Friday, April 29, 2011

Tai Chi to Treat Knee Pain?

While living in Hong Kong, I would sometimes see small groups of older Asians doing an odd kind of exercise. They would slowly move their arms and hands back and forth, while standing in a partial crouch. It looked sort of like martial arts in slow motion. Inside I would chuckle, thinking, "C'mon now, you call that exercise?" Because at the time I was getting what I thought was a real workout -- sweaty, intense, lung-busting -- by racing about on my bicycle for two and a half hours at a time, chasing golf carts up inclines and sprinting up mountain slopes.

Then came my battle with knee pain (chronicled in my book Saving My Knees). It was a humbling and frightening experience. At times I thought maybe my doctors were right, and I simply would never get better. Finally I dedicated myself to a long, slow program of recovery, based on what I'd learned about what joints need to become healthy again. And it worked.

During my struggle to save my knees, sometimes I would see the tai chi exercisers I had scorned. Instead of smugly passing by, I would pause and watch them. The more I saw, the more impressed I became. Because the new me -- the me that understood that going slow can make sense when your condition is hard to heal -- perceived tai chi in a new, positive light.

Since then, what I've read about this activity has only served to make me more curious about its possible benefits.

For instance, tai chi has a reputation for being "meditation in motion," as a Los Angeles Times article this week reminds us. That's a winning combo for chronic joint pain.

In saving my knees, I learned the importance of motion to ensure, and restore, joint health. My first of four golden rules for bad knees is "use it or lose it." Scientific studies (I cite them in my book) have found repeatedly that cartilage in joints starts going bad with immobility.

Meditation too is helpful, calming the troubled mind of a chronic pain sufferer. For a while, when negative thoughts constantly colored my thinking, I meditated daily, trying to find a peaceful space where my body didn't hurt all the time. The mind can be a very powerful force in healing.

Tai chi appears to have other benefits too. It may improve balance. And, more relevant for this blog, a study showed it helped with knee osteoarthritis.

WebMD has a short piece about tai chi here touting the activity as "low-impact, weight-bearing and aerobic." That also sounds like a winning combo to me. The weight-bearing part may not make it a preferable exercise for all knee pain sufferers, but low-impact is what your damaged cartilage needs for a while, until you can sufficiently strengthen it.

Okay, there are some of my rambling thoughts about tai chi. Has anyone out there tried it who wants to share a story?

Sunday, April 24, 2011

Why Is Stretching So Darn Popular, If Its Benefits Have Been Greatly Oversold?

At last we come to the end of my series of posts on stretching. To recap briefly, we looked at:

When stretching can be dangerous (Part I)
Why stretching doesn't fix the real problem (Part II)
Flaws in the biggest pro-stretching claims (Part III)
The real, if limited, benefits of stretching (Part IV)

Today's conclusion is the fun part for me. In the previous installments, I cribbed from other authors to make points, both anti- and pro-stretching. Today I'm flying solo, partly because I am wading into uncharted waters.

The question of the day: Why is stretching so popular if, as scientific evidence has begun to suggest, it doesn't provide the benefits it's supposed to? And why will some people keep stretching, no matter what any scientific study shows, or what any expert says?

This is fun to write about because it's "stretching as a phenomenon of the physical fitness culture." It's sort of a meta look at stretching and its persistent aspects.

So here are my reasons that stretching has become well entrenched in our physical fitness culture and isn't going anywhere soon:

1. If your knee is injured and the joint and the surrounding muscles feel tight, stretching often does make you briefly feel better.

This was my experience, after I hurt my knee and learned some stretches. What no doubt happened: the quadriceps stretch (my favorite) lengthened the muscle(s), taking pressure off the point where the bad cartilage under my kneecap pushed against my femur during bent-leg sitting. Still, it didn't take long for the muscle to contract again, so stretching was only effective for a short time. Later I realized that it wasn't fixing the underlying problem anyway.

2. Stretching seems sensible because it's natural.

We often yawn and stretch. After a period of inactivity, such as a long car ride, we get out and stretch. These types of stretching are natural. They reflect what our body wants to do, and they feel good. Of course neither is the same as focused muscle stretching that claims to have certain benefits. Still, someone can make the argument that all these forms of stretching belong to the same "family" and, by extension, they're all natural and good.

3. Stretching loosens us up. Looseness is associated with good health, tightness with bad health.

This is a very interesting point. If you do a double-column list of what we associate ordinarily with physical tightness, and what we associate with looseness, you'll discover everything bad falls on the left (tightness), everything good on the right (looseness).

Death is rigor mortis, a stiffening of muscle and sinew (tightness). When injured, parts of our bodies don't move well or easily through a natural range of motion (tightness). A natural part of the aging process includes becoming stiffer and less flexible (tightness).

Conversely, what do we expect of a young, healthy athlete? A strong, supple, flexible body -- in other words, looseness.

Faced with this fact set, stretching advocates will confuse cause and effect. They conclude that someone is injured (tightness) or prone to injury, so he needs to stretch more. They overlook the fact that injury naturally causes tightness (for example, a relatively small amount of swelling will virtually shut down a joint).

4. Stretching has its own interest group.

At first blush, this sounds sinister, and perhaps brings to mind hordes of well-paid Washington lobbyists. Well, to be considered an interest group, you don't have to be agitating in the shadows for personal profit and gain.

The interest group for stretching is a fairly benign one. It mainly comprises thousands of physical therapists and personal trainers who have been schooled in the art of stretching. They swap stretches, learn new stretches. They offer clients "assisted stretching," making valuable their ongoing involvement in the client's exercise routine.

Now suppose you received hours of training in something, learned how to do that something well, possessed an expertise in that something -- and then were told, "Uh, you know what -- that thing you learned and have been teaching -- it's really not useful after all. Sorry!"

What's your first reaction going to be? If you are like 99 percent of humans on this planet, you'll resist this new knowledge (check out cognitive dissonance here). You've become invested in whatever that something is (that they're now saying doesn't work!), so you might just ignore studies that conflict with your deeply held beliefs, thinking to yourself, "Anyone can do a study. A study can show anything!"

And, even if faced with a hundred studies that suggest you're wrong about this something you believe in, you might rationalize, "Well, a lot of people are still doing it, and they seem to get a benefit, so who cares what the studies show?"

5. Stretching has been conflated with warming up.

If muscle stretching were a biological organism, seeking to ensure its survival (I'm using a creative analogy here), the smartest thing it ever did was to align itself with something that certainly does work: warming up before exercise.

In fact, early studies that showed stretching to be effective actually showed nothing of the sort, because they looked at stretching as part of a warm-up routine (examples of warming up: lifting light weights before working out with heavier ones, jogging slowly before a race).

Warming up makes a HUGE amount of sense, I believe.

Stretching, not so much.

6. Stretching has taken on characteristics of religion, and no proof will kill it.

This point is also very interesting. Let me illustrate it with a real-life example: I was cruising message boards, looking for comments about stretching. One pro-stretcher, who seemed to be bright and willing to consider science-based data, was arguing with an anti-stretcher. They went back and forth, in civilized fashion, then the pro-stretcher finally made a curious comment that went like this:

Actually I don't care what the scientific studies show. They could all say that stretching doesn't work. I'm still going to do it. I'm going to do it because I know it does work.

What kind of argument is this? It's an argument that lies outside the realm of science and logic and reason. It's an argument from faith, common to religion. You can't kill an argument from faith. It's simply impossible.


I want to make something clear before I sign off on stretching. I don't hate stretching. I'm not committed to stamping out stretching. I'm not dogmatic about what I believe -- in fact, I am the kind of guy who is willing to concede that he could be wrong about everything he knows (or thinks he knows).

But I am also firmly of the belief that, just because everyone has done something a certain way for a long time, that does not make it automatically right.

As humans, we are gifted with rather large brains, to examine and improve the world around us. And that's what we should be committed to doing.

Saturday, April 16, 2011

Yes! A Little Validation for the Ideas in "Saving My Knees"!

Next week I'll finish the series on stretching. The basis theme of the last installment is, "Why does stretching have such an ardent following, and why will humans probably do it until the end of time, even if God Himself were to appear and announce that it doesn't work?"

This week, I wanted to take a break from the stretching-fest to show that the "radical" ideas in my book Saving My Knees: How I Proved My Doctors Wrong and Beat Chronic Knee Pain are being validated, slowly but surely.

For example, anyone who's read the book will remember one of my four golden rules for bad knees: Use It or Lose It.

Now, check out this April 12 Wall Street Journal article on bad knees entitled "Doctor's New Advice for Joint Pain: Get Moving." This is the lead:
Doctors increasingly are recommending physical activity to help osteoarthritis patients, overturning the more traditional medical advice for people to take it easy to protect their joints.

Here's the banner quote:
"The most dangerous exercise you can do when you have arthritis is none," says Kate Lorig, director of the Patient Education Research Center at Stanford University.
You'd be surprised at the number of doctors though who believe in -- what I like to call -- the "your knees are like a car" analogy.

Which works like this: You buy a brand-new car and drive it out of the showroom. That car will run fine for a certain number of miles, then begin to break down. Now you can go easy on that car -- shelter it in a nice garage, replace the oil regularly, avoid running it at excessive speeds etc. -- and the engine may last 130,000 or 140,000 miles instead of 110,000.

But, with enough use, after enough time, the car will break down. It just wears out. Gosh! That does sound kind of like your knees, huh?

Except the analogy really doesn't make sense at all, when you think about it. And it doesn't for an obvious reason: you're a living, breathing organism. Your car isn't. Your car isn't a hotbed of cellular activity, able to replace worn tissues and adapt to external forces. If you drive over a potholed road on the way to work each day, your car doesn't develop sturdier shock absorbers to better withstand the impacts. It's just a chunk of metal and plastic parts.

You're not. Triathletes have been shown to have thicker-than-normal knee cartilage. That's an adaptation to their sport and training. How many cars, outside of a Disney movie, are capable of growing larger-than-normal engines to adapt to regularly racing down freeways at fast speeds?

Yet the "your knees are like a car" thinking is surprisingly common. I encountered it on a message board recently. A doctor (!!!!!) was advising a knee pain patient against cycling. Why? Because it entailed a lot of repetitions, which would wear down the bad cartilage faster. I haven't gone to med school, and I recognized how silly that reasoning was. Even so, it's a perfect expression of the "your knees are like a car" analogy.

So the Wall Street Journal recognizes moving is a good thing for bad knees. Bravo! Of course few 21st century physical therapists would dispute the value of exercise (even if some old school doctors still resist the notion).

Where I sharply part ways with most physical therapists, however, is that I believe in joint-first, not muscle-first, exercise (taking my inspiration from a very smart man, Doug Kelsey, who first enlightened me to the fact that bad cartilage can improve, slowly, under the right exercise regimen).

Now it appears I have more scientific evidence supporting a joint-first approach, this from the April 2011 issue of the Journal of Pain (yeah, I guess there's a journal for everything, huh?). The article's title: "Experimental Knee Pain Reduces Muscle Strength." (I can link only to this abstract -- sorry -- because the full study is behind a paywall.)

The conclusion (my bold):
This study showed that knee joint pain has a significant impact on muscle function. The findings provide evidence of a direct inhibition of muscle function by joint pain, implying that rehabilitative strengthening exercises may be antagonized by joint pain.
Here's a translation of the bold type: "Joint pain inhibits how well muscles function. Thus, the existence of pain in your knee joints may counteract the effects of doing exercises to strengthen the muscles."

In other words, to simplify further and distill the nub of the thing: Joint pain limits how effective muscle-strengthening exercises are going to be (what's more, the study found that the more pain, the greater the reduction in muscle strength):
Knee pain reduced the muscle strength by 5 to 15% compared to the control conditions (P < .001) in both knee extension and flexion at all angular velocities. The reduction in muscle strength was positively correlated to the pain intensity.
The obvious objection to this finding, of course, goes like this: "Well, naturally, people with more knee pain have less muscle strength! That's because they stop using the leg with the bad knee so much, because the joint hurts, and therefore the muscles begin wasting away."

That objection is wholly irrelevant here, however. This study induced "experimental knee pain" -- which is to say, the subjects didn't have pre-existing knee pain. They were all perfectly normal. The "knee pain" patients had hypertonic saline (a form of salt water) injected into their infrapatellar fat pads to create knee pain. Then their muscle strength was measured and found to be reduced.

This study features a key takeaway for those eager to heal their knees: If joint pain is working against the effect of exercises to build up your muscles, might you have things bass ackwards, as they like to say in fifth grade?

Maybe the right approach is strengthening the joints first (and getting on top of the joint pain), and THEN attempting to strengthen the muscles.

That's what I did, during a recovery that spanned the better part of two years. And that's what worked, after the traditional "muscles-first" physical therapy approach failed miserably for me.

Sunday, April 10, 2011

On the Real Benefits of Stretching If You Have Knee Pain

I became a stretching skeptic partly because of my unusual history.

All my life, I've been tight-jointed (the kind of person who is usually advised to stretch). At the same time, as a youth, I loved sports: basketball, baseball, winter pickup games of touch football on frozen fields.

I never stretched beforehand. And I never got injured.

When I finally did have a serious injury, in my mid-forties -- cartilage damage in both knees -- at the advice of my physical therapist, I started stretching. Every day. I stretched and stretched and stretched (and did a number of exercises that he prescribed as well).

But I didn't get better. At some moment I began to wonder, "What does this stretching really do anyway? And what's the mechanism by which it fixes what's wrong with my joints?" It soon became clear that stretching didn't fix anything -- for me, and I suspect for many other knee pain sufferers as well.

Still, it can't be completely useless, right? Today we'll look at the question, "What's the best case to be made for the benefits of stretching?"

Here are some arguments that strike me as defensible reasons to stretch.

1. Stretching just makes me feel good.

If you happen to simply like the feeling after a good stretch -- of being loosened up, and relaxed, and ready to take on the world -- great! This seems like a valid reason to stretch.

2. I believe stretching is helping improve the condition of my knees.

Belief is a powerful force! In Saving My Knees I discuss the dietary supplement glucosamine. My doctors were vague and unhelpful on several fronts, but when it came time to prescribe something, on two occasions that something turned out to be glucosamine. Later I discovered the black joke: glucosamine has been shown not to work. Let me explain in brief:

* A number of scientific studies have emerged in the last decade indicating that it's not effective.

* Even if you don't believe these scientific trials that looked at pain relief and arthritis symptoms (after all, others claim a beneficial effect), at least two studies examined glucosamine on the level of molecular biology. They showed that the supplement, after being swallowed, is essentially ripped apart by the liver. The amount that ends up circulating in the blood is far lower than what's needed to have a salutary effect on your knee cartilage.

* If you're still skeptical, ponder this. People claim they need glucosamine to "feel better" and immediately notice when they skip taking a pill. Meanwhile, glucosamine is supposed to act on cartilage, a tissue that has no nerves and heals very slowly. So riddle me this: How is it that glucosamine takers get such immediate, snappy neural feedback in taking a pill that's supposed to improve the health of something that has no nerves and heals very slowly?

The glucosamine story is probably a placebo story. The stretching story may also be a placebo story, to some degree. But a placebo story doesn't have to be bad. Beating knee pain requires mental fortitude and a positive outlook. So if stretching lifts your spirits and you think it works, it can be somewhat irrelevant whether it actually does or not.

3. Stretching is necessary to preserve knee motion after surgery.

In Dr. Ronald Grelsamer's book What Your Doctor May Not Tell You About Knee Pain and Surgery, he says:
Following an injury or surgery, your knee will not want to straighten all the way. And it will not want to bend. Indeed, bending or straightening stretches the ligaments and tendons, which is painful. If you give in to the knee's reluctance to straighten and bend, two things may happen: Your knee pain may persist or worsen. Moreover, you might permanently lose knee motion.
Certainly, right after surgery there will be a period when you won't want to move much and will avoid bending or straightening your leg. However, you need to. Post-surgery, you're especially at risk of developing scar tissue (reducing range of motion and hindering function).

So, with the aid of a physical therapist at first, you need to bend your leg through as wide a range of motion as possible. This seems like an acceptable reason to stretch. But still, note that stretching isn't what's most important. You're not trying to achieve "range of stretching." It's range of MOTION -- and stretching the leg, to push it through the range, is what's required at that point.

Later, when the joint is capable of bearing weight and you're strong enough, regular motion and bending exercises can replace the stretching.


You may think I've overlooked a big reason to stretch: to redress issues of tightness or imbalance that cause unusual and harmful wear patterns in the joint. I think though that "tightness" and "imbalance" are often structuralist code words that don't get at the heart of the problem and don't offer a real, lasting solution (for more on structuralism, check out this earlier post).

I think the stretching-to-fix-tightness-or-imbalance doesn't make a whole bunch of sense. It's a way for doctors and PTs to avoid the real issue: you need to fix the joint (which most of them are still mystified about how to do). Most imbalances serious enough to cause your joints to degrade, it seems, couldn't be fixed by stretching alone. Surgery perhaps.

NEXT TIME: A meta look at the attraction of stretching: why, even if the heavens parted and God himself appeared and said stretching was useless, everybody would keep stretching. Why has this activity so thoroughly captured the imaginations of those in the physical therapy and medical community for so long?

Saturday, April 2, 2011

Stretching, Part III: A Critical Look at the Biggest Pro-Stretching Claims

Last week we looked at what often needs fixing with bad knees -- defective or missing cartilage, inside the joint -- and how stretching (whatever you think of it) won't help mend this problem.

But of course stretching proponents don't make such a claim anyway. So what are their claims, and how do these fare when scientifically tested and scrutinized closely?

Fortunately, the most common beliefs about stretching and knee pain happen to appear in one place (how convenient!): Say Goodbye to Knee Pain by Marian Betancourt and Jo Hannafin. Dr. Hannafin appears to be a prominent orthopedic surgeon; Betancourt has written books on health and women's issues. The copyright is 2007, so the book certainly isn't outdated.

Let's walk through the purported benefits of stretching, one by one. Betancourt and Hannafin are represented by bold italics; I follow in (mostly) normal type.

1. Stretching is critical to increasing flexibility of your muscles ...

Yes, it's true that stretching helps increase flexibility. It's also true that if you have someone constantly stretch out your neck every day (for many hours at a time), you might be able to achieve this:

The point being: there are lots of things that are true, about stretching and about many phenomena in the world at large, but the larger question is, why is the end result desirable? In the case of stretching, who really needs greater flexibility, outside of a normal range? (Paul Ingraham makes this point and many others in his excellent, fact-based analysis of stretching, which I recommend.)

But what about professional or even serious athletes? They aim to compete at the highest levels. Don't they need to be more flexible?

Certain athletes, such as ballerinas and gymnasts, obviously benefit from stretching. Which is kind of logical, if you simply watch their routines/dances, which include bending the body into positions that are hard to attain, even for someone with superior flexibility.

Most sporting activities don't resemble ballet and gymnastics, though. For other athletes, such as cyclists, sprinters and weightlifters, stretching has been shown to impair performance.

Example: four minutes of static stretching had the effect of slowing down sprinters in a study reported in the February 2009 issue of Medicine & Science in Sports & Exercise ("Effects of Static Stretching on Repeated Spring and Change of Direction Performance").

2. Stretching reduces your risk of injury during exercise or everyday activities ...

This claim has been thrown seriously into question.

In Australia, a year-long study of 2,600 soldiers found the same rate of injuries among those who stretched their leg muscles before exercise and those who didn't. On one message board I came across (a stretching debate was going full tilt), a poster derided this study's findings, saying that soldiers wear combat boots and he doesn't.

Okay then, try this on for size: the Centers for Disease Control and Prevention conducted a mass review of 350 stretching studies over four decades. And it also concluded there's no evidence that stretching prevents injuries.

3. Initially, stretching is important because it warms up the muscles and readies the body for exercise ...

Paul has the best line by far on this claim, which is more than faintly ridiculous on its very face. He says, "That's like trying to cook a steak by pulling on it."

What's ironic is that stretching advocates apparently have figured out as much -- though they haven't connected the dots yet. Listen to this guide at (you can find similar thinking in plenty of other places, but this is the first offender I chanced upon):
Always warm up before you stretch. It's a bad idea to stretch cold muscles.
But a stretching fanatic might rightly wonder: "Wait a second. Isn't that why I'm stretching? To warm them up? So I have to do some other activity to pre-warm them? What the heck's going on?"

The truth is, the most sensible way to really warm your muscles isn't to stretch. It's to do your intended activity at half-speed or half-force (i.e., jogging slowly to prepare for running a race).

This will increase blood flow to muscle tissue, boost the temperature of the tissue, and increase the range of motion in an activity-specific way. Stretching won't.

4. It is also important to stretch after you exercise or are active, to ease the tension in your muscles ...

I'm not quite sure what this claim is, but let's say the authors are advancing the "stretching prevents the onset of muscle soreness" theory. That's a common belief.

However, an analysis of ten randomized trials that appeared in the Cochrane Database of Systematic Reviews disputed this conclusion. Stretching before exercise or after had little or no effect on how sore someone's muscles felt.

Paul Ingraham quotes a clever line here: "Only soreness can prevent soreness." In other words, soreness is part of the price you pay for training, and increasing loads, and taxing muscles to get stronger.

So there you have it: four big stretching claims to approach with a good dollop of skepticism.

NEXT TIME: So what is stretching really good for? There must be something, right?