Sunday, October 27, 2013

Which Supplements Work Best for Osteoarthritis?

The October issue of Nutrition Action Newsletter looked at pills that claim to reduce pain associated with osteoarthritis. As I’ve said before, I like Nutrition Action Newsletter for its level-headed, science-based analysis (its bias, if it has one, is for sensible eating and exercise and weight reduction -- and what’s not to like there?)

First, obesity was identified by an assistant research professor at University of Michigan’s School of Public Health as “the number-one risk factor for osteoarthritis.”

What’s so bad about excess weight, according to this article:

(1) Each extra pound increases the load across the joint “three to five times,” says an arthritis expert.

(2) The heavier you are, the higher your risk of injuring your joints, which can lead to osteoarthritis.

(3) Heavier people have higher levels of inflammatory chemicals circulating in their body, which can break down cartilage.

Now, what about their verdict on those “pills for pain”?

* Glucosamine

“Glucosamine doesn’t work, period,” David Felson of the Boston University School of Medicine says. Nine trials that found a benefit for glucosamine were run by the supplement industry. Still, despite the lack of evidence, Felson says if patients “think something is working and it’s not dangerous, I don’t discourage its use.”

That’s a wise stance for a doctor to take, I think.

* Chondroitin

Like glucosamine, chondroitin is an essential element in cartilage. Taken as a supplement, however, it is no more effective at relieving pain than a placebo, rigorous trials have found.

* Glucosamine and chondroitin

The combination didn’t work better than a placebo in the National Institute of Health’s large GAIT trial. At first it appeared to benefit a subset of subjects with moderate to severe pain. But, as I wrote in Saving My Knees, “this may just be a statistical anomaly.”

Yup. That’s exactly what it was. When researchers monitored the patients for two more years, they saw no benefit.

* MSM (methylsulfonylmethane)

MSM is sometimes substituted for chondroitin (which is more expensive) in supplements. In three trials, researchers question whether MSM would make much of a difference, if any, for treating arthritis.

* Avocado and soybean unsaponifiables (ASU)

The one good study from the last 11 years found no benefits for pain, stiffness or joint function.

* Vitamin D

A two-year study showed vitamin D was no better at reducing pain and slowing cartilage loss than a placebo.

* SAM-e

In half a dozen trials, 1,200 mg of SAM-e (S-adenosylmethionine) provided as much pain relief as anti-inflammatory drugs such as Celebrex or ibuprofen. However, a rheumatology professor cautions that the trials were small and characterizes the results as showing only a “small pain relieving effect.”

Then there’s the price: $80 to $110 for a month’s supply of 1,200 mg a day. That’ll put a dent in your household budget.

So, all in all, a fairly dismal showing for supplements that aim to reduce knee pain. SAM-e looks the most promising. Of course, if something seems to work for you, even if medical science says it’s useless, you might as well keep taking it.

Saturday, October 19, 2013

Beating Knee Pain: Exercise More and Eat Less

How should you try to reduce your knee pain?

Lose weight?

Or exercise more?

It turns out, not surprisingly, that the correct answer is both combined.

Researchers at Wake Forest University conducted a study that showed diet and exercise together proved “superior in virtually every outcome,” according to Stephen Messier, the lead investigator.

The 454 subjects, who were over 55 and either overweight or obese with mild or moderate arthritis of the knee, were instructed to either lose weight, exercise, or both, over an 18-month period.

Some of the findings:

* The diet group subjects (who lost an average of 20 lbs.) saw bigger reductions in “knee compressive force” than the exercise-only group (where weight loss averaged only 4 lbs.).

* Both the diet and diet and exercise groups had greater reductions in the inflammatory marker Interleukin 6 than the exercise-only group.

* The diet and exercise subjects had less knee pain, better function and better quality of life than those who only exercised.

Okay, here’s my take on all this.

Yes, it does somewhat seem like “No kidding, Sherlock” stuff, if that’s what you’re thinking. If doing one thing is good for you, and doing another thing is also good for you, why wouldn’t doing both be best for you?

True, but what I find interesting is (and I can’t be sure of this; this observation comes simply from reading some bullet points on the study’s results), losing weight may be even more important than exercise for beating knee pain (note: if you’re overweight, of course). For one, inflammation was tamed best by those subjects in the study who were either dieting and exercising or just dieting.

“Losing weight” is such a critical message to communicate to knee pain sufferers that, even though I’ve promised you all I’ll try to avoid repeating myself on this blog, on this point I’ve happily repeated myself: just go here and here and here to read more.

Also, the strategy of losing weight has a simplicity that exercising doesn’t. With exercise, there are a lot of questions that lack clear answers: What kind of exercise? How much? What if your knee hurts as you’re exercising? What if it doesn’t hurt during, but afterward? Etc.

Losing weight is comparatively simple. You’re 160 pounds. You should be 140. So lose 20 pounds.

“Simple” in this context refers to an absence of ambiguity about what needs to be done. Don’t misunderstand me. I don’t mean to imply losing weight is easy. It can be very, very difficult.

But the question is: How motivated are you? I can assure you, I was extremely motivated.

Here’s a photo of what I looked like around the time of my knee pain battle. Not a lot of fat on this frame.

But I still managed to lose about three pounds, believing that every little thing mattered if I was going to overcome my knee problems. Where there’s a will, there’s a way!

Saturday, October 12, 2013

With Knee Studies, It Pays to Read the Fine Print and Do Some Digging

Last summer, I wrote this post:

News Flash: Injections of Hyaluronic Acid May Do Your Knees More Harm Than Good.

That, at least, was the conclusion of a “meta-analysis” by Swiss researchers of 89 clinical trials that looked at the effectiveness of “viscosupplementation.” This procedure aims to bolster a knee pain sufferer’s synovial fluid, which when healthy is a viscous lubricant that acts like a cushion too. When unhealthy, it thins out and performs its essential functions poorly.

The Swiss researchers found that, in 18 large-scale trials, viscosupplementation made such a small difference as to be “clinically irrelevant.” What’s more, some studies suggest the procedure can lead to a higher risk of cardiovascular and gastrointestinal problems.

So that’s settled?

Not quite.

Along comes a new meta-analysis of 29 studies that finds “intra-articular hyaluronic acid injections provided significant improvement in pain and function compared to saline injections.” The authors of this analysis note that all products in these studies were FDA-approved, unlike in the earlier Swiss investigation.

So whose meta-analysis is correct?

Well, the most recent one has a couple of big red flags that should give anyone pause.

* Follow the money.

The end of the Business Wire release for the latest meta-analysis contains an interesting disclosure:
The meta-analysis was supported by the Hyaluronic Acid Viscosupplementation Coalition, a collaborative of hyaluronic acid injection marketers.
Hmm. That doesn’t smell good.

Let’s face it: Viscosupplementation has grown into a sizable medical business. When a meta-analysis claims that this procedure -- which a number of companies have probably spent millions of dollars developing and testing products for -- is useless, well, what do you expect them to do? Fight back.

Now it could be that the first meta-analysis got everything all wrong. Sure, that’s possible. But I’d rather that a set of neutral, disinterested researchers determine that than a couple of what appear to be Phd consultants.

And how was their meta-analysis “supported” (a lovely weasel word, with positive connotations and an utter lack of specificity)? Were they paid to do the meta-analysis? And what guidance were they given by the coalition, if any?

* Consider the source.

At least the results of the meta-analysis were published in the New England Journal of Medicine, right?

Uh, not quite.

In fact, I was left scratching my head after reading the title of the publication: Clinical Medical Insights: Arthritis and Musculoskeletal Disorders. I’ve perused lots of medical papers related to knee pain and treatments for the problem. So I’m familiar with many of the names of publications. But not this one.

Who’s behind Clinical Medical Insights (it appears a number of sister publications use this same moniker)? This is where things get interesting.

An outfit called “Libertas Academia” puts out the Clinical Insights series. It belongs to the ranks of so-called open access publishers. In theory, the concept of “open access” sounds great, especially if you (like me) have run headfirst into a paywall when trying to get a copy of the published results of a particular medical study. What’s more, the per-article rates for regular journals are invariably steep ($30 to $40 say). But with open access, the publisher makes the content free.

Great -- except where does the money come from to support such an operation? Answer: the authors seeking publication. Libertas Academia says here that it charges from $950 to $1,980 as an “article processing fee.” (Which raises a curious question: Who paid for the report on this latest meta-analysis that found positive benefits of viscosupplementation? Maybe the Hyaluronic Acid Viscosupplementation Coalition?)

If this business model is starting to make you squirm, you’re not the the only one. This writer, in reviewing nine open-access publishers (including Libertas Academia), labels them “predatory.” He explains, “Their mission is not to promote, preserve, and make available scholarship; instead, their mission is to exploit the author-pays, open-access model for their own profit.” The publishers provide “little or no peer-review,” he alleges.

Also they “spam” academics, inviting them to submit articles which sometimes aren’t even in their field, according to this frustrated researcher who said he got eight spam e-mails from Libertas Academia, despite requests to stop. Not surprisingly, open-access publications have acquired the nickname “vanity journals.”

If you’re still not convinced, check out this tale of a nonsense-filled, spoof academic paper submitted by a Science magazine editor to open-access journals. More than 100 accepted it despite errors so blatant, “Any reviewer with more than a high-school knowledge of chemistry and the ability to understand a basic data plot should have spotted the paper's short-comings immediately.”

Anyway the point here:

Just as not all knee studies are created equal, so all meta-analyses are not either. Caveat emptor (or whatever the “patient beware” version of that Latin saying is). Viscosupplementation may help your particular knees, true. But be wary of “research” supported by makers of the products. They may not be the best neutral source of information, to say the least.

Saturday, October 5, 2013

Why I Conducted the Knee Experiment I Did

The most valuable part of my story about healing my knees is this, I think:

I devoted one year of my life to an intensive, well-documented experiment to “save” a pair of knees that a doctor grimly informed me were beyond saving.

I was so serious about this experiment that I even quit my full-time job (sitting too much was one of the obstacles to healing, I had discovered).

Why did I do all this?

Chiefly, for two reasons:

(1) I wanted to prove that doctors (and others) who say damaged cartilage and joints can’t heal are just plain wrong.

(2) I wanted to prove that the right way to heal was not to worry about your muscles (at least not initially), but to focus on easy, high-repetition exercises that your joints like (this is an approach I took directly from the writings of Doug Kelsey at Sports Center).

And here I am, some five years later, with two knees that feel perfectly normal.

The fact that I had success, bucking conventional wisdom, made me want to shout my story from the rooftops (hence the book and the blog).

But let me be clear about what that one-year experiment meant, as I see it. It wasn’t “You too can heal your bad kness if you quit your job and do exactly what I did.”

I see it more like “proof of concept.” I went to extremes (quitting my job, manically counting the steps I took, keeping a highly detailed knee journal) to show bad knees can heal naturally.

That doesn’t mean you can’t heal yours unless you quit your job and log every step you take. Rather, it means, simply, that healing is possible -- and I would argue, the right program is one of light-load, high-repetition motion. As for the particular details of what you need to do, well, that depends on your particular knees, doesn’t it?

I realize that’s frustrating for some people to hear. Many knee pain sufferers want a specific blueprint for getting better: what kind of exercises, how many of each, how many times a week. I don’t offer a blueprint, but rather an outline into what matters -- and the insight into why I think it’s important.

Knowing you can get better -- that the pessimism and negativity and “surgery is your only option” attitudes are wrong -- isn’t that a great message?