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.

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