Saturday, February 23, 2013

Try To Be Optimistic Because How You Feel Affects What You Feel

Here’s a knee pain finding with a message well-worth heeding.

A South Korean study of 660 men and women, all older than 65, found that being depressed can make symptoms of knee osteoarthritis feel worse.

Researchers used X-rays to measure how severe each subject’s osteoarthritis was. Naturally, those with the most damage reported the most pain. However, some of the subjects with mild to moderate arthritis also reported severe pain.

Now, setting aside limitations of X-ray measurements (and there are many, for conditions that involve soft tissues), what can we learn here?

An Arthritis Today article about this study quotes Jon T. Giles, an assistant professor of medicine at Columbia University:
“Painful sensations are relayed through the brain in a very complex way, and can be modulated up or down,” he says. With stress, poor sleep, anxiety and depression, which are known to influence pain levels, “stimuli feel more painful than they would in someone without the adverse psychosocial factors.”
Now here are a few of my thoughts.

And if you have knee pain, you’ll be relieved to know that none equates to “Don’t worry, be happy.”

Because chronic knee pain stinks.

Of course there’s a good chance you’re depressed. If you’re anything like I was, you’re depressed because you have discomfort and pain most of the time. You’re depressed because merely climbing a set of stairs or carrying your toddler across the room causes a flare-up in your joints. You’re depressed because you know that almost everything you want to do in your life will involve your knees, and you’re doubtful that they’ll ever be normal again.

In short, you have a lot of very good reasons for feeling depressed.


Negativity levies a real tax on your body. That’s an inescapable truth. So even though you may be perfectly justified in your anger/bitterness/sadness, you have to realize you’re paying a price for it.

What to do? Here are a couple of ideas.

First, consider a de-stressing activity, such as meditation. I did it for a while, during my knee pain recovery (this was a period, by the way, when it wasn’t just my knees giving me problems). I found it useful.

Second, get into a long-term program that has one objective: healing your knees. This will restore something that is essential to getting better: hope.

This brings me to a closing rant.

In the Arthritis Today article, reactions to the study above included this suggestion: that care providers such as doctors screen patients for conditions such as depression and refer them for treatment (drugs, etc.) when needed.

I can imagine, upon hearing this, a gathering of doctors murmuring in approving tones, “Yes, yes, that sounds like an excellent idea.”


Here’s what irks me about that seemingly sensible suggestion. One major reason that knee pain patients suffer depression is because no one shows them a path to escaping knee pain. In this regard, doctors are the worst, from my experience.

In many cases, I suspect (again drawing from my experience), patients bounce around among doctors who just kind of shrug and say “You have knee pain, but I wouldn’t advise surgery just yet.” Further, patients are diagnosed with unhelpful, baffling terms such as “patellofemoral pain syndrome” that don’t tell them, in clear, specific terms, what’s wrong with their knees.

And then they’re found to be depressed. Well, no kidding.

Before doctors go about blithely prescribing pills for depression related to knee pain, they might want to ask themselves if they’ve done everything possible for their patients in terms of finding a good, long-term plan for eventually escaping that pain.

Saturday, February 16, 2013

Bad Knees, Weak Hips, and the Other Problem With Structuralism

If you’re a runner, perhaps you’ve heard this theory before:
Runners with weak hip stabilizers appear to have tendencies to rotate the thigh inward and to excessively adduct the hip (i.e. run knock-kneed) to create stability to compensate for the weakness of the hip stabilizers. These maladaptive movement patterns put strain on the knee, and over time an injury emerges.
I took that from this article in “Competitor: Your Online Source for Running.” The author of the piece further simplifies the hip-knee relationship to:

Muscle weakness in hip --> bad form --> knee injury

Assuming you believe all that, you should also see a common sense solution:

Strengthen the weak hip muscles.

Easy enough, huh? Apparently not.

20 women (who weren’t injured yet who showed signs of abnormal adduction while running) participated in a study where half went through a six-week program of hip strengthening and instruction in single-leg squats. The other half (the control group) did their normal training.

And the results?

Nothing. Nada. Zilch.

The knock-kneed runners who strengthened their hips continued to run the same way as before.

So was lack of hip strength really causing them to run knock-kneed? Or was it something else?

And, more to the point if you’re a structuralist type (someone intent on tracing problems back to crookedness and muscle imbalances): How fixable anyway is what you think is wrong? (I’ll set aside the question of whether running knock-kneed predisposes you to injury -- let’s assume for now that it does).

This seems to be “the other problem” with structuralism. The number one problem, I think, is that the search for structural deficits is overused as a diagnostic tool. The “other problem” (the depressing one, really): It’s very hard/impossible to correct many structural “faults.”

A great example is leg length discrepancy. Having legs of different lengths, in the structuralist world view, sets you up for all sorts of problems. But what’s the remedy? Unfortunately, you can’t mail order an evenly matched set of limbs.

Have no fear though. In a long, fascinating essay on structuralism (subtitled “The Story of the Obsession With Crookedness in the Physical Therapies”), Paul Ingraham notes a 1984 study showing that leg length discrepancy doesn’t make any difference for back pain (within reason of course -- if a doctor saws six inches off your right leg after a car crash, yeah, that’s going to affect your walking and a whole bunch of other things).

And so it is with other bits of structuralist orthodoxy, Ingraham goes on to explain. Another study looked at imbalances of major muscles in elite players in the Australian Football League. Any structuralist worth his salt can tell you what that should lead to: higher rates of injuries. But researchers found that “asymmetry in muscle size was not related to number of injuries.”

Ingraham’s essay is a terrific read for its bountiful evidence and good insights. For instance, he says structuralists are masterful dot connectors. He gives this as an example of how they think:
A podiatrist might tell you that your fallen arches (dot!) cause greater strain in your knees (dot), which in turn force you to use your hips differently (dot!), which leads to hip weakness (dot), then muscle imbalance in the core (dot!), which finally results in back pain (dot!).
What’s the first thing you notice there? I’ll tell you what I see: the potential for incredible, bewildering complexity. After all, almost everything in our lower extremities can be connected, somehow, to almost everything else. Treating chronic knee pain under such a belief system then becomes like solving some higher order math equation. This suggests your treatment will probably be long and frustrating, as your structuralist, dot-connecting physical therapist explores various hypotheses about what might be “truly” causing your knee pain.

My approach was much simpler. I operated on the assumption that my joints were just injured, or weak, and needed to be slowly strengthened and coaxed back to health.

This approach worked very well for me. I suspect it would work very well for many other people suffering from chronic knee pain too.

Saturday, February 9, 2013

What Are You Waiting For? Get Moving!

As I’ve noted in the past, I get regular e-mail alerts from Google about the latest Internet content that relates to knee and cartilage problems. Sometimes a theme will emerge, repeated across a number of alerts. One theme I’ve written about several times before: Lose weight! Another I’m writing about today: Get moving!

If you have chronic knee pain, don’t take it lying (or sitting) down. You need to move that bad joint to have any hope of saving it. All the evidence firmly points in that direction.

Let’s start with the University of Minnesota School of Public Health. Researchers there reviewed 193 studies conducted between 1970 and 2012 that looked at treatments for osteoarthritis-related knee pain that didn’t involve drugs or surgery.

This meta-analysis showed:
Exercise fared the best at improving pain and mobility, as long as subjects followed through with a program, while the researchers found that few physical therapy interventions were as effective.
The favored activities: low-impact aerobic exercise and water exercise (yes!) as well as strength training (eh -- be careful!).

A Wall Street Journal reporter noted the shift in thinking that has occurred, writing “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.” Exercise reduces pain and improves mobility of the hurt joint.

“The most dangerous exercise you can do when you have arthritis is none,” Kate Lorig, director of the Patient Education Research Center at Stanford University, says in the Journal article.

In fact, the reason you have problems in the first place may be because you’re not moving enough. According to Indian orthopedic surgeon Madan Hardikar, there are two key causes of knee pain: (1) for the old, it’s natural wear and tear of the joints (2) for the young, it’s a sedentary lifestyle (he cites the country’s IT workers, who put in 12- to 15-hour workdays at a computer and who often don’t get any exercise outside work either).

To conclude, here’s a cool arthritis story (even though it doesn’t involve knees, but hands):

Margaret Crowell was an elite tennis player who had osteoarthritis in her thumbs and hands. An orthopedic specialist said nothing could be done to prevent the disease from worsening.

Luckily, Crowell refused to believe him and give up. She discovered the benefits of gentle exercise and movement and managed to reverse her symptoms. Now she gives classes for older adults that emphasize slow stretching and agility movements.

So there you go.

As with the need to lose weight, there’s no debate here.

Move, move, move!

Saturday, February 2, 2013

With Knee Pain, What We Believe Influences How We Interpret What We See

This is a famous drawing:

What do you see?

Do you see the dainty, pert-nosed young beauty, her head turned away? Or the large-featured old hag?

If you see the young woman, and your friend sees the hag instead, your first reaction may be to scoff and say, “No way! Look again!”

Now, suppose you are studying cartilage defects in human knees and learn the following set of facts:

* Between 34 and 62 percent of people having knee surgery are found to have cartilage defects.

* Some 50 percent of athletes (from recreational to professional) who have cartilage defects don’t have knee pain.

* The vast majority of people with moderate knee osteoarthritis don’t have functional limitations.

What would you conclude?

Colin Hoobler, a physical therapist, connects the dots thusly in this Q&A:

“... it’s entirely possible that your knee pain isn’t caused by your cartilage defects, but something else (muscle weakness, inflexibility and/or lack of coordination).”

(A quick aside: the “lack of coordination” explanation for knee pain I find a bit odd; I’ve never encountered it before and it seems to make sense mainly if this lack of coordination causes you to fall on your knees a lot. :))

Now, if you remember back to last week, you’ll realize that on the matrix for knee pain treatment and beliefs, Mr. Hoobler probably belongs in the upper right corner (among those recommending treatment that is “Not Joint Focused”). He will work on addressing your muscle weakness, tightness and general klutziness.

That’s because, when presented with the group of facts above, he sees one picture. But might there be another picture here, if we look again?


It might be described like this:

“It’s entirely possible that your knee pain is caused by your cartilage defects, but you don’t have to get rid of them to become pain-free, as they’re actually quite common and don’t always cause problems.”

This is great news! This belief (that I didn’t have to restore my cartilage to a pristine state) sustained me during a long recovery from knee pain.

In fact, this was my thought process as I embarked on the journey:

“An MRI shows I have “mild” chondromalacia, but my knees are really crunchy and always inflamed. Any MRI is imperfect*, so maybe it hasn’t detected what’s really wrong with the cartilage (after all, chondromalacia starts with damage deep within the tissue). I’m betting the problem is with my cartilage. I can either despair -- oh no, it’s damaged and will never be perfect again -- or I can take solace in the fact that lots of people are walking around with defects and feel fine. I just have to strengthen the tissue slowly (and hopefully it will heal along the way, as it’s done in various studies). Yeah! I can do this!”

But why would some defects be painful while others aren’t? Recall that cartilage has no nerves. Hugely significant. So the tissue itself isn’t sending out pain signals, but rather nearby structures are. Pain may result when the cartilage becomes too thin or too soft or too ragged -- but it won’t be a problem with all lesions.

So when you look at your bad knees, what picture do you see?

* Serendipity! As I was writing this, along came this brief article saying that MRI exams underestimated the size of cartilage defects by 70 percent (compared with what surgeons actually found during an arthroscopy), according to one study. So that MRI that suggests you have a small problem, or no problem at all, may not be trustworthy.