Saturday, October 30, 2010

Another Reason Not to Like Standard Physical Therapy for Chronic Knee Pain

A quick recap: Standard physical therapy's answer for PFPS (or chondromalacia, or runner's knee) is to try to strengthen the quads, the hips, the butt -- anything but the knee.

Why is this so bad? After all, some patients do get better under this regimen, right?

Well, if you believe what I do, it's bad because with difficult cases of chronic knee pain, this approach has a very high fail rate. It's bad because muscle-strengthening exercises can be too much for a weak joint to tolerate, injuring a patient even further (as happened with me).

And this week I thought of a new reason why it's bad: Because the clock is ticking for a knee pain sufferer ...

That means, from the onset of pain, you have an optimal window for finding the right path and getting on it. It could be a window of years, depending on the individual and the condition. But eventually, that window will start to close a little, then a little more.

I'm using this metaphor to refer to the threat of structural changes in the joint itself that throw up obstacles to healing. My greatest fear, when I had knee pain, was that I'd develop knobby bone spurs interfering with the knee's range of motion. In other words, I'd become full-blown arthritic and my best chance at winning the battle would fast recede.

The prospect of structural changes transforming my joints, in ways that could not be fixed short of surgery, scared me the most.

I recall listening to my left knee bend once, and it was if I had a band in there that would make a little dull snapping noise as it passed over some other object. Luckily, the "band" never hurt or impeded my normal motion. I proceeded with my program to get better, and whatever was causing the problem, now appears to be gone.

But for a while, I thought it was a permanent structural change. The longer hurt knees hurt, the greater the chances of the joint degrading in significant structural ways. That's why it's important to take advantage of that window of opportunity early on, when the pain first appears and it's easiest to get better. Unfortunately, that's exactly the time when Joe Patient, knowing nothing about his condition, wanders into a physical therapy clinic and gets a bunch of bad quad-strengthening advice.

My first visit to a physical therapist was June of 2007 (I'd have to consult my files to be sure of the month, but that's about right). The physical therapist treated me off and on until sometime in January of 2008. He urged me to strengthen my leg muscles; I did exercises he prescribed, sometimes feeling a little better, sometimes a little worse.

At one point, my knees blew up following his advice to lift weights in the gym, and I took a long downward slide. Basically, if my knees were about a 5 on a scale of 1 to 10 when I first visited him, by the time I left, they were a 3 or 4. So he left me in a deeper hole than he found me.

Meanwhile, this whole time, the clock was ticking. My joints were in danger of becoming permanently worse. Luckily I saw the light in time, the scales fell from my eyes, and I realized that the path away from pain was to fix the thing that hurt: to strengthen my knees first and forget about my quads for a while.

But if you're reading this, and you have painful knees, you may be thinking: What if I've passed the point of no return? What if it's too late? Well, it probably isn't. That thought is just one of many negative thoughts that flit through your head all day long because you're struggling so much with pain and discomfort. I've been there.

Next time: We'll look at a clinical study that shows you can strengthen knees. Scientific validation! Time to get geeky. Stay tuned.

Saturday, October 23, 2010

Why Patellofemoral Pain Syndrome Is Poorly Understood

I came across this on the Internet the other day -- the observation that patellofemoral pain syndrome (henceforth "PFPS" -- usually I hate acronyms, but I don't want to wear out my fingers typing that grandiose-sounding name again and again) is poorly understood -- and I thought I'd take a whack again at one of my favorite pinatas: the PFPS "diagnosis."

First, I don't argue with the statement that the condition is poorly understood. Just consider this observation from a July 2006 article in the New Zealand Journal of Physiotherapy Association: "Despite its prevalence, there is no clear consensus in the literature regarding terminology, the aetiology or treatment for PFPS."

So why is medical science baffled by PFPS so much? The kneecap almost sounds like the body's Bermuda Triangle, where a normal disease process goes and gets lost and becomes God knows what.

Here's my theory: PFPS is poorly understood partly for the same reason leg pain syndrome is poorly understood.

For those unfamiliar with leg pain syndrome (LPS), it's a collection of symptoms that describes certain aches and pains in the leg. They can appear in the arch of the foot, the back of the heel, the knee, the hip, the front of the leg -- in a number of places, really. The pain is often brought on by exercise or rapid movements of the limb.

The condition is poorly understood and hard to treat. What works for one case of LPS may not work for another. For instance, one sufferer of LPS may have a tear in the muscle in the arch of his foot, while another may be suffering from a sore tendon in the front of his knee. The two, of course, need different treatment modalities, making it difficult to devise standard practices for handling cases of LPS.

If you haven't figured it out by now, the last two paragraphs are bullcrap. There is no such thing as LPS.

It's just an exaggeration of what PFPS is: an overly broad and not-too-useful diagnosis that ends up confusing the patient. Because, to start with, PFPS simply means "knee pain." Actually, to be fair: "pain around the kneecaps with certain characteristics."

But what's missing here? The same thing that makes the LPS diagnosis pretty worthless: any kind of explanation as to what's causing the knee pain. What use is a diagnosis that regurgitates the symptom cluster, then folds up its tent and goes home, finished?

What if you had a high temperature and visited a doctor who pronounced your problem as, "feverish head syndrome," or FHS. Pretty soon, as cases of FHS became widespread, you'd be reading sentences like, "Despite its prevalence, there is no clear consensus in the literature regarding terminology, the aetiology or treatment for FHS."

Because FHS isn't really a diagnosis (American Heritage dictionary: "the act or process of determining the nature and cause of a disease or injury).

Neither is PFPS.

Saturday, October 16, 2010

How Traditional Physical Therapy Almost Ruined My Knees

This is the story that I figured, one of these weekends, I'd get around to telling.

It's the story that explains why, in preceding posts, I may sound a tad bitter when I disparage those who believe in "quad-strengthening" to relieve chronic knee pain.

Yeah, I'm a little bitter -- a little angry even -- because of a bad personal experience, which showed me in convincing fashion why this "strengthen the quads" focus is pretty dumb.

Here's what happened:

I had just returned from a two-week vacation with my fiance in Tibet. Beautiful countryside, and we ambled about at a slow pace (Lhasa, where we spent most of our time, is a two-mile-high-plus city, which left us gasping for oxygen much of the time). At that point, I'd been battling knee pain for about five months. So it was still early days for my condition, you might say.

When I flew back from Tibet, my knees felt pretty decent. I even started to wonder: "Could I be cured?" (Of course now I know joint problems don't mysteriously resolve in two weeks, but in Tibet I did manage to find, by accident, a sweet spot of motion interspersed with non-stressful resting positions.)

Soon after my return, I marched into my physical therapy appointment with a big grin: "I feel pretty good," I said. My therapist responded with a broad smile and said, "It's time to hit the weights!"

Of course, I thought. This is the perfect opportunity to build up my quads, at last! For months I had been thwarted in my efforts to do so -- my knees reacted badly to the exercises that my PT prescribed. He had modified my daily exercise regimen, ad nauseam, to no avail. But my joints feel better now, I thought triumphantly.

He showed me a "safe range" for doing leg presses and seated leg lifts. For example, with leg presses, he told me to push the chair on the machine as far back as possible and to focus on doing the exercise at a nearly full extension, so as not to put pressure on the kneecap. He also showed me a "safe range" for the leg lifts.

I began visiting a gym during my lunch hour. During the exercises, my knees felt fine. My muscles would burn a little and I thought, "This is great, I'm finally getting my quad strength back." But I soon noticed something rather odd. The next morning after my little workout, I would wake up with a small, focused, intense burning in my knee joints -- a symptom I'd never had before.

My PT didn't seem worried by this, so I kept doing the exercises. Unfortunately I began noticing more of the next-day symptoms, and what's more, the overall condition of my knees took a dip for the worse. It soon became obvious that my problems were roaring back. So I stopped doing the leg presses, thinking they might be too stressful. Then, after a while, I noticed for the first time my knees were becoming uncomfortable DURING the seated leg lifts. I took this as a bad sign. Plus, I had developed a small amount of swelling in the joints.

But you know what I was thinking, in the back of my mind, this whole time? I can't give up; I need to strengthen my quads ... once my quads are strong enough, this swelling and pain and discomfort will go away ... my physical therapist must be right about this; after all he studied anatomy and went to school to help people like me and besides everywhere you look online, the advice for cases like mine is "strengthen your quads!"

Then one day I stopped kidding myself. I wasn't getting better. I was getting worse -- a lot worse. Whatever hole I had been in before had become about twice as deep. Occasionally I would leave my desk during the workday and slowly shuffle around nearby streets, just to try to relieve, a little bit, the awful burning in my joints. And that's when I began to realize that the traditional approach of physical therapy to treating bad knees -- those with chondromalacia, PFPS -- was badly flawed.

Now if there's a PT reading this, I bet that person is thinking, "Well, the problem was that your physical therapist had you doing too much! You were lifting too much weight, or lifting weights too often."

To which I would reply: I could have done less weight, and probably it would've taken longer for the symptoms to arise. But why not face the real issue: my knees were still weak. Strengthening muscles requires a lot of force (relative to strengthening joints), and one thing that weak knees can't tolerate, is a lot of force.

About that time, I began to drift away from physical therapy (until then, I had been the perfect patient, doing my stretches and exercises every morning). I began crafting my own program to save my knees, a program that took almost a couple of years, but that gave me back my knees and the physically active lifestyle that I missed so badly.

That's my story. Anyone else want to share?

Saturday, October 9, 2010

Some Good Knee Advice From a Surprising Source

I've started venturing onto message groups, to share bits of my story, hoping to help others who are being failed by their doctors and physical therapists, as I once was.

I joined Yahoo's "chondromalacia community" as a recovered chondromalacia sufferer, a very rare species indeed. On joining, I was welcomed with a short e-mail that included 5 DOs and 5 DON'Ts for anyone coping with chondro. I didn't expect much from a "welcome to our group" message, but I was pleasantly surprised. The advice is better than you'll get from most physical therapists and doctors.

Below (and I would credit the author, but the note was unsigned) are the recommendations, with some brief comments from me after each:

--- Chondromalacia Do's

1) Keep searching until you find a doctor who will give you a thorough exam (1 - 2 hours), looking at the entire body. You'll probably have better luck with a pain specialist, osteopath (D.O.), doctor of applied kinesiology or a really good physical therapist. Most orthopedic surgeons give you about 10 minutes.

(RB: Yes! My experience is that doctors tend to give patients who have bad knees, but basically a normal range of motion and no noticeable swelling, the bum's rush, to put it bluntly. They will make a non-specific diagnosis, such as the dreaded "patellofemoral pain syndrome." Why getting a specific diagnosis matters: To fix what's wrong with you, you first need as much detail as you can get about what's wrong. Is there a problem with your meniscus? Plica? Cartilage? Tendon? So yes, do get a doctor who will investigate thoroughly.)

2) Become your own doctor. Do as much research as you can about knees, doctors and all the different treatment options there are. Concentrate on what is "wrong" with you, not just controlling the symptoms. This is a great resource to get started. Read each section on the patella:

(RB: This is a great idea on two fronts. First, you need to understand how knees work to understand and take control of your treatment, instead of putting yourself passively in the hands of someone else -- a physical therapist or doctor -- who, in the best-case scenario, will see you for half an hour once a week. You need to know enough about knees to be smart about them the other 167 1/2 hours. Also, "don't just control symptoms" is spot on. Don't become a "med head." Drugs make you feel better, but do nothing for restoring your knee health.)

3) Try to keep moving your knee as best as you can. Try swimming, no-resistance cycling or walking if you can tolerate it.

(RB: The right kind of movement is absolutely critical. I designed my whole recovery program around this idea. But it has to be easy-enough movement so that your knees tolerate it well.)

4) Start with the least invasive treatments first.

(RB: Yup. One thing I learned, when investigating surgery: surgery begets more surgery. That should give you pause.)

5) Keep thinking positively! You need to have the attitude that you WILL get better.

(RB: Very true. At some point, I became an intensely negative ball of energy. I hated my life because I hated this hurting person I had become. But plastic happiness isn't the answer either, I don't think. Rather, it's attaining inner peace while finding a good, sensible recovery program that gives you hope. I started meditating and found it beneficial.)

--- Chondromalacia Don'ts

1) Don't simply accept that you "just have to live with it." Chronic knee pain can often be fixed.

(RB: Agree 100%. Mine was fixed completely, no surgery. So call me Exhibit A for that point.)

2) Don't even consider surgery until you've exhausted every other, less-invasive option and cannot function in your daily life.

(RB: This advice may sound harsh, but I think it's dead right. Surgery simply isn't much good for cases of chondromalacia. A famous New England Journal of medicine study discovered that knee-pain patients who underwent sham surgeries (the surgeon only pretended to operate and did nothing to the joint) did just as well, if not better, than those who had an arthroscopy that included trimming rough cartilage and flushing the joint with saline solution.)

3) Don't exercise through severe pain, even if the exercises are prescribed by a physical therapist. Pain is the body's way of telling you something is wrong.

(RB: This is where I'd modify the advice a bit. Don't exercise through ANY pain is closer to what I believe. Also, another tweak: Don't exercise through pain, or do exercises that cause pain the next day. This "next day" part is what trips up almost everyone, I've learned. Most people don't understand well enough how cartilage damage occurs and fail to connect next-day pain with the exercises they did the day before. Or if they make the connection, they just try to shrug it off. Bad move.)

4) Don't blindly accept your diagnosis. Doctors make mistakes, especially when it comes to knees.

(RB: Yes, I can attest to this. Doc 1 told me: You have arthritis. Doc 2 told me: No, you don't have arthritis (but he said I would if my joints kept deteriorating). So doctors aren't infallible.)

5) Don't stop exercising. Even if you can only work the upper-body or exercise in a pool, you've got to try to stay healthy and strong. Don't immobilize the leg - that could make your situation worse.

(RB: I would modify this one slightly too. When I suffered from knee pain, I gradually became a bit leery of the word "exercise," though I confess I use it a bit loosely myself. If you have bad knee pain, you need movement/motion. "Exercise" in too many people's minds suggests hopping up and down in an aerobics class or doing squats, which is not a good idea for bad knees, I found. But you do need to move your knees as often as possible; immobilization to "let it heal" is totally wrong-think with cartilage issues. I also would hesitate to use the word "strong," because it's a "save the knees by building up the quads" code word. The truth is, you need to be patient and restore the health of the joints. During that time, your legs may not be strong at all. But if the joint is getting better, you're moving in the right direction.)

Saturday, October 2, 2010

Why Drugs Aren't the Answer to Knee Pain

I think everyone fighting chronic knee pain at some point reaches that dark place where they think, "God, if only this pill were more effective! If only it could drown out the pain for a little while and let me once again do the things I love!"

Be careful what you wish for.

Pfizer developed a potent arthritis drug called tanezumab. They began to put the experimental medication through studies to test its efficacy. And this unfortunately is what they discovered, according to a Bloomberg News story (the bold is mine):
An experimental arthritis drug from Pfizer Inc. reduced pain more than researchers anticipated, doctors said. It also allowed previously hobbled patients to overuse and permanently damage their joints.
Bone destruction developed in 16 of 6,800 patients taking the medicine, tanezumab, as part of Pfizer’s development program, and they all needed a complete joint replacement for the affected knee, hip or shoulder, according to a report in the New England Journal of Medicine. Pain-free patients may have put excessive pressure on their fragile joints because they weren’t getting natural pain signals to take it easy, said the lead researcher, Nancy Lane.
There was no dispute over whether the drug worked:
Reduction in knee pain ranged from 45 percent to 62 percent in those given the Pfizer drug, depending on the dose, compared with 22 percent for those given placebo.
But its larger failure -- the "rapid progression of arthritis" that occurred in 16 subjects -- may cause a rethink about chronic inflammatory pain:
“Pain has an important role in the avoidance of self-harm, but chronic inflammatory pain has generally been considered to be wholly undesirable,” said John Wood, professor of neurobiology at University College London, in an editorial that accompanied the research. “The study by Lane et al. suggests that a complete quenching of pain in patients with osteoarthritis may not necessarily be a good thing.”
Here is one of those places where medical science is going to get smarter in the next decade or two, I predict. I think chronic inflammation is wholly undesirable. But I think the associated pain, at least within reasonable limits, is actually desirable. The burning has levels of intensity, which are a way of providing invaluable feedback, telling you what not to do. Drugs to mute that pain -- to mask it, to immerse a knee pain sufferer in a cloud of false, pleasant feelings -- are simply obstacles to healing.

When I was frustrated and desperate, seeking to beat patellofemoral pain syndrome and tame a pair of knees that were constantly inflamed while sitting, I was given drugs by a doctor who said I had arthritis. One afternoon at work, I took the pills -- one was to combat inflammation, the other was to combat the effects on my stomach of the first pill. I have to admit, they did make normal bent-knee sitting easier.

And the next morning, when I woke up, I noticed my knees felt worse than normal.

Why? Because the arthritis drug allowed me to ignore the inflammation pain signals and engage in an activity (sitting) that I simply wasn't strong enough to do yet. When I realized what was happening, I swore I'd never take one of those damn things again. And over the next two or so years -- which included more than a few bad days, and a long recovery from knee pain -- I never did.

Anti-inflammatories allow knee pain sufferers to do things they shouldn't. For example, on a message board once I read about how someone had trouble climbing and descending stairs, so he just popped a couple of Advil for the pain ... and I just shook my head. Sure, the Advil will enable someone to climb stairs better. But if your knees can't handle stairs, why not try to figure out how to strengthen them so that they can, and in the meantime -- I know it's hard -- avoid stairs. It can be done.

Do you really want to heal? Or do you just want to forget you hurt?

One last important note: I know there are people who have knees that hurt terribly, and having gone through my own hell, I wouldn't take pain drugs out of their hands. It's awful when your knees hurt all the time. I've been there. But if you want to heal -- and you can; that's my message of hope -- beware of medication. I think it does much more harm than good.