Friday, December 24, 2010

Best Christmas Wishes to All

I had an ambitious blog post in the hopper along the lines of "How do you heal through pain-free motion when you're always in pain?" And I will get to it. Next week.

That's because -- alas -- my body has been steadily running downhill since about 10 p.m. last night, when a bit of viral grinchitude derailed my ambitious plans for Christmas Eve. Yes, I have a cold, with the raw throat and swollen sinuses as proof. My productivity, not surprisingly, has dropped off a cliff.

So I thought I'd weigh in briefly now with the obligatory holiday wishes and come back, hopefully recharged and restored, with some thoughts next weekend about exercising when you're in pain but don't want to exercise through pain. I began stitching together a post on that very topic this morning, but when you're not feeling good, it doesn't take long to run out of gas.

The good news is "Saving My Knees" is still on schedule. It looks like it'll be ready about January 8th as an electronic book through I'll have a lot to say about that in a few weeks -- why only an e-book, how someone without a Kindle can read an e-book (short answer: there are lots and lots of ways).

But for now, I'm just eyeing the bed, after a call to the wife (who's still in China, a piece of my personal story I'll talk about some other time). It's been a good year for me and my knees. In about August 2010, I reached the point where not only was the knee pain that forced me to quit my job in April 2008 gone, but also I was back to racing my bike up hills with guys 20 years younger than me -- and most of the time, I was beating them.


So take care all. Keep your knees warm. Try to enjoy Christmas. If you're frustrated by your physical therapy, by your doctors, by yo-yo'ing back and forth and never really feeling like you're getting anywhere, there is a better way out there. That's what I discovered, the hard way, and why I wrote "Saving My Knees."

Blessings to you all.

How Is It Possible to Exercise Without Pain When Pain Is All You Know?

This question got me thinking a lot recently. Because when you have to move to heal your knees, but you want to avoid movement that causes pain, and you're always in pain ... well, how do you ever get out of the starting blocks?

While catching up recently on Doug Kelsey's great blog, I noticed he said this in November about pain, while counseling a hurt runner on how to return to his sport:
You have to go hunting for the point where symptoms show up, adjust, re-train, and go again. This is where people make mistakes. They fail to edge the training. They fear the pain. Pain is the guide; not the problem.
So if you're always in pain, is the answer to just exercise anyway and accept that there will be a certain amount of pain?

This is a very tricky question. Anyone who's been reading my blog/comments elsewhere (such as on KneeGuru) knows that two keys to saving my knees were: (1) Going slowly and being patient (2) Modifying activity when pain and even mild swelling occurred.

Here's what I did, and what worked for me, with regard to pain and exercise and daily activities:

First, I listened very carefully to my knees. Bad knees throw off many different kinds of unhappy signals. I worked hard to figure out which ones meant impending problems and which were just the background grumblings I had to live with. I reacted quickly to the pain/discomfort signals that I thought spelled trouble.

If I awoke and my knees felt subpar, for example, I might cut back my step count that day from 6,000 to say 3,000 or 4,000 (I'd also try hard to figure out what caused the backsliding in the first place, so as to change my future behavior.) But my adjustment was usually only for a few days at most. It doesn't do much good to be on an exercise "program" that consists of lurching about; consistency is good.

I learned, too, that pain signals can arrive a full TWO DAYS AFTER the offending activity (hyaline articular cartilage has no nerves -- that's a BIG issue when you're trying to heal). Once I had knee pain two days after moving a heavy fan. Puzzled, I studied my knee journal to see what else could have caused the pain. Nothing -- I'm 99 percent sure it was moving that fan.

My recovery was a matter of learning how to recognize pain signals (delayed and otherwise), backing off, strengthening my joints, then pushing the envelope again.

That's right: I was always pushing the envelope. I never thought to myself, "Okay, I'll just get to the point where my bad knees can walk two miles without too much of a problem, then that'll be good enough -- I'll just accept I have bad knees that can walk only two miles." I wanted to heal and make my knees strong again, so I could resume the intense cycling I loved. I had big goals.

This is what Kelsey is talking about with that nice phrase, "edge the training." You have to push yourself beyond what's safe and comfortable.

The preceding reflects my personal experience. I realize I had a certain luxury though: my knees weren't absolutely shot by the time I intervened and managed to rescue them. Other people aren't so lucky. They're at the point -- because of failed physical therapy, or too much progressive damage over the years, or the severity of their initial injury -- where they simply can't get free of the pain.

So that brings us back to the original question: how do you exercise if everything always hurts?

Here are some of my thoughts for those with fairly constant pain. Discuss these with a medical professional to see if he/she thinks they make sense for you, in your situation:

* Can you do short bursts of activity? There was a period of my recovery, when I was half-convinced my doctors were right and I'd never get better, when I just did "walkarounds." Every ten minutes, I'd walk for a minute. It was a strange and boring regimen (bring a book!). For example, I'd go to a small park and walk around for a minute, then sit on a bench for nine minutes, then slowly walk for a minute, then sit back down etc.

Are there any motion-based activities your knees like? Moving in a swimming pool? Cycling backwards on a stationary bike (it requires less force and takes pressure off the joints)? At one point -- when I thought maybe I needed to go back to square one with my poor joints -- I even contemplated buying a continuous passive motion machine, secondhand, and just using that to give my joints frequent motion without too much strain.

* If nothing works for you -- you're still always in pain! -- you could experiment. I became a world-class experimenter. In fact, this helped stave off the boredom from what is, in the best of circumstances, a very, very slow recovery. Dedicate a week to a program of movement -- keep it at the same level all week (obviously if your knees start sliding downhill, adjust).

You do need to be fairly scientific-minded when you experiment, I found (buy a pedometer to track your steps!). If you don't keep as many day-to-day variables as constant as you can, then it'll be hard to tell whether your program of walking 4,000 steps a day is causing the problems, or whether it was that ill-advised trip to the racetrack when you had to stand for two hours in the same spot. In my book, I talk about how I became a guinea pig of my own making.

Also, I discovered that, with recovery from a slow-healing injury, it's best to focus on trend lines, not individual data points. In other words, say you start exercising Monday. On Tuesday, you say, "Eh, I feel about the same." Wednesday, you say, "I feel just a little worse." Thursday, you say, "It's been three days, overall I feel a little bit worse, I'm going to try something different."

The problem is, you may not have given your new regimen enough time. Try it for a couple of weeks. If, at that point, you say, "I'm definitely worse and going downhill," then maybe you are going in the wrong direction. But if you say, "I feel about the same," then you're probably winning. Why? Because you feel about the same but you're moving a lot more. That extra movement is laying the base for even more movement, and that's the path to healing bad knees.

* If experimenting isn't your cup of tea, or you don't feel you're getting anywhere, I'd look for a good physical therapist who is equipped to measure, scientifically, the strength of your bad joints and help you fashion a program to improve them. This involves more than someone examining your knees and saying, "Okay, do 10 of these and 20 of these" and so on. You need a physical therapist who can tailor a specific, joint-friendly exercise program for you.

Okay, that's a long-enough entry. I'm sure I'll return to this subject later. Now back to the book -- I'm coming down the home stretch and think we'll be ready to launch next weekend. Exciting moment! More information to come later and I will reveal why it's coming out only as an e-book. Stay tuned! :)

Saturday, December 18, 2010

Beating Knee Pain: The Attitude Re-Alignment

As I said here, I'm not at all convinced that issues of physical misalignment (the patella incorrectly tracking) usually explain knee pain. However, another kind of misalignment can be a big obstacle to getting better.

This kind of "misalignment" I came face to face with on one of the message boards I now frequent, where knee pain sufferers gather to share stories, advice, and from time to time, a little encouragement. Someone recently posted asking to hear from others who had "end-stage chondromalacia."

That phrasing intrigued me. Think about it for a moment. If you have "end-stage" anything, you're pretty much finished, right? If I came to you and said, "I have end-stage skin cancer," your reaction would probably be to clutch my hand, quietly murmur "I'm so sorry," then wait for me to disclose how much time I had left on this earth.

Well, it turns out there is no such thing as "end-stage chondromalacia." Or at least I've never heard of it, or read of it. I Google'd the phrase as well. Not a single hit. I doubt that a physician ever said to anyone, "You have end-stage chondromalacia."

However, I don't doubt that this person is in a lot of pain and missing a lot of knee cartilage. He or she is thinking: "My cartilage will just keep wearing down. It's not coming back. I'll just have to wait for a total knee replacement. Things won't get better."

Once you're convinced you have an end-stage condition, what does your life become? Answer: a matter of dreading the inevitable. Forget about hope. Negative thoughts dominate. Bad days are expected. Good days (or good moments) are explained away as flukes; they don't really matter because you're on a one-way street called Misery Lane.

I've been there. Early on, I was determined to beat knee pain. But I couldn't, even following my physical therapist's advice to the letter. A doctor told me my knees would never get better. And, not unexpectedly, my attitude -- little by little -- reset on me. Eventually I became an intensely negative ball of energy.

Part of healing meant doing an attitude re-alignment. It's not easy. It's hard as hell. Especially for someone like me -- I'm not by nature anything resembling a blithe optimist. But I realized my mind was working against me, and that wasn't good, so I began meditating. I just wanted to find some quiet interior space where I didn't hurt and wasn't angry all the time.

Of course meditating alone doesn't do it. You also need a plan -- a really good one if you've got "end-stage chondromalacia." You have a small margin of error.

What would I do if I were in that position?

I would seriously think about getting on crutches for a while and getting access to a continuous passive motion machine. Robert B. Salter did an incredible experiment in the early 1980s that showed an astounding rate of healing of full-thickness cartilage defects (yup, that's right down to the bone) among rabbits that were hooked up to a continuous passive motion device.

But here's the rub: at the same time, you'd probably have to go non-weight-bearing on those knees for a while, then gently introduce weight-bearing activities. I don't know exactly how this plan would be carried out. Right now this is just me musing aloud, trying to find a solution. Because trying to find a solution is positive at least.

I hope this knee pain sufferer can connect with a really smart physical therapist, someone like Doug Kelsey at Sports Center. If I were this person, I would even consider moving to Austin, Texas (where the clinic is). As I say in my book, a good physical therapist is worth his (or her) weight in gold.

That's because the best way to kill a negative attitude is with a plan that shows there is a path to getting better. Who cares if it's a long one? As long as you can see the light, and see the way to move toward it, you have some hope. And that's really important.

Saturday, December 11, 2010

What Are You Doing for Your Knees the Other 98% of the Time?

Anyone who reads my book (to be available the first week in January, it appears) will see me, in chapter eight, engaging in a bit of "medical study deconstruction" -- namely, taking apart a large study that was done about the effect of physical exercise on knees and showing how it comes up short in a number of ways.

It was a fun and illuminating exercise (fun because, to my wife's dismay, I spend a lot of time with my brow furrowed, thinking about things). To those who wonder what insight a layman could possibly have into a formal medical study, well, you might be surprised. The application of basic logic will get you far in analyzing complex subjects, even without specialized knowledge. For instance, judging the truth of the statement "the green disarticulation contours were green" doesn't require an understanding of what disarticulation contours are, why they are drawn, how they are drawn, whether they should or should not have been drawn in this specific instance. To recognize the sentence is true, you just need to identify an identity: "green equals green."

Okay, that example may seem a bit trite, but my advice is not to let the "experts" scare you away from examining their work, cloaked in all its jargon and statistical raiments. At the very least, after a thoughtful examination, you'll be in a position to ask some good questions.

And one question I asked, regarding this study, was "What were somebody's knees doing the other 98 percent of the time?"

Let me explain: The study looked at people who exercised, to see if they were less likely to develop osteoarthritis of the knee later in life. One category of exercise, fittingly enough, was walking. They were asked if they walked for exercise, and if they did, if they went less than, or more than, six miles a week.

Through how the categories were constructed, the researchers made it sound as though six miles a week was a lot of walking. So I decided to do a little math.

Let's say Joe Smith walks six miles a week for exercise. How long does it take to walk a mile? Well, I've walked one in 13 minutes before, but the average is probably closer to 20 minutes. So that equals two hours a week total. How many hours is Joe awake each week? Let's say Joe gets a full eight hours of sleep a night -- an optimistic assumption, but we'll go with it. That means Joe is awake 112 hours (16 hours x 7 days).

Divide 2 by 112 and you get 1.8 percent: That's right, Joe spends less than 2 percent of his waking hours on walking for exercise. Why does that matter? I hope you can see now where I'm going with this. What's happening with his knees the other 98 percent of the time? That's HUGE. (And the study in question makes no mention of this as a potential issue.) After all, his knees don't just magically detach from his body whenever he happens not to be exercising.

One of my complaints about physical therapy stems from this 2/98 problem. My therapist laid out a program of exercises and stretches that took me ... about two hours total, each week. Yet he didn't seem concerned about what my knees were doing the rest of the time! He never asked me questions that I would ask any knee patient, knowing what I know now. (Do you lug things to work? Do you often carry a loaded backpack? If so, about how much does it weigh? Do you often carry a child around the house? If so, how big is the child? Do you navigate a lot of steps during a typical day? Do you run for a bus? Do you run at all during a typical day? If so, for what distance and how often? Do you squat a lot at work? Do you stand a lot at work? Etc., etc.)

These questions are important because they are the other 98 percent! If your PT isn't asking about the other 98 percent, I believe you need to do the asking and thinking yourself. Because your job/house/lifestyle/whatever greatly affects how you use your knees. And how you use your knees -- over 100 percent of your waking hours, not just 2 percent -- is a big determinant of how your knees feel (and heal), I learned during my recovery.

Saturday, December 4, 2010

I Followed Your Advice, So Why Aren't My Knees Getting Better?

Sometimes I imagine this question, in a slightly querulous tone, coming from someone who has read either my entry here about what I did to save my knees, or this loonnnggg thread here, on Knee Guru's bulletin boards, that also reveals how I got better. (Quick disclaimer: I steer away from giving advice, so I took some poetic license with the title of this post.)

At Knee Guru, several smart people greeted me by peppering me with questions, curious about my "exercise regimen." How did I do this, how did I do that, what did I mean by this, what did I mean by that? And then, I have no doubt, they tried what worked for me: lots of easy, joint-friendly motion (for example, I did "walkarounds" in my apartment, where a wind-up timer would go off every 15 minutes, to alert me I needed to get up and walk a little, about 70 steps. Cleaving to that routine kept dosing my knees with movement).

After a few days of copying everything I did, I'm guessing many of them gave up in frustration, because their knees felt about the same.

So let me take a moment to make a few more in-depth observations about how I healed.

First, and it's hard to overstate the importance of this: recovering from a slow-healing injury isn't linear. What that means: you don't feel 15 units of healthy today, 16 units of healthy tomorrow, 17 units the day after that, and so on until you're at 100 percent again. If only healing were like a smoothly ascending straight line on a sheet of graph paper! Because then, as soon as you discovered the proper solution to getting better, you would know immediately that you'd found it because you would begin feeling an improvement every day forward.

Unfortunately, on the long road to saving my knees, there were ups and downs. Over a single month, I might happen to feel worse on the 22nd than on the 5th -- even though I was getting better over the entire month. So I learned that what I really needed to focus on was the trend line of healing. I had to be patient and squint hard to see that line. It only becomes clear over the course of some time.

Which brings me to point two: whatever path you choose to heal, it will probably take many months to bring you to your destination. For me, it took the better part of two years. This too has enormous implications, because early on (if you're like I was), you're casting about in frustration and desperation for a solution, any solution. So you try different things, in the same manner that a clotheshorse swaps out hats -- okay this guy says if I eat asparagus, that's good for the joints, I'll do that, wait this guy says I need to squeeze a beach ball between my knees, okay let's see if that works, now this guy says ...

Essentially you're a butterfly in the garden of healing, flitting from flower to flower, never committing to anything. Will you get better this way? I doubt it. You need to find a path, stick with it for a while (to verify that it's the right one), and then persist to the end.

Last observation on healing: the worse off you are, the longer it will take to make a few small gains. This too is critical to know. If your knees are really bad, it could take five or six months to make them just a little better. During this time, sadly, you may be tempted to just give up, thinking, "If it takes this long to go a little way, it will take me 20 years to get better!"

But what I observed about healing: it starts going faster as your knees get stronger.

I quit my job right at the end of April 2008. I had to; I couldn't sit in one place, with my knees bent normally, without a lot of uncomfortable burning, and my joints were going downhill fast. As soon as I quit, I devoted myself to a program of gentle motion, in amounts that my knees could tolerate. I focused like a laser on my goal.

Four and a half months later, I felt a little better, but not much. I began to have serious doubts. Would I really be able to beat this thing? What I didn't know was that my dedication to slow and steady motion was already helping my knees prepare for the next level of my program -- that November, I started walking on hilly trails, very carefully at first. Had I not spent the summer building up my knees, I don't think they could have withstood the rigor of that kind of exercise.

So if you're wondering why you're not getting better, even though you think you're doing what you should be, just consider these points above. Healing isn't linear. It's not swift. And, early on, it can be really, really slow. This is all important to know to win the battle.