Saturday, June 18, 2016

The Post-Recovery Period: It’s Not Always Smooth Sailing Either

I’ve been meaning to post this for a while.

One thing I’ve always tried to be is honest about my experience with my knees. What I went through, and what I learned, may help you. Or it may not. But at the least, you deserve an honest account. No one out there should find out I’m limping around on crutches and waiting for a total knee replacement, and that’s the coda to my book, because nothing worked out the way I thought it would and I hid that from everyone for years etc. etc. etc.

Today I’m here to talk about an occasion since 2011 when things were not great. Last year, I felt some light burning in my knee joints during a six-week stretch, while sitting at my desk at work.

Oh no, I thought. Am I going down this road again?

I’m fairly certain I know what precipitated it. One day I decided to do an insane session of short sprints, followed by quick recoveries, on my stationary bicycle. I had never done that before nor have I since. I think it just tipped my knees into a bad place – out of homeostatis, Dr. Dye might say.

But here’s the thing: I’m a whole lot smarter about knees now. So what I did:

* I dialed back on my bicycle riding for a few weeks. I still went out long miles, but alone and at an easier pace.

* At work, I said: You gotta get up and move! I had fallen into a bad routine where I never left the office. I worked at my desk for 10 hours straight, with a few breaks, such as for lunch, which I ate on site (my employer provides some free food and soups). So I resolved from then on, every day without fail, to LEAVE the building and WALK through the city for about 20 or so minutes (I’ve missed maybe one day, when the rain was just coming down too hard).

And those burning knees went away.

I’m sharing this with all of you in the interest of full disclosure, and because I really don’t know what’s happened in my knee joints, in terms of healing. Maybe there is some residual change in there that makes me susceptible to slipping back into an inflammatory cycle. But I am very sure that something got better, much better. I really do ride hard now: I sprint, I climb painfully long hills, I motor along at 28, 29 miles an hour -- and it feels really good.

Part of the reason I’m sharing this too is because I think that had I stuck with easy riding -- no more sprinting, go out with the “old timers group,” never break much of a sweat -- I doubt I ever would have had a problem again. Seriously. But I wanted to get right back at doing what I loved most, riding hard.

So I think my own story is useful as a cautionary tale. Perhaps you can return to your former activity, but you have to be vigilant. Bad knees that went south once can go south again.

And now a happy postscript: This year has been a very good one for my knees. Today I went on a 74-mile bike ride -- a very hard 74-mile bike ride -- and my knees are fine. (My legs? Eh.) We powered up a lot of small hills. At the end, as we approached a final half-mile hill at an 8 percent grade, I told another rider, “I’m less than zero.” I was completely exhausted.

But I felt great later. And right now, if I suddenly had amnesia and someone reminded me that I’d had knee problems in 2007, I’d probably say, “You have to be joking.” Because everything feels pretty normal.

Saturday, June 4, 2016

Welcome to the Blog! A Few Things …

I thought it was about time to do one of these posts, following a recent complaint I got about "commercial marketing" on this site (I'm assuming in the comments section).

There are very few ground rules here for people who want to leave comments/ask questions, but for anyone curious:

* Spam comments will be deleted.

These by the way have become harder to detect. At first spam comments were along the lines of “Great post!” with the commenter embedding a url in their profile name. The url generally led the clicker to some clinic that had most likely paid the spammer to drive up its traffic count.

Once the spammers figured out they were getting deleted this way, the tactics evolved. So now they sort of pretend to be engaging with the post for a couple of lines, often in a fairly transparent and superficial way. And of course, the url is still buried in there somewhere.

Again, I don’t mind at all if you link to a web site, an essay that helped you, a book, whatever – as long as you’re here to participate in the dialogue. If you’re a drive-by spammer, who is just looking for a way to staple an advertising flier to the nearest utility pole then move on, that’s different.

I check the comments weekly and try to clean up the ones that don’t contribute to the dialogue. As I said, advertisers are getting more sophisticated. But be forewarned: if you’re a first-time commenter and include a short comment and a prominent url, you will be looked upon with suspicion.

* The best way to ask me a question is in the comments section.

I get a lot of requests for advice/consultations, and many make me more than a bit uncomfortable. I wrote a book to tell my story, thinking it would help a lot of people with similar problems and also, as much as anything, offer hope when all seems hopeless. To me there was huge value in just documenting well the story of someone who beat knee pain when he was told he couldn’t and exposing all the untruths out there, about everything from “damaged cartilage can never get better” to “you need to focus on strengthening your quads.” Pernicious myths abound when it comes to knee pain.

Also (and I’m not exactly proud of this), I was full of anger about the way I was treated as a knee pain patient, and I’m sure others can speak of a similar experience: shrugging doctors who can’t recall what your issue is from one visit to the next, bouncy physical therapists who have never suffered a day of knee pain in their lives and all work from the same tired playbook, an industry of snake-oil supplements that has sprung up that studies have shown have no clinical efficacy, a roster of more serious drugs to keep the pain at bay and the knee pain sufferer on a dazed eventual walk toward surgery, which is where you wind up when you don’t take charge of a program to get better.

But I never claimed to be a doctor or a physical therapist myself, so I try to avoid giving advice. I try to avoid suggesting much in the way of exercises, except for the most simple ones. In fact, I got better doing an extremely simple exercise: walking, in slow, measured doses, with breaks, always listening to my knees.

So when you come to me and want to share your story via e-mail, my inclination is naturally to shrink away. It’s very flattering, but I’m not the guy you want. Doug Kelsey’s clinic has coaches who are very well-equipped to counsel and advise, and they work by phone now I understand. That’s really who you want. This is why I say “no” when people want to e-mail me with long descriptions of their problems. If they offered to pay me by the hour, I wouldn’t say “no,” I would say “hell no.” Because that would be even more wrong.

So what should you do? Leave your comments below a recent post. A lot of smart people now are regular visitors to this blog. A community has developed here of people who look out for each other, share what has been working/not working, and in many cases, have thoughts/insights that I would not have or that would simply be more appropriate or helpful for you. So share, by all means. But let’s keep the dialogue open and public (you can remain anonymous behind a screen name; that’s fine). You might be surprised at the volume of excellent suggestions (and all the support) you get from others on this site. Plus, I’ll see your comment too, of course, and might have some ideas as well.

Last, let me close on a positive note: Thank you all for reading. Honestly, I figured I’d have shuttered this blog by now. I don’t contribute to it as regularly anymore. But it always gives me pleasure to see all the people chatting below the posts, and I know I’ve created a kind of valuable if small ecosystem on the vast Internet, where intelligent people can talk about knee pain and feel free to shred some of the myths that hold us back from healing – and talk about the difficulties of their personal struggles too.

Healing bad knees isn’t easy. But I’m convinced it can be done. I did it. :)

Sunday, May 22, 2016

Another Open Comment Forum

Someone suggested I do these periodically, and it seems like a good idea. (Gives me a break too, and my life just keeps getting busier, so I'm good with that!)

As usual, I'll flip the mike around so everyone out there can talk in the comment section about what they want to.

If you're stuck for a subject, here's an idea: Discuss what you find most puzzling about your knee pain. Of everything that doesn't make sense, what's the biggest mystery you wish you had an answer to?

And, of course, if you don't like that suggested topic, feel free to disregard. Cheers, and hope everyone is having a good spring!

Saturday, May 7, 2016

Why Do So Many Physical Therapists Want to Hurt Us?

A recent experience with a frozen shoulder prompted this post. It also also relates very much to my days with knee pain because I noticed a similar dynamic at play.

First: the frozen shoulder is almost unfrozen now. That’s the good news. Frozen shoulder by the way is a term for adhesive capsulitis, a condition where the movement of the shoulder becomes quite restricted and simple tasks – such as threading your belt through loops with an arm behind your back or extending your arm over your head – become difficult or even impossible.

Before I knew it was a frozen shoulder (I thought I had torn my rotator cuff), my doctor advised physical therapy. Okay, that’s fine I thought. I waited however until I got a diagnosis, thinking that it made no sense to begin physical therapy before we even knew the exact problem. After frozen shoulder was diagnosed using an MRI, I made the appointment with the therapist.

His advice: perform stretching and range-of-movement exercises. In a variety of exercises, I was challenged to move my arm to the extreme that I comfortably could, and even try to go a little further. We did some exercises together. He also kneaded the tissue a little, then photocopied a couple of pages of exercises for me to take home.

Okay, I thought. Got a plan. That’s good.

There were about eight different stretches/exercises. I did them each morning. My range of motion began to improve.

But I felt terrible. Immediately after the exercises, I would notice a clicking/snapping of a tendon in my shoulder. This may have been the byproduct of inflammation. At night, I often had trouble sleeping. Once I had to take some Advil to get through the night.

A few days after that I had this realization: this just isn’t working. Sorry, but I’ve seen this same bad movie before, when I had knee pain. Sometimes it takes courage to reject a failed course and rip up what seems like a solid plan and come up with a better way forward.

But if I couldn’t even get a good night’s sleep, I knew I wasn’t getting better.

So I poked around online, looking for exercises for frozen shoulder. I found some illustrated on YouTube that were super easy. Swing your arms, loose and easy, like a pendulum, trying to let gravity do most of the work. Swing them up and down. Swing them back and forth. Swing them in circles.

Okay, I’m going to do that, I figured. It’s motion. Motion is good for joints, I learned from having bad knees. I tried to swing my arms 10 to 15 minutes every morning.

And the frozen shoulder began to get better, over the course of weeks. Now I’m almost over it. Thank goodness.

All it took was easy, gentle motion. Sort of like slow walking, or pool walking, or easy cycling to heal a pair of bad knees.

Maybe you’re thinking: Fine. It worked for you. But this stretching regimen surely makes the most sense for most patients with frozen shoulder.

Maybe not. From a paper, Adhesive Capsulitis: Use the Evidence to Integrate Your Interventions (Phil Page and Andre Labbe):
It has been suggested that “gentle” therapy (painfree pendulum and active exercises) is better than “intensive” therapy (passive stretching and manipulation up to and beyond the pain threshold.
Anyway, this post is getting long. Let's return to the original question: Why do so many physical therapists try to hurt us to make us better, when gentle therapy might produce better results? Here are some quick theories:

* Physical therapists tend to be young, healthy individuals. They know of your condition through what they’ve read in textbooks; they haven’t actually suffered your condition. They are missing an experiential bit of knowledge that may be quite useful.

* Physical therapists tend to be well-schooled in muscle groups, in forces and opposing forces, and various stresses on different parts of the body. They sometimes sound like physics nerds. That may encourage them to focus on stretching/working muscles in a more intense manner than may be warranted.

* Physical therapists tend to be in good shape, not surprisingly. I suspect a lot of them work out. People who work out are familiar with that old saying, “no pain, no gain.” They may carry a bit of that bias into the practice of their profession.

In any event, in this case, I found what was effective turned out to be easy motion. I wouldn’t be surprised if we find that to be a more successful intervention for many joint issues.

Friday, April 22, 2016

When Physical Therapy and Steroid Injections Don’t Seem to Matter

I came across an interesting study not long ago – not about knees, but tennis elbow (it's no longer up, so I can't link to it).

It turned out that about three-quarters of people with tennis elbow (who have damage to tendons in their forearm) recovered on their own after about a year.

Okay, maybe not surprising. The next part is though:

There was no significant difference between people who received no medical intervention and spontaneously got better and those who had both steroid shots and physical therapy sessions.

After a year, both groups were doing roughly the same.

The study involved 157 people, from ages 18 to 70. One group received six weeks of physical therapy and two steriod injections (the second group had the therapy and placebo injections). Then the third group got no special treatment.

The most aggressive combo, of physical therapy and steroid injections (to knock down the inflammation), showed a marked benefit at six weeks, no improvement at 12 weeks, and worse symptoms at 26 weeks.

Then, at the one-year mark, this article tells us:
Overall, improvement with physical therapy plus placebo injection or steroid injection was about the same as with no treatment at all.
Okay, now here’s my take.

First, steroid injections are dangerous. I really believe these are a deal with the devil: a quick “ah” sensation of relief, at the cost of leaving damaging chemical residue in your joint that weakens it.

As for physical therapy, good physical therapy can be a life saver, but all too often we get bad physical therapy. For example, I recall my own experience when I had knee pain and along the way developed tendinitis diagnosed as golfer’s elbow (which is similar to tennis elbow).

Here’s some of what was done and prescribed:
(1) electrical stimulation (worthless for me, I’m quite sure – but others have had success with this)
(2) stretching exercises (may have damaged the tendon further – how much sense does it make to stretch a cold tendon? Doing so may have created a few microtears in the tissue.)
(3) exercises that were probably too low repetition to stimulate constructive tendon healing.

If that’s similar to the physical therapy that someone gets for tennis elbow, then I wouldn’t be in the least surprised to find out it’s basically ineffective.

However, the right physical therapy can change your life. I devised a program of eccentric exercises, thanks to Doug Kelsey and other sources online, that I’m pretty sure helped me rescue the tendons in both arms. That program I bet would’ve changed some outcomes in this study.

Anyway, for knee pain the right move is not to do nothing and hope it resolves. Don’t take away that message. The point is rather that the solutions we’re directed to, such as conventional physical therapy and high-powered anti-inflammatories, may not be good solutions at all.

Saturday, April 9, 2016

A Bike Is a Bike Is a Bike -- Or Is It?

Here’s a short post in reaction to something I read in the comments. Someone was frustrated about how his knees reacted badly to a session on a stationary bike but were okay on a real bike, out on the road. Which makes no sense at all, right?

After all, a bike is a bike is a bike. Right?

Ten years ago, before my experience with knee pain, I would have said reflexively, “Sure. No appreciable difference.”

But once you have knee pain ... well, I’m not so sure. Your knees in this state are more tender and more easily disturbed. You start to appreciate subtleties, slight differences between Activity A and Activity B that actually can matter.

Personally, I’ve noticed differences in how my knees react to riding a stationary bike versus a bike on the open road.

The stationary bike has certain advantages. It’s easier to control the force exerted. You can simulate an 18-mile stretch of easy, flat road if you want to. Hell, you can even spin backwards.

But what I find more interesting is that riding on the open road may have certain advantages too. It’s easier for my knees to ride hard on the road than on a stationary bike. Why? Maybe because I’m shifting my body around, moving on the seat more, slightly altering the way that my joints take the pedaling force. Or maybe because sometimes I’m slowing (or even stopping for traffic lights), other times accelerating. Or maybe because occasionally I’m standing up on my pedals. I don’t know.

Then there are the bike setups to consider. Chances are very good that your stationary bike and road bike aren’t configured exactly the same way, in terms of distance from seat to pedal, for example. Does that matter? If you’ve got great knees, probably not. If you don’t, it might.

Anyway, this is just my way of urging you to stop and think a bit if you’re doing two things that you think are basically the same and one bothers your knees and one doesn’t. Maybe they aren’t really the same. And maybe that slight difference is actually important.

Saturday, March 26, 2016

Inflammation in Early Ostoearthritis: It's Not Your Imagination

After my “Ghost in the Machine” post, I received a link to an interesting paper (published in Therapeutic Advances in Musculoskeletal Disease only a few years ago). It isn’t a meta-study, but more a state-of-what-we-know summary.

First, you have to understand a little background. The prevailing paradigm is that rheumatoid arthritis is the inflammatory arthritis. The immune system goes beserk in an RA patient, and a blood test shows high levels of inflammatory markers, such as C-reactive protein.

Now, contrast that with the traditional understanding of osteoarthritis: It too causes havoc in a knee joint, but it’s a “wear and tear arthritis” and noninflammatory. And so, when I asked my doctor if my knee pain might be implicated in inflammation elsewhere in my body, he more or less scoffed.

That paradigm is now shifting, it appears, so if you’re one of those knee pain sufferers who is wondering about an onset of other aches and sorenesses, you’re not crazy. Medical thinking may be just slow to catch up with what we’ve long suspected: there probably is a ghost in the machine when someone has chronic, low-grade inflammation.

But I may be crossing a bridge too far (at least for this paper). Let’s look at what it actually says, using a few snippets:
Although rheumatoid arthritis is clearly associated with higher levels of inflammation, osteoarthritis is by no means a “noninflammatory condition.”
No surprise to most of us. But what’s more:
Inflammation is present in osteoarthritic joints well before the development of significant radiographic change . . . Cartilage breakdown products in synovial fluid as well as microfissures in articular cartilage are present long before any degeneration can be noted using current MRI technology or gross arthroscopic visualization.
Translation: Inflammation and other bad stuff is going on in your joints WELL BEFORE you can see anything on an X-ray or an MRI. So if you go to your doctor with burning, aching knees, and he says (after studying your X-rays and MRI), “Well, they look fine,” don’t be fooled. That doesn’t mean they are fine.
The development of chronic inflammation in OA following joint trauma or overuse can be understood as a vicious, self-perpetuating cycle of local tissue damage, inflammation, and repair, such that the osteoarthritic joint has been likened to a chronic wound.
This is IMPORTANT. Note the operative phrase “vicious, self-perpetuating cycle.” This is the cycle you somehow have to break. I had a sense of this when I quit my job and devoted myself to the full-time pursuit of healing my bad knees. To me, I was fast running out of time and needed to take a dramatic step to get on top of my chronic inflammation.
These studies, demonstrating significant synovial inflammation in early osteoarthritis, suggest a window of opportunity may exist in which disease-modifying interventions targeting inflammatory processes might be the most efficacious for the prevention and treatment of osteoarthritis.
Okay, this is the part I’m somewhat tepid about, but I understand the authors’ proclivity for a solution that comes in a neat little pill (that some pharmaceutical company can charge $800 a month for). I would modify their conclusion somewhat, saying instead that there’s a window of opportunity to subdue that inflammation. You may benefit most from a drug (but be careful, as some will degrade cartilage and what’s more encourage you to do things that are too taxing for your weak joints). Or you may need a tonic that’s free: the proper amount of easy, appropriate motion, and the ability to keep your knees in non-stressful positions.

For more, please check out the study. The second half dives deep into the weeds, flinging about terms that I expect most of us will struggle to comprehend, as the authors look at particular pathways of inflammation. If you have an appetite for such, go for it. Mine is somewhat limited, I confess. :)