Saturday, September 28, 2013

On Hope, and One Reason I Write This Blog

I got a really neat comment recently (edited a tad for length etc.):
I stumbled upon your book whilst spending hours online searching for advice on chronic knee pain. You have given me a sense of hope I had all but lost. I have recently been told I have irreversibly damaged the cartilage in my knees, told there is nothing I can really do, advised to take glucosamine and to strengthen my quads with exercises I cannot possibly contemplate at the moment. It seems such a relief to hear your story.

I am in the depressed, downward spiral of thinking that, at the age of 41, is this it? How am I going to live like this when even climbing a set of stairs is a challenge? I used to thrive on exercise and being active. To have this unwelcome change in my lifestyle has been extremely difficult to cope with, especially as I have two young children and a wonderful husband I want to be enjoying life with. I just want to thank you for taking the time and effort to share your story. You have given me a glimpse of a hope I had all but lost and well-balanced, well-researched advice I am going to attempt to follow. I know the road is very long with many likely falls along the way but to hear that it can be done inspires me in a way I haven't been for some time. Thank you.
Wow. Thank you.

Sometimes, I confess, I feel a bit remote from this blog. Namely: I had chronic knee pain. But I managed to fix it. And the memory of the hole I was in has started to recede.

Then, every once in a while, I get an uplifting, heartwarming comment like this that says to me:

There are millions of people out there who are going through what you once did. They’re scared too, trying to figure out what to do. Some are over 40, as you were, and maybe they too were essentially told, “Ah, you’re just getting old; learn to live with the pain.” Many are getting the same bad advice you did (such as to focus on “strenghtening the quads” when, as Doug Kelsey of Sports Center notes, “having stronger muscles is helpful but weak muscles are not the primary problem”). So don’t stop spreading a message of hope!

I still recall a phone conversation I had with my father, back when I was living in Hong Kong, trying like hell to heal my bad knees -- and succeeding.

My voice was shaking with anger. I was talking about my experience with my knee doctors. I was most upset with them because, after a physical exam would reveal no major structural problems, each would more or less shrug when asked what could be done about my knee pain.

Of course one said that sometimes patients with knee pain get better, sometimes they don’t. So I followed up with what seemed like a logical question: Why do some get better? But he wouldn’t answer.

Later, thinking about that scene, I got irritated. Hell, if I was a knee doctor, and my mission was to heal, and some of my patients improved while others got worse, I’d be lying awake in bed every night, thinking:

Why? What are the ones who heal doing differently? Or what’s different about them?

One of the most inspiring messages I got from Doug Kelsey early on was this response to an imaginary comment from a doctor:
"Well, you have arthritis. Your knees are just wearing out and there's really not much you can do about it."

Hogwash. Hooey. Balderdash. It's just nonsense.
Kelsey's rejection of the gloomy fatalism that bad knees will be bad knees, and only get worse if anything, was for me very encouraging. It helped convince me that I could heal. And I did.

Taking away hope, wrongly, from a suffering patient is a terrible thing to do.

Saturday, September 21, 2013

Wedge Shoe Inserts: Another Dud for Those Seeking Knee Pain Relief

One purpose of this blog is to celebrate what medical science shows works for knee pain while deprecating what doesn’t. (Note: with the caveat, of course, that even treatments/supplements/devices that have failed to withstand the withering scrutiny of scientific researchers will still have adherents who swear that “X” helps for their particular knees, science be damned.)

In that spirit (my addition in brackets), note the lead of this article:
Lateral wedge shoe inserts don’t appear to relieve knee pain in patients suffering osteoarthritis of the knee [that happens to be on the inner part of the joint], a new study finds.
Now, this wasn’t just any old study. Rather, it was the more powerful variety: a “meta-analysis” of existing studies. Such a review is potent, when done well, as those conducting it can choose to discount or disregard studies that are somehow flawed, leaving them to analyze the highest quality data. So the findings of a meta-analysis generally should carry more weight.

Why in the first place did anyone think lateral wedge shoe inserts would relieve knee pain?

Well, the thinking goes like this:

A wedge for the outer part of the foot will reduce the load on the inner part of the foot (and hence the inner part of the knee joint). Simple enough. And not such a far-fetched notion. It reminds me of the argument for kneecap taping to remove some stress from the injured area.

But when the researchers evaluated 12 studies involving 885 subjects, they found no proof that lateral wedges, inserted in shoes, were effective for knee osteoarthritis. So now you can save $10 to $500 (the price for wedges, from the cheapest off-the-shelf insoles to an expensive customized pair).

However, it may still make sense for doctors to recommend the inserts on a “case-by-case” basis, says Robert Shmerling, an associate professor of medicine at Harvard Medical School. “Even though the average response was no different between wedge insole users and non-users, individual response can vary.”

Yup. I’m a science-minded guy, but he’s got a point. Treatments that don’t work for 99 percent of us may work for some people in the other 1 percent.

For example, evidence is building that glucosamine is probably ineffective, yet some people still claim to be unable to function without it. I recently complained about physical therapists who prescribe one-legged squats for weak knees, which I think is pretty stupid, but a commenter said doing one-legged squats fixed his ailing knees. If someone were to advise knee pain sufferers not to do jumping jacks while wearing a backpack full of lead, I’m sure someone else would protest that he healed his bad knees by doing jumping jacks while wearing a backpack full of lead.

When it comes to ways to beat knee pain, it just goes to show you can never say never.

Friday, September 13, 2013

The Treadmill Desk, and the Importance of Motion

There was a cool article in the New Yorker earlier this year titled “The Walking Alive” by Susan Orlean.

It was about what appeared to be a small movement in the workplace to ditch the traditional sit-down desk in favor of moving while working.

The centerpiece of the article, the “treadmill desk,” isn’t a piece of heavy-duty cardio equipment. You walk at a pace of only one to two miles an hour, so you shouldn’t be laboring for breath or having trouble typing while at your “walking workstation.”

The first official treadmill desk was introduced by Steelcase, an office furniture company, in 2007. It costs more than $4,000. Other manufacturers include TreadDesk, TrekDesk and Exerpeutic.

Dr. James Levine -- who specializes in “inactivity studies” -- helped design the original Steelcase model. Levine, the article tells us, began thinking about walking back in 1999, after he did a study at the Mayo Clinic.

The study looked at why some people gained weight while others didn’t, even when they ate the same amount (and presumably “exercised” the same amount too). The subjects were observed with what Levine refers to as “an atrocious amount of detail.”

A curious finding was made. The non-weight gainers did move more than the others, though in subtle ways. They fidgeted, jiggled their legs, paced, stood on the balls of their feet. All this quiet restlessness burned as much as 800 calories a day!

So the treadmill desk puts sedentary office workers into motion. Why that matters is beautifully captured in this passage about the harmful effects of sitting a lot.
Sitting puts muscles into a sort of hibernation, cutting off their electrical activity and shutting down the production of lipoprotein lipase, the enzyme that breaks down fat molecules in the blood. Your metabolic rate drops to about one calorie a minute -- just slightly higher than if you were dead. Sitting for more than two hours causes the presence of good cholesterol to drop, and, in time, insulin effectiveness plummets. This can lead to cardiovascular problems, certain kinds of cancer, depression, deep-vein thrombosis, and type-2 diabetes.
I like the idea of the treadmill desk, partly because it’s easy motion. Easy motion, small steps, light loads on the joints -- all seem smart to me.

Now, is a treadmill desk a good idea if you have chronic knee pain?

Maybe, but I’m guessing probably not.

The desk may be a good idea to prevent chronic knee pain, but when you already have it, too much movement can overwhelm tender joints. I recall my own experience in Hong Kong when I realized that motion was critical to healing bad knee joints. I tried moving pretty much nonstop: shuffling along, walking for hours. And my knees got worse.

Still, I really like the idea of the treadmill desk. Get off your butt. Start moving. And meanwhile, get all the desk work done that you need to.

What’s not to like? And if the price tag is too daunting, the New Yorker tells us that a number of Web sites offer instructions on building your own model, using an ordinary treadmill and IKEA components or even milk crates and doors.

Saturday, September 7, 2013

When Doctors Don’t Give You the Information You Really Need

A personal story:

My wife recently took our son Elliot (the latest addition to the family!) in for his two-month checkup. The pediatrician pronounced him healthy, then out came the needles. The two-month checkup could be called the Vaccine Barrage: he got a total of four.

Congyu received a four-page document titled “Your Baby’s First Vaccines.” It contained a lot of information: how vaccines work, which diseases they prevent, when children should get routine vaccines, the various risks of different ones.

The handout also included this:
Most vaccine reactions are mild: tenderness, redness, or swelling where the shot was given; or a mild fever. These happen to about 1 child in 4. They appear soon after the shot is given and go away within a day or two.
The pediatrician told my wife (I was at work at the time) that our son might develop a fever later that day.

Then she left the doctor’s office, missing at least one crucial bit of information.

Can you spot it?

Hint: It has to do with that fever.

Give up? Okay, here it is:

If he does have a fever -- which appears to be not uncommon -- at what point should we be concerned? And here, I’m talking about a real, concrete number. 100? 101? 102? 103? 104?

After all, some children have severe allergic reactions to vaccines, with dangerous fevers that can spike to 105. Also, Elliot is at an age when what would be a “mild” fever for an adult is considerably more serious. Plus, Congyu said that after giving birth, and before her discharge from the hospital, a doctor told her that a temperature exceeding 100.4 degrees was very dangerous for our small child.

I think you can tell where this is going.

Sure enough, that afternoon his temperature was elevated. That evening, a rectal reading (which is regarded as the most accurate way to measure) indicated he was running a fever of 100.9.

So, as concerned parents, what should we have done? Should we have heeded the warning of that first doctor who somberly informed Congyu that a temperature of more than 100.4 was very bad for an infant? Or should we have just accepted that Elliot had a fever, as was predicted, and it was no big deal? Might it be that a 100.9 degree virus-induced fever was a matter of concern, but not a vaccine-induced fever at the same temperature?

How could we know? We were never told.

So we did what most responsible parents would do: We called our pediatrician’s 24-hour help line. The doctor on call heard me out, as I related the details of my son’s condition, then told me not to worry. If we wanted to bring down the fever, we could give Elliot a lukewarm sponge bath, or a small amount of children’s Tylenol (which, incidentally, are other helpful details that we never got -- what to do for the fever, if the child has one).

So there you have it: A four-page handout, a doctor’s advice ... neglecting a critical piece of information -- the actionable “what do I do if a certain condition exceeds a certain level”? Because if I had called that help line, and told the doctor my son’s temperature was 103, or 104, I bet I would have gotten a different reaction. Because clearly the doctor had some (undisclosed) algorithm at work in his head that went like this, “A fever of less than X, just tell the patient not to worry.” What was the magic number X though?

Again, we were never told.

Now what does this have to do with bad knees?

Have you ever been to a doctor who, after examining your knees, recommends that you “avoid activities that cause pain.”

You nod. Sounds sensible. Then, sometime after leaving, you start to wonder: “What the hell does that mean exactly?”

Does he mean just intense pain? What about the mild pain you experience from climbing stairs? And if you have to avoid climbing stairs, what do you do exactly? Or what about if you don’t have pain during an activity, but immediately afterward? Or what if you don’t have pain until the next day?

Granted, these are harder questions than, “At what temperature should I seek medical help if my two-month-old child has a vaccine-induced fever?” But they’re some of the most important questions facing patients whose knees hurt all the time.

Back when I had bad knees, I don’t recall ever getting any good guidance from doctors on how best to “avoid activities that cause pain” while going about my everyday life. That’s a shame. Whether it’s this sort of information -- or specific advice about when to be concerned about vaccine-induced fever in a young child -- I think physicians can do better.