either unnecessary or avoidable. Emergency room care is very expensive treatment, so this indicates a lot of waste. People lacking health insurance sometimes wind up in an emergency room because they can’t afford regular doctors.