Saturday, March 10, 2018

Why I’m So Optimistic About Cartilage Healing, Take 2

I got a comment from a reader below this post. If you remember, I was looking at a two-year study that showed a surprising number of improvements in cartilage defects (well, I found the number surprising anyway). This reader was less enthusiastic:
If I am interpreting the study correctly, most of the defects of the patella actually progressed. For younger people, perhaps for the majority of this site readers, this is bad news. Perhaps, I am wrong, but it seems to me that most of us here suffer from chondromalacia, of one degree or another, and as it is about patella cartilage damage, there isn't much joy in that study. There's another one from 2008, where the level of degradation of patella lesions was high compared to all the investigated knee compartments and the percentage of cases where improvement of a lesion was observed was abysmal.
First, let me address a couple of quick things: (1) Yes, I’ve seen a study too where defects in the patella cartilage didn’t improve as often as defects in cartilage elsewhere in the knee – but still, there were some instances where they did improve. (2) To clarify, the study I reference in the post isn’t looking at just defects in the cartilage behind the patella, but rather, throughout the knee.

Okay, a quick recap:

The table below is 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.

The condition of each subject’s cartilage was graded for five different knee compartments (at baseline, and after two years). 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

Okay, so did most of the defects in the study progress? Well, yeah. Of course. But it doesn’t matter because you have to adjust for the “floor” and “ceiling” effect.

In this case, “floor” means a defect can’t get worse. “Ceiling” means it can’t get better.

Example: If a defect is graded “0” at baseline, two years later, it can only be “0” or worse. It can’t get any better than 0. There is no -1! Conversely, a defect graded “4” at baseline can only stay the same or (if indeed cartilage can heal) can get better.

Now, look at the number of defects that have a “ceiling” effect (grade of 0) or a “near ceiling” effect” (i.e., defects initially graded 1).

There are 117 that start out with a “ceiling” effect (just add the numbers in the first row) and 196 with a “near ceiling” effect (that's the second row). So for this group of 509 defects, there’s a high chance they’re going to get worse. Sure enough, we find a whopping 389 got worse. Awful, right?

Not at all.

Look at the bottom of the table. Here, our attention turns to the “floor” effect (defects with an initial grade of 4) and “near floor” effect (initial grade of 3). There are 5 defects with a “floor” effect and 14 with a “near floor” effect.

How many defects improved? Only 10 – which seems like a small number compared with 389, but consider that we started with only 19 (yes, I know, “small sample size” alert).

Of course, when you look at the number of changes overall, many more defects got worse because most faced the ceiling effect. But look at raw percentages, and the story becomes more interesting:

Defects that started in the “ceiling” or “near ceiling” effect categories
Got worse: 76%
Stayed the same or got better: 24%

Defects that started in the “floor” or “near floor” effect categories
Got worse: 26%
Stayed the same or got better: 74%

Wow! Almost a perfect inversion!

Now, why does this matter (once again) if you really care about cartilage healing (which, again, you shouldn’t obsess about in the first place, because pristine cartilage isn’t a sine qua non for eliminating knee pain).

Because if cartilage really can’t heal, all those defects graded 3 or 4 should be staying the same or getting worse; three-quarters of them shouldn’t improve!

One last fun thing in closing: is there a line in the table (you’ve probably already spotted it) where we can escape the “floor” and “ceiling” effects as defined here? Sure: at baseline, 88 defects landed smack dab in the middle of the table, receiving a score of 2. That means a loss of thickness of less than 50 percent.

Now notice what happened to them two years later. Yes, eight were found to be worse. But more than three times as many, or 27, improved to a grade of 1.

So that’s why I see the glass as half full (even though, for the umpteenth time, don’t obsess over cartilage healing!).

Saturday, February 24, 2018

Open Comment Forum: What’s the (Surprising) Thing That Your Knees Hate?

It seems like we’re overdue for another open comment forum. Talk among yourselves in the comment section below!

What you can use this forum for: (1) Introducing yourself, and some of the knee pain challenges you’re grappling with (some other readers may have a thought or two about what might help you (2) Including a status update of how you're doing (3) Writing about anything else you want to!

If you’re stuck but want to contribute something, here’s a question to get the ball rolling: What’s the (surprising) thing your knees hate? In other words, if you say your knees hate carrying an 80-lb. safe up six flights of stairs, no one is going to be surprised. If, however, your knees hate warm massages, well, that’s a bit odd.

So there you go! I hope everyone is doing well. I just finished riding 52 miles on my bike; the legs feel tired, but in a good way. The knees continue to be happy. Cheers!

Saturday, February 10, 2018

Unloading Your Joints: More Proof It’s the Way to Go

I’m a fan of Boston professional sports teams, so I follow a lot of news about them. That includes injury reports, unfortunately.

In October – exactly six minutes into the NBA basketball season – the Boston Celtics lost forward Gordon Hayward for the season. He broke his ankle in a gruesome injury.

Hayward is slowly, slowly rehabbing. He recently posted an account of what his recovery is like, and I thought it worth mentioning for a couple of reasons.

One: Does this sound familiar?
The hardest part of all of this is the mental grind. It's a lot of time doing pretty boring things to get the slightest bit better every day, and of course, sometimes I don't get better. Sometimes I take a small step back because my ankle didn't react well to the thing that I did the day before. And so we have to walk it back a little. That's the hardest part, and the most frustrating part for sure.
Anyone in a long-term recovery program for chronic knee pain can identify with this agonizingly slow pace of healing. Still, recognizing this is how healing happens -- little steps forward, then backward, then repeat -- is useful to avoid getting too discouraged.

Also, of course, notice his mention of those nagging setbacks that you're going to face. You will make mistakes, and push a little too hard some days, and that will lead to frustrating delays.

Two: Listen to how Hayward is exercising his ankle.
... I am slowly progressing with the AlterG. This is the first time I’ve ever used the AlterG, and if you don’t know what it is, it uses air pressure technology to allows you to rehab without putting your full body weight on your legs. It’s like you don’t have the full effect of gravity on you (which is where the name comes from).
We all know what AlterG is, right? (I wrote about it here.) AlterG is a rather expensive piece of equipment that allows you to run and walk on a treadmill at less-than-normal forces. While it costs more than a total trainer, the objective is similar, and involves lightening the load on your hurting knees (or ankle).

Gordon Hayward is a $30 million-a-year man. That’s a big contract. He could afford any kind of rehab he and the Boston Celtics wanted. That they chose a piece of technology that’s essentially a cousin of the total trainer should convince you that the joint unloading approach really works for the smartest, quickest recovery.

It’s not just Doug Kelsey and me saying it – it’s the medical staff of the Boston Celtics, dealing with athletes who make far more money in one year than I’ll ever see in my lifetime!

Saturday, January 27, 2018

Osteoarthritis, and a Post-Industrial Era Mystery

The latest issue of Harvard Magazine looks at a curious mystery.

Two biology researchers from Harvard University discovered the mystery after visiting medical institutes across the country and examining skeletons over the centuries.

They were searching for evidence of knee osteoarthritis (bone-on-bone rubbing in places where the cartilage has completely eroded, which leads to polished bone surfaces that are a telltale sign of the disease).

When they compared the skeletons from the prehistoric and industrial eras to those from the postindustrial, they found that the prevalence of knee OA has more than doubled since World War II.

You might think: Sure, of course it’s higher. People live longer. More people today are obese.

But controlling for age and body mass index didn’t make the difference go away. To be sure, obesity contributes hugely to knee OA. But it wasn’t causing the spike in cases.

The researchers still aren’t sure what’s going on, but they’re testing a hypothesis that I think will yield their answer.

Physical inactivity, they speculate, may be what’s to blame. The mid-twentieth-century shift to service-sector jobs put more people in workplaces where they got less movement. The modern desk rat was born.

We sit, and sit, and sit, and sit, and then wonder one day why our knees hurt.

Because our knees weren’t designed to do nothing at all for long stretches?

Or, as the article says, in more prolix language: there’s a “suspicion that OA is a case of human physiology being partly maladaptive to modern environments.”

Healthy, joint-nourishing motion IS important.

This, I believe, is the key to preventing knee pain, or once you have it, recovering your pain-free knees once again.

Saturday, January 13, 2018

The Difficulty of Taking a Step Backwards to Move Forward

With New Year’s resolutions thick in the air, I thought this might be a good time to talk about what might be the hardest thing to do when trying to heal aching knees.

A lot of people, especially fit people, quickly take to heart my message of “motion” when it comes to healing. After all, living things that stay at rest gradually become weak and begin to fall apart.

So athletic people immediately want to go outside and start walking 5,000 steps a day to recover their knee health.

But the motion imperative can be very dangerous, as too much motion just leads to more knee pain. The key, I strongly believe, lies in figuring out the “proper amount” of appropriate motion. And, as I've said many times before, determining the “proper amount” can be very, very hard, especially initially.

What’s sometimes needed is a willingness to go backwards to go forward.

For me, that involved scaling my program way, way back. I went from walking thousands of steps a day to simply walking once around a pool and resting for ten minutes, then repeating the sequence. Talk about boring! This also represented a kind of “rock bottom” moment for me – if that’s all the movement my knees could tolerate, they must be much weaker than I imagined.

As it turned out, hitting rock bottom was one of the best things that happened to me. I needed to accept where I was – where I really was, and not where I thought I was – to start improving. Those simple pool walkarounds made my knees feel consistently good, and I needed that. I needed to escape the frustrating swings of emotion, where my knees felt good for a few days, then bad for a few, and my progress seemed to stall.

Going too fast, too aggressively, can leave you baffled and frustrated. Sometimes it pays off to go backwards – figure out the least strain you can put on your joints, while having them consistently feel better.

Once you establish that baseline, then you can start to move forward.

Saturday, December 30, 2017

Happy New Year, Everyone!

It’s that time of December again, when we take stock of the year that was and start to dream of the possibilities of the year ahead.

I’d like to take a moment to thank the readers of this blog (and the book). My plans, at least for now, are to keep blogging at least semi-frequently until the book sales taper off. I think it’s nice for people who read Saving My Knees to find me online and active.

The book arose from frustration: doctors, I think, are unduly pessimistic about the ability of bad knees to heal, when given time and the proper treatment. I showed it was possible with my own knees (“proof of concept” to validate a hypothesis). My knees are normal today.

The book also arose from anger: after extensive research, I became upset at what physical therapists thought was the “proper treatment” for my knees, and disappointed in my doctors – who I felt should have known better – that they condoned this protocol.

Anyway, I’m not trying to hog the spotlight today. I really wanted to make this an appreciation of you readers, especially those people who share comments and insight on this site. I didn't write the best-selling knee book, but I think I’ve got the smartest readers. ;)

I’ll take that.

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!)