Saturday, December 28, 2013

Popular Knee Surgery Works No Better Than a Placebo

Couldn’t resist writing this one up. The results of the following study have been making the rounds lately, in publications from the Wall Street Journal to the New York Times:
A popular surgical procedure worked no better than fake operations in helping people with one type of common knee problem, suggesting that thousands of people may be undergoing unnecessary surgery, a new study in The New England Journal of Medicine reports.
Specifically, researchers wanted to know about the effectiveness of arthroscopic surgery for patients with a torn meniscus, a crescent-shaped wad of cartilage in the knee. The operations are very common. About 700,000 are performed in the U.S. yearly, at a total cost of $4 billion.

But how much do they help?

A Finnish study set out to find the answer: 146 patients, from age 35 to 65, who had wear-induced tears of the meniscus and knee pain (but apparently not arthritis) took part. About half had mechanical issues such as locking or clicking in their joints.

The last-minute way that subjects were directed into one of the two groups was kind of cool:
Most patients received spinal anesthesia, remaining awake (one hospital used general anesthesia). Surgeons used arthroscopes to assess the knee. If it matched study criteria, nurses opened envelopes containing random assignments to actual or sham surgery. In real surgery, shaver tools trimmed torn meniscus; for fake surgery, bladeless shavers were rubbed against the outside of the kneecap to simulate that sensation. Nobody evaluating the patients later knew which procedure had been received.
Then, after a year ...

Each group reported a similar improvement. (That sound you just heard was billions of dollars flushing down the U.S. health care toilet.)

Of course the New York Times quotes surgeons defending the procedure for certain patients. And of course the surgeons have a point: for certain people, especially those who are young and in much pain from a major tear in the tissue, surgery is no doubt the best option -- maybe the only option.

But always remember: Surgeons are part of their own SIG (special interest group). They have been trained in, and have acquired expertise in, the act of performing surgery. They make their money doing so (not exclusively, true, but still, the honest, thoughtful ones realize the conflict this leads to).

It’s like when a member of the Avocado Growers Association says more Americans should be eating avocados -- for their health, of course.

So Frederick Azar, first vice president of the orthopedic surgeons academy, not surprisingly finds grounds to dismiss the study's results. He tells us he operates mostly on patients outside the study's purview, who have mild to moderate arthritis and meniscal tears that appear to be painful.

He might be wise to take a glance upstory at Dr. Kenneth Fine, an orthopedic surgeon also quoted. Of 100 people with knee pain, Fine says, a “very high percentage” will also have a tear in their meniscus. He goes on:
People love concreteness: ‘There’s a tear, you know. You have to take care of the tear.’ I tell them, ‘No. 1, I’m not so sure the meniscal tear is causing your pain, and No. 2, even if it is, I’m not sure the surgery’s going to take care of it.'
That’s the kind of wisdom we need more often.

Oh, did this news seem kind of, well, familiar to regular readers here?

If so, you may be remembering this post from May in which I reported another study showing that this kind of surgery was ineffective. For that study, the patients did have arthritis.

Now that we’ve covered the arthritis and non-arthritis sufferers, casting doubts about the usefulness of the procedure generally, maybe we can finally shave a billion or two off that annual $4 billion medical bill.

Sunday, December 22, 2013

Happy Holidays

Best wishes from me, Congyu, Joelle and Elliot!

This is my annual "Merry Christmas" (or whatever holiday you celebrate) post.

I hope everyone out there is finding some success in healing their bad knees. What I can tell you (from my own experience) is that it's incredibly slow, and that's even if you're doing everything right.

The right attitude, and a spirit of determined optimism, help tremendously. The holidays are a good time to gather strength from friends and family and to vow to renew lapsed commitments (you know, you planned to start a movement program, but then things kind of happened, and you only half-heartedly followed through).

And, after a few guilty swigs of eggnog, you might think again about weight loss as a way to reduce knee pain.

There's a lot that knee pain sufferers can do! Damaged knees don't have to be forever. That's my message.

Well, that, and have a great week everyone. :)

Saturday, December 14, 2013

Time to Hit the Bottle to Banish Knee Pain?

Okay, this week we go a bit tongue in cheek. For all you boozehounds out there, I got this comment recently:
I don't mean for this as a cure of PFPS (obviously) but has anyone else noticed a remarkable reduction of symptoms after consuming (small/moderate) amounts of alcohol. The effect seems to last for at least a day after consumption!
This comment brought to you by the Whiskey Distillers of America!

Seriously, is there any reason for alcohol to have such a happy effect on someone’s grumbling knee tissues? I think there are in fact two good reasons (though I’m doubtful either would last for an entire day after one stops imbibing -- so it’s possible that there’s something completely unrelated going on with this guy).

For one, alcohol dulls all sensations. Sometimes drunk people walk into walls and hardly feel the impact. Now, the comment made reference to “small/moderate amounts of alcohol” -- so that’s not getting blotto clearly -- but the nerve-deadening effect of alcohol would just be played out on a smaller scale.

Now, that’s the more obvious reason -- which I’m sure the commenter has already taken into account. The not-so-obvious reason is the one I find more interesting.

Alcohol relaxes you. In doing so, it relaxes muscles. And some of those looser muscles naturally belong to your upper legs.

Why does that matter? Knee pain while seated (the so-called “moviegoer’s sign”) is a hallmark symptom of patellofemoral pain syndrome. What’s happening typically is the cartilage in your knee joint isn’t strong enough to handle the additional force that comes with bent-leg sitting. You wouldn’t think merely sitting is that physically stressful. But it’s enough to send weak knees over the edge.

If you want to increase that pain, just tighten those thigh muscles -- through stress or nervousness or whatever -- and that will pull your kneecap a tad closer to your underlying femur, which should increase your discomfort. However, if you relax, by having a drink (or two or three), the opposite should occur: a lessening of symptoms.

I think this is the same reason that stretching feels good. You loosen muscles and take pressure off that sensitive junction where kneecap-cartilage-femur meet.

In my opinion, neither stretching nor having several Corona Lights is really a lasting solution for knee pain. But might they be good for temporary relief? Could be.

Saturday, December 7, 2013

The Final Word on Glucosamine and Knee Pain

That, at least, was what one reader sought in a recent question to the New York Times’s Gretchen Reynolds, for her Ask Well column. He was understandably confused.

While his orthopedic surgeon scoffs, “Don’t waste your money,” a physician’s assistant swears that “I couldn’t get in the car and drive to work in the morning if I didn’t take glucosamine for joint pain.”

I’ve written a few times about glucosamine: here, here, here and most recently here, for starters. Today I thought I’d take a deeper dive on the subject, on a molecular biology level, because that’s where things truly get interesting.

I first became skeptical of glucosamine’s efficacy when it did nothing for me when I had constant knee pain. I took the supplement daily for months. No perceivable benefit. None. At. All.

I didn’t research glucosamine intensely though until I was well into writing Saving My Knees, which was my ambitious quest to rectify what I thought was a lot of wrong-headed information about treating chronic knee pain -- including the pernicious notion that bad joints could never heal. That just wasn’t true, and I was living proof.

At some point, I became aware of a massive, well-run trial, the results of which were published in the New England Journal of Medicine in 2006, that found glucosamine and chondroitin sulfate don’t work. Well, the study did show a benefit for those with moderate-to-severe pain who took both supplements. However, a doctor specializing in biostatistics quoted by the New York Times at the time said, “This is a spurious subset result if I’ve ever seen one.” He turned out to be correct -- the “advantage” for this subgroup washed out on further examination.

So glucosamine is a dud, right? Case closed?

It sure seemed that way to me. Didn’t help me. Didn’t help subjects in a large, well-conducted clinical trial. Sure, some people claim they can’t function without it. But some people would probably report less knee pain if you gave them “magic Ritz crackers” that they really believed were magic. Plus, why is it that glucosamine advocates claim to get relatively fast relief from a supplement that’s supposed to be restoring their cartilage, which is a long-term, months-long process?

But I’m a curious guy. I wanted to know exactly where the glucosamine story broke down. And where the story broke down, it turned out, was where glucosamine itself broke down.

To wit (and now I’m going to start quoting, so you can follow my journey of discovery better):
Orally ingested glucosamine “appears to undergo a significant first-pass effect in the liver, which metabolizes a significant portion of the dose to CO2, water and urea.” (Source: “Arterial Smooth Muscle Cell Proteoglycans Synthesized in the Presence of Glucosamine Demonstrate Reduced Binding to LDL” in Journal of Lipid Research)
Uh oh. That doesn’t sound good. But what does that mean in practice?

Fortunately, there's a clinical study that shows us: 18 subjects, all with osteoarthritis, took 1,500 milligrams of glucosamine sulfate. Then their blood was drawn at periodic intervals. The concentration of glucosamine peaked from 90 minutes to three hours after the supplement was taken, with the amounts ranging from 1.9 to 11.5 micromoles.

From an article summarizing the results:
At best, some patients had about 11 micromoles of glucosamine circulating in their blood several hours after taking the pills. Yet previous studies suggest that it may take glucosamine concentrations of about 10 times that amount to rebuild cartilage. Even at the highest concentration, the typical supplement would contribute only a small percent of the glucosamine needed to build stronger joints.

Taking higher doses of these supplements might increase glucosamine levels to the point needed to fight arthritis, but ... getting too much of this sugar may raise the risk of diabetes.
One of the study’s researchers, Timothy McAlindon, said patients were probably safe using small amounts of glucosamine, while tartly concluding, “The main injury is primarily to the wallet.”

That’s a damning comment, certainly. But there’s more. In 2009, Jeremiah E. Silbert wrote “Dietary Glucosamine Under Question” in the journal Glycobiology. Up front, he makes clear his credentials, “Our laboratory has focused its work on glycosaminoglycan metabolism for many years.”

Warning: His article is technical and dense -- about what you’d expect from someone who speaks chondroitin sulfate cellular biosynthesis as a second language. I struggled with a number of paragraphs, but even so, it was clear that he wasn’t impressed by the idea of popping glucosamine pills.

For one, the glucosamine is diluted hugely:
We found that the radioactive glucosamine [externally introduced] was diluted many fold by glucosamine formed from glucose [naturally occurring] ... dilution by glucosamine derived from glucose was 160- to 635-fold.
At the low levels that glucosamine is found in the bloodstream, it appears to be useless, unfortunately:
We have concluded that insignificant trace amounts of glucosamine enter human serum after ingestion of a standard oral dose of glucosamine sulfate or glucosamine chloride (1500 mg), far below any amount that might contribute directly to chondroitin synthesis. Moreover, this level is limited to a few hours after ingestion, with no establishment of any substantial lasting concentration. It is far below most of the concentrations used for in vitro cell or tissue culture incubations by others, usually for days or weeks, in proposing mechanisms to protect chondrocytes, inhibit chondroitin degradation, diminish inflammation, or provide imunosuppression in articular cartilage mechanisms ... Until consistent actions on cartilage can be demonstrated at the low concentration and limiting time periods that we found, claims of a meaningful direct effect on cartilage or chondrocytes are questionable.
And, at the conclusion, he sounds a warning note that the supplement may not even be as harmless as portrayed:
There were statistically significant glucose elevations with glucosamine ingestion by three subjects who were found by the glucose tolerance test to have previously undiagnosed diabetes. This is the first time that results of this sort have been found with diabetics that were not under treatment and warrant further investigation.
So there you have it. Way more than you ever wanted to know about glucosamine, on a microscopic cellular level.

What then should be the final word on glucosamine? You’re probably expecting me, like the orthopedic surgeon earlier, to scoff and say, “Don’t waste your money! It flat-out doesn’t work!”

I think that a wiser final word comes from the Ask Well column when a doctor observes that at recommended doses, glucosamine is generally safe and some people do say they benefit, so he tells patients “it’s up to them” if they want to buy the supplements.

But he also advises people to keep their expectations low. “In my experience, most people do not benefit.”

Sounds like a good final word to me.