Happy New Year, Everyone!

It’s that time of December again, when we take stock of the year that was and start to dream of the possibilities of the year ahead.

I’d like to take a moment to thank the readers of this blog (and the book). My plans, at least for now, are to keep blogging at least semi-frequently until the book sales taper off. I think it’s nice for people who read Saving My Knees to find me online and active.

The book arose from frustration: doctors, I think, are unduly pessimistic about the ability of bad knees to heal, when given time and the proper treatment. I showed it was possible with my own knees (“proof of concept” to validate a hypothesis). My knees are normal today.

The book also arose from anger: after extensive research, I became upset at what physical therapists thought was the “proper treatment” for my knees, and disappointed in my doctors – who I felt should have known better – that they condoned this protocol.

Anyway, I’m not trying to hog the spotlight today. I really wanted to make this an appreciation of you readers, especially those people who share comments and insight on this site. I didn't write the best-selling knee book, but I think I’ve got the smartest readers. ;)

I’ll take that.

Why I’m So Optimistic About Cartilage Healing

I figured I’d tackle this one straight-on today.

First things first: No, the holes in your cartilage don’t have to heal for your knees to feel better. This is absolutely not a prerequisite. There are many people walking about with cartilage defects and no knee pain. That’s not a bad club to be part of. After all, you just want to be rid of knee pain, right? Who cares if your cartilage is as smooth as a baby’s bum?

Second thing: I am occasionally asked if I have a follow-up MRI in my possession to prove that my cartilage did, indeed, heal. See my post here about why, no, I haven’t done this and why I don’t think it matters much anyway.

Another reason it doesn’t matter much: there appears to be much stronger evidence out there than a single MRI from yours truly. That takes us back to the original point: Why do I think cartilage can heal?

Take a good hard look at the table below. I copied it from a study, “Factors Affecting Progression of Knee Cartilage Defects in Normal Subjects Over Two Years.” The 86 people who participated had MRIs done of their knees at the start of the study, then two years later. (Yes, these were “healthy subjects,” but I’ve seen another study that includes knee pain sufferers that came to similar conclusions.)

The condition of each subject’s cartilage was graded for five different knee compartments. The scoring again goes like this:
Grade 0 = normal
Grade 1 = focal blistering
Grade 2 = irregular surface and loss of thickness of less than 50%
Grade 3 = deep ulceration with loss of thickness of more than 50%
Grade 4 = full-thickness wear of cartilage with bone exposed

Now look at that table. I’ve color-coded it in a way that I hope enhances readability. Let’s consider the the 14 defects that started out as Grade 3. If cartilage simply wears away, and that’s the end of story, you would expect their follow-up grade to be either 3 or 4.

But what actually happens? Yes, three of them stay at Grade 3, and five worsen to Grade 4. Yet four improve to Grade 2, and two of them – one in seven – improve all the way to Grade 1.

Yes, the sample sizes are small. Still, the pattern is repeated elsewhere (the extremes, at Grade 4 and Grade 0, suffer from the floor and ceiling effect, of course). Look at the 88 defects that started out as Grade 2. A full 31 percent of them, or almost a third, improve to Grade 1.

Yes, there are valid questions to raise. What is the nature of this new cartilage? Is it weaker fibrocartilage (actually, another researcher has found that though new cartilage starts out that way, over time it begins looking more like regular hyaline). Also, could there be misreading of results? (My take: yes, probably some, but I doubt on this extensive a scale.)

To me, this constitutes very interesting, and compelling, evidence that cartilage changes are a two-way street. Cartilage doesn’t just get worse. It’s always getting worse and getting better. And if it can get better, then why not try to enhance that ability? (Note: this was a “natural” study, meaning that some subjects saw positive changes in the tissue, and they weren't even on a special regimen!)

Taking the Big Leap: It’s Not an Easy Call

Every so often I like to mix into this blog something both personal and current. How’s this: At the end of September, I got laid off in a restructuring.

It happens. If you’re a little older and experienced, it happens more often.

But, as readers of my book may realize, I take a perverse pleasure in proving wrong the people who underestimate me. Orthopedic doctors in Hong Kong didn’t think my knees would get better. After extensive (and obsessive) research, I found what I thought was lots of evidence that they were dead wrong.

It took me many months, with much detailed record-keeping and experimenting and patience, but in the end, I healed. My knees returned to normal. This became the greatest achievement of my life, and nothing else is really even close.

Today I wanted to revisit a hard decision I made, now that I find myself among the ranks of the unemployed again. Early in 2008, I made up my mind to quit my job in order to try to heal my knees. Sitting at work with bent legs was impeding my effort to heal, because my knees were constantly inflamed.

First, let me make something clear: I could never advise another knee pain sufferer to quit his or her job. That’s a very individual decision. It’s also a calculated gamble. Had I never managed to heal, I would have found myself unemployed, and maybe even unemployable.

But if you’ve got chronic knee pain, it may be worth considering. If you do, here are some questions worth asking yourself:

• How much do activities that I must perform at work worsen my knee pain? Those “activities” can even be non-activities, such as sitting. Or maybe you’re roaming a warehouse eight hours a day, fulfilling Internet orders. Or maybe you’re dealing with a crushing amount of stress.

• Do I have any evidence that my knees will improve if I devote myself to healing them? Do you have a good feel for what your knees like and don’t like, and what kind of program will provide the kind of nourshing motion that will enable them to get better?

• If I leave my job, what support do I have? Financial support could be savings (and you’ll want to calculate how long it will last). Emotional support could be friends and family.

• How hard will it be for me to rejoin the workforce in six months, or even a year? Clearly, some of this depends on factors beyond your control, such as the job market, but certain high-demand professionals may find it easier to transition back into full employment.

• What are my goals, in terms of healing, before I rejoin the workforce? And, if things don’t go well, when do I give up and either live with the pain or turn to pain medication or surgery? It’s good to have goals before you set out on what could be a challenging journey.

• Is there a way for me to keep working, but only part-time? If you recall, in Saving My Knees, I proposed an experiment, with my doctor's support, to try to rehabilitate my damaged knees. My employer agreed, but unfortunately, the experiment was too short. Still, it did prove to me that I was on the right track with my thinking.

Again, it’s a difficult, courageous leap to take, and not for the faint of heart. It may be worth it for you, or it may not be. I can’t decide that for you. Only you can.

Inflammation and Knee Pain, One More Time

I’ve already touched on renegade inflammation and knee pain a few times, such as here and here.

But the subject of inflammation and knee pain is intriguing enough, and relevant enough (and what’s been found lately is also contrary enough) that it deserves plenty of space.

Take this article, now two years old:

Knee osteoarthritis should no longer be thought of as a "noninflammatory" condition, as inflammation associated with synovitis or effusion plays a bigger role in worsening pain than mechanical load, according to a new report from the Multicenter Osteoarthritis Study, published online November 10 in Arthritis & Rheumatology.

There were 1,111 people in the study, aged 50 to 79 years, who either had knee osteoarthritis or were at risk for it. Initially, 21 percent of the subjects reported frequent knee pain.

One of the doctors involved noted an unexpected result:

I was surprised that we found no relation of bone marrow lesions to pain sensitization because one of our hypotheses, based on animal models, is that mechanical and/or inflammatory lesions can lead to sensitization.

What was related to “sensitization” instead? Synovitis, or inflammation of the synovium.

Oh, another interesting finding that has grim implications:

The authors suspect that once sensitization has occurred, just cooling the inflammation might not be enough to correct it.

So what’s the takeaway? Trying to quell inflammation early may be smart, the researchers suggest:

[Their findings] do suggest that early targeting of inflammation might reduce sensitization ... Preventing the altered neurologic processing of nociceptive signals that usually occurs in OA might also prevent the progressive worsening of pain.

Looking for a Bionic Knee Brace? Read on.

I saw this story last year and bookmarked it. It’s knee-related and kind of fun:

A pair of Nova Scotia researchers are close to producing a "bionic" knee brace that enhances ability and reduces fatigue, and have now landed a lucrative contract to produce a beefed-up version for the Canadian Armed Forces.

Production has indeed started on the “Levitation brace” (I found it selling online for $1,999). The device is a bit pricey, but knee braces are one decent option for bad knees:

The civilian product . . . is intended for athletes going through rehabilitation, workers needing to alleviate knee stress and fatigue and older people with worn-out knees.

It turns out the brace’s inventors know a little about suffering with knee pain:

Both men had knee issues. Garrish (Bob Garrish, the company’s chief tech officer) suffers from osteoarthritis in both knees, and Cowper-Smith (Chris Cowper-Smith, the company’s CEO) was suffering at the time from anterior knee pain, which is also known as runner's knee.

The military application is rather interesting. The brace would help soldiers who are often crouching and standing while wearing packs up to 120 lbs. Also, the company is looking at making a special version to absorb the high-impact stress when paratroopers drop out of planes.

I’m a big fan of devices/tricks to unload bad knees. Has anyone used a brace – probably not this one, but something simpler? How well did it work?

Open Comment Forum: How Does Diet Affect Your Knee Pain?

Well, it’s about time again for an open comment forum. So, below in the comments section, please talk among yourselves. I’ll keep my piece short.

If you’re looking for a topic, here’s one: how have you found that diet affects your knee pain? This is something that interested me during my recovery. I read a lot about foods that supposedly help damp inflammation. Readers of my book know I ate a lot of garlic because of its reputation as a supercharged anti-inflammatory.

In the end, I’m not sure it did much, or anything. But that’s not to say diet was totally uncorrelated to my knee pain. I noticed a slight negative effect when I gorged on saturated-fat-heavy food, such as pizza.

So what’s your experience been? Please comment below. Or feel free to discuss whatever you want to, or just introduce yourself to everyone.

Happy Halloween!

Karen’s Success Story: Cycling with a Twist

I recently fished a recovering-by-bicycle story out of the comment section. I love it because it shows how a little ingenuity can take you a long way, and Karen’s attitude is definitely that of a winner. Here it is below, with light editing:

"About two years ago I began experiencing pain in my knees going up and down stairs after workouts. It gradually got worse until I decided to see a doctor. I received X-rays, two cortisone shots and the knowledge that I don’t have arthritis. (I used to work out regularly three to four days a week.)

"I pouted around, got depressed, gained 20 pounds and about one year and a half later finally started seeing a trainer to help me get back in shape. It was very, very slow progress, but after about six months I was able to go up and down stairs without pain. However, the workouts began to get increasingly frustrating because the strength-training exercises pretty much all hurt. Squats were terrible. My trainer was really positive and kept trying to motivate me, but it seemed like everything he tried hurt.

"So I quit and started reading up on knees and ran across your blog.

"Last fall, my husband and I first saw pedal-assist electrical bikes all over Europe. I tried riding a bike when my knees were at their worst and couldn’t. But I tried a stationary bike again and this time had NO problem whatsoever! So my husband and I walked into the bike store and I walked out with a Trek Lift.

"Without sounding corny, it has changed my life. I ride my bike every day I can. I feel normal again. I feel like I’ve actually worked out. My husband and I used to ride together, but stopped due to my knees. Now I leave him in the dust! He loves it because I push him to ride harder and he sometimes even drafts off me. LOL!

"I’ve found that I use the motor the most on very steep hills, when I need to push off at a stop sign, or cross the road quickly. The bike feels best for me in the “ECO” mode in a middle gear. It has the smoothness of a stationary bike and I'm still working to pedal. Plus all the fun of riding outdoors. The best part is that my knees feel better than ever! (My knee problems stem mostly from pressure on the knees, for example: hopping up and down on my toes. But luckily, I’ve never had any problem walking.)

"I wanted to share my cycling SUCCESS story and maybe it will inspire someone else to give a pedal-assist bike a try. Thank you for sharing your success stories too!"

Thank you, Karen! Anyone else want to share a success story? Just drop it in the comment section. Success stories are always in vogue!

The Great Lie in the U.S. Health Care Debate

I want to talk about something a little different today. If you're an American with bad knees, yes, it affects you – but it also touches the lives of many millions more than than that.

I want to talk about the great lie in the debate about U.S. health care.

First, this isn’t about Democrats, Republicans, Democans, Republicrats, whatever. Personally, I’m an Independent. I think both parties have become corrupted by money, but that’s a subject for another day, and another blog.

The great risible lie is this: U.S. health care is a free market that people choose or choose not to be part of, and like other free markets, the solution to our current woes – millions of uninsured, soaring drug prices, unaffordable insurance, etc. – can be found simply by unshackling market forces.

This is ludicrous.

Look, if I walk into a Honda dealership, and demand an Accord for free, the salesman (if he’s not laughing too hard) will point me to the door and tell me to get lost.

Sales of autos operate well within the free market model. There are competing dealerships; comparison-shopping isn’t hard to do; a Honda Accord buyer who doesn’t find the deal he wants can substitute a like product (a secondhand Accord, or another model from a different carmaker) to satisfy his need for private transportation. Also, we all agree no one has a “right” to a car.

But if I walk into a hospital emergency room, staggering and vomiting blood and without a penny to my name, the nurse on duty won’t point me to the door and tell me to get lost. That hospital has a legal obligation under the Emergency Medical and Treatment Labor Act (passed by Congress in 1986) to care for me. If I don’t have insurance, it doesn’t matter. What’s more, the law doesn’t let doctors half-treat me or dump me on another hospital for failure to pay.

And, at some point, most everyone will wind up in an emergency room. It happens, even to people who eat their kale every day and exercise vigorously and do a hundred other things right. We’re all going to need a health care “product” at some point – and we’ll need it for much more than emergency room visits -- whether we can pay or not. If we can’t pay, everyone else gets to pay for us that day when we land in the ER (see Note #6 below).

The alternative is stark: All those people without insurance, and without a means to pay, we let die.

Who wants that? Who thinks that even makes sense in the richest nation on earth, which spends so much on health care?

I know there are a lot of ideas on fixing the U.S. health care system: offering insurance across state lines (which will do very little), tort reform (which will do a little, but not nearly enough). But the first thing we have to face: every American is in this system together. We need a proposal that starts with that as the first principle. Everyone gets covered. Maybe that leads to single payer. Maybe that leads to Medicare for all. Or maybe there’s a different way.

But let’s be honest about who’s in the U.S. health care system.

We all are.

Some additional notes:

1. The U.S. pays two to three times as much per person as most other industrialized countries on health care. Despite this, the quality of our health care is ranked only 28th worldwide, below Slovenia’s. The U.K., which is ranked fifth, spends less than half what we do per capita. So it’s like we order filet mignon at Le Cirque, and in return get a turdburger in a styrofoam clamshell. Why isn’t everyone incensed about this? This isn’t a Republican issue, or a Democrat issue. It’s a people-opposed-to-stupid-spending issue.

2. On free-market “comparison shopping” for medical services: It’s practically impossible. Don’t believe me? Read this. The author says he should have been the perfect shopper for medical care: (1) he lives in Massachusetts, a state that passed price transparency laws to help patients shop for care (2) he’s a physician (3) the surgery at issue was minor and not urgent, giving him plenty of time to shop around (4) his research focuses on consumerism and price transparency. So it’s like the author of the Kelley Blue Book shopping for a used car. And how did the process go? Terribly. How’s this an efficient free market when price discovery is a nightmare?

3. Did you hear the story about Fin Mox? It’s an antibiotic for fish. But people were buying it for their loved ones – er, loved “fish” – because they couldn’t afford regular antibiotics. I’d link you to the Amazon page, with the hilarious comments from people whose “fish” didn’t have health insurance, and for whom Fin Mox was a blessing – but Amazon took the page down. The richest country in the world has poor people buying antibiotics for fish to get the medicine they need? That’s a disgrace.

4. Read this from emergency room physician Farzon Nahvi. He treated people – including a man with a brain bleed, whose life he saved – who later said, “Thanks, but I wish you hadn’t done that.” Because they didn’t have the money to pay the staggering emergency-room bills. Nahvi quotes Paul Ryan on health care: “You get it if you want it. That’s freedom.” Nahvi observes “Being given services without your consent, and then getting saddled with the cost, is nothing like freedom.” No, and let me complete the thought: it becomes closer to indentured servitude – or actually slavery, since indentured servants at least have to sign a contract.

5. One thing that puzzles me: if you believe in a free market in labor, you should definitely hate the current health care system. A full 56 percent of Americans get their health care through their employer. Many people are shackled to jobs at large companies, resistant to changing, because they don’t want to lose that precious insurance benefit. So think of all the people who could be innovators, or who could switch to a more productive job at a smaller company, benefiting the economy, but don’t because they need their gold-plated health insurance plan. So we squander the potential in our labor force. Why aren’t more conservatives upset about this?

6. A report last year showed one of five Americans visit the emergency room at least once a year. Separately, a study showed that a whopping 71 percent of these visits were either unnecessary or avoidable. Emergency room care is very expensive treatment, so this indicates a lot of waste. People lacking health insurance sometimes wind up in an emergency room because they can’t afford regular doctors.

The Second Edition of Saving My Knees Is Out!

Here it is, with a new cover, new preface and five additional short chapters. Putting it together was more of an effort than I expected. Pardon me while I take a victory lap!

The first time, I formatted the book myself. It’s definitely doable, but tedious. I wrote out the steps last time, and on reviewing the process, I thought, “Eh, I’d rather skip this if I can find someone to do it for a good price.”

Did I ever. One of my luckier moments this summer was finding Allen of eB Format. He was responsive, intelligent, reasonably priced (less than $100) and did a nice job. He improved a few things without my asking. I said I’d mention his fine work on the blog, and his website’s here if anyone’s interested.

Now on to the book:

In the second edition, at the end I tried to answer a few criticisms that have surfaced – not that I’m really thin-skinned or anything, but for instance, when someone reads your book and likes it but can’t tell what you did to heal – well, that’s probably a failure of the writing or organization. By the way, if it’s unclear to anyone reading right now, I healed with high-repetition, low-load exercise, which for me was a very structured program of walking.

No fancy stretches, no miracle shoes, etc. Walking your way to health sounds simple, but there was a lot more to my story than that, which is what led to an entire book. I wanted to tell a story: of what happened to my knees, and how I got through it.

Which brings me to a second criticism: It would be a fine book, some readers have opined, if you could skip over the non-knee bits here and there, such as when, during my summer devoted to recovery, everything started going wrong, including my discovery of mold on my camera lenses. I completely understand this. Most people with knee pain just want answers. What do I do, what works, what doesn’t?

I conceived of this book as something different though: a story, with a central character (me) and a progression through the stages of knee pain, the experiments with things that didn’t work, and then the discoveries that led to healing.

Also, I thought it was useful to give readers an idea of what kind of person I am (competitive, type A, active, with a relatively injury-free history). That does figure into how I got into such a mess, and was related to the challenges of getting out. And the camera lens mold turned out to be part of a larger crapfest of a summer, and that turned out to be important too, because you will go through times like that when you have knee pain – every little bad thing that happens will seem like more grief dumped on you, and you’ll think that nothing will ever get better.

So there you have it. I also did the update because I wanted to include a chapter on Scott Dye and his “envelope of function” framework. I knew a little about Dye while writing the original book, but there was much, much more I only found out about later. I wish he could’ve been part of the first edition.

For first-time visitors wondering whether it’s worth their time and money: check out the blog. Poke around some. All the content here is free. If you like what you find, and want to find out the full story – well, Saving My Knees is it.

Cheers!

Update: I want to be clear that, if you bought the first edition, I'm not trying to suggest you buy the second too! That seems absurd. What's in the additional chapters (which are generally short) can be found around the blog (just do a search for "Scott Dye" for example; I talk about him in one of the add-on chapters). I will ask Amazon if people who bought the first can be automatically upgraded to the second, but I'm not optimistic Amazon will be able to do this.

Second Update: I reached out to Amazon. I was told that readers who bought the first edition could contact Kindle customer care, and someone there could help them download the latest version. A reader below in the comment section reports that this did work. Here are the url's Amazon gave me:
www.amazon.com/clicktocall
www.amazon.com/clicktochat

Can You Guess the Top Five Posts on This Blog?

I was hoping today I could announce the second edition of Saving My Knees was out. But alas, while I was downloading it to Amazon's Kindle publishing center, with the new cover and five additional short chapters, Kindle burped up an unfriendly message.

Namely it had found 11 spelling errors.

Now, nine weren’t really spelling errors, but two were legitimate typos, which made me cringe. So I am going to see if my ebook formatter will correct these two, then we’ll be off to the races – for real this time.

Meanwhile, I thought it would be fun, especially for relatively new visitors, to show you the five most popular blog posts I have done. You see, I have access to the dashboard behind this blog, which shows all sorts of nifty details, such as where visitors are coming from and how many views each post has gotten.

The winner, by a long shot, is “If You’re Overweight and Have Knee Pain, You Need to Read This” – 37,363 views so far. Nice!

The others rounding out the top five:

2. Here Are My "Radical" Beliefs About Healing Bad Knees (17,422)

3. "What Should I Do If I Have 'Weak' Knees?" (14,155)

4. Comment Corner: Sleeping Position, Signals From Bad Knees (10,417)

5. Why I think Cycling May Be the Best Activity for Rehabbing Bad Knees (9,220)

One thing I noticed while doing this little roundup: all these posts are from 2011. So maybe, gulp, I’m running out of things to say?

After the second edition comes out, I’ll probably write fewer posts, and just invite people to chat among themselves. It’s always interesting to hear from people out there who are struggling with knee pain, and listen as others try to help them. Thankfully I’m no longer struggling (which is perhaps why I’ve become a bit boring ... ah well).

Low Dose Naltrexone for Damping Inflammation?

Sometime visitor “Racer R-X” (that’s his full handle, if I recall correctly) occasionally drops a comment below one of my posts.

I’ve maintained for a while that I get the smart readers in the world of knee pain – thoughtful, analytical people who are in full-on search mode for ways to get better. Every time I hear from Racer R-X, I’m reminded of this.

He’s pretty much beaten his knee pain and is back on his bike, powering up mountains. It took him a while to reach that point, he learned a lot, and I’d love for him to tell his complete story here at some point. (There are bits and pieces in the comments he’s left, scattered over a number of posts.)

Anyway, he dropped in a link to an article, "The use of low-dose naltrexone as a novel anti-inflammatory treatment for chronic pain."

First, people with stubborn knee pain usually suffer from the bad kind of inflammation: chronic inflammation that has a harmful effect on their joints. Getting inflammation under control is important to getting better.

This article suggests that low doses of naltrexone may be helpful for certain people:

Low-dose naltrexone (LDN) has been demonstrated to reduce symptom severity in conditions such as fibromyalgia, Crohn’s disease, multiple sclerosis, and complex regional pain syndrome. We review the evidence that LDN may operate as a novel anti-inflammatory agent in the central nervous system, via action on microglial cells.

Yes, no overt mention of knees, but complex regional pain syndrome may be a factor in some cases of knee pain, according to one reader of this blog who has researched this extensively.

Naltrexone apparently is used mainly to treat dependence on alcohol or opioids. It’s sold under the trade names Revia and Vivitrol, for example. If you’re having trouble with subduing inflammation, I encourage you to take a look.

Advantages of taking naltrexone include its moderate price (less than a dollar a day) and infrequent side effects.

Disadvantages are worth pointing out too: It’s unclear how to determine the best dose for particular individuals, and the default dose commonly used (4.5 mg) isn’t a size that tablets are now created in. Also the authors note: “Even though naltrexone has a long history of safe use with a wide range of large dosages, we know very little about the long-term safety of the drug when used chronically in low dosages.”

As usual, my standard disclaimer applies: This is not in any way my endorsement of this drug. I’ve never tried it myself; I don’t know anyone who has either. But when I was dealing with knee pain all the time, I eagerly read about anything and everything that might help me. So consider the above link in that spirit.

The Latest Reason to Skip That Steroid Shot for Knee Pain

If you’re trying to fight inflammation in a bad knee by using drugs, opt for the milder, non-steroidal stuff.

That’s the takeaway from a study published this year in JAMA.

There were 140 subjects, average age 58. They had pain and inflammation because of knee osteoarthritis. For every three months over two years, the subjects received knee injections that consisted of either the corticosteroid triamcinolone or a placebo.

What researchers then found was rather surprising.

Knee pain declined slightly in both groups, but by about the same amount – so the steroid didn’t even outperform a saline placebo. However, those who got the corticosteroid injections had “significantly greater cartilage volume loss.”

The researchers’ conclusion doesn’t mince words: These findings do not support this treatment for patients with symptomatic knee osteoarthritis.

Controlling inflammation is good, but it’s probably a good idea to take a pass on steroids.

What Jane Brody Wishes She Had Known About Her Knees

Check out “What I Wish I’d Known About My Knees” by Jane Brody of the New York Times. It’s a very good article, and you can feel her weary skepticism shining through. Jane Brody has been through a lot trying to get rid of knee pain. For instance, in the 1990s, she wrote a flattering column about the potential of glucosamine. But alas, in the end the supplements didn’t work. She tried a lot of other things that didn’t work too before finally undergoing a double knee replacement.

Many of the procedures people undergo to counter chronic knee pain in the hopes of avoiding a knee replacement have limited or no evidence to support them. Some enrich the pockets of medical practitioners while rarely benefiting patients for more than a few months. 

I wish I had known that before I had succumbed to wishful thinking and tried them all.

She tried arthroscopic surgery for a shredded meniscus. She mentions a systematic review of 12 trials and 13 observational studies that determined that arthroscopic surgery to improve knee arthritis and tears in the meniscus offered no lasting relief or improvement in function.

She also tried hyaluronic acid when she was told her knee arthritis was bone on bone. But, she reports:

The painful, costly injections were said to relieve knee pain in two-thirds of patients. Alas, I was in the third that didn’t benefit.

One of the best parts of the article wasn't even in the article. I fished it out of the comment section. Note the underlined sentences. This commenter, presumably an orthopedic surgeon, is fully aware of the profit motive at work behind all those needless arthroscopic procedures:

I started my orthopedic residency in 1995. We had a monthly journal club where we met at a fairly expensive restaurant (paid for by pharmaceutical or joint replacement companies!) to discuss the articles in the latest orthopedic journals. 

The article that generated the most buzz was a double blind study of patients with meniscal tears. Half the patients got the actual arthroscopic repair, the other half underwent the same general anesthesia and had the same surgical incisions but no actual arthroscopy. Double blind means neither the patients or the surgeons knew which patients were in which group. No difference was seen in the two groups. Some protested that the study was unethical by subjecting the placebo group to the risks of general anesthesia and infection. In retrospect the same could have justifiably been said about those getting the actual procedure. 

Two decades plus, nothing has changed. Arthroscopy is the bread and butter for orthopedic surgeons. A general orthopedist might do a handful of knee replacements in a week while they do twenty scopes. The latter can be scheduled like a factory line, each scope taking less than half an hour to perform. Doesn't pay like a knee replacement but it's far less grueling on the surgeon (and the patient!). Far less likelihood of complications. 

Nothing's changed in 2+ decades, don't hold your breath waiting for the ortho docs to give up their bread and butter!

Something to keep in mind if a surgeon suggests going into your joint to "clean it up a little"!

Housekeeping Stuff: Second Edition of SMK, Spam Comments

I’m hoping to get a second edition of Saving My Knees out by the end of the summer, or early fall. The major reason for a new edition is to update a few things, such as how my knees have been since I wrote it (they generally feel great) and what I’ve learned since then (such as the envelope of function framework for understanding knee pain).

But not to worry: I’m not backing away from what’s contained in the heart of the book. I still think the program I followed made the most sense. I may have focused a bit too much on this idea of restoring my cartilage, but I will say: my cartilage was very crunchy before, and it isn’t any longer. So something apparently improved.

Now, on to the subject of what have become increasingly sophisticated spam comments:

I expect that the people who really need to read this won’t, because they don’t really read this blog. Rather, they’re like those people you see briefly in a neighborhood, stapling advertising fliers to a telephone pole, then moving on.

I realize there are ways of escalating against spam comments, such as (most severe) putting comments in a pen until a moderator (that would be me) can approve them. Then nothing that’s spammy gets in the comment section.

But honestly, I don’t think that’s good for people who want live back-and-forth discussions here, plus it’s not great for me either, having to constantly moderate. I’d rather jump in on my usual occasional basis and clean up the comments. So far it seems to be working.

What is a spam comment? This is a good question. As some of you may know, when my book first came out, I was accused of promoting it on the KneeGuru website and thrown out of their online community. In that case though, I was actively participating in the boards. I went on there and told my story and answered questions. Honestly, I strongly believed that I had a message that needed to be spread that I wasn't seeing anywhere else.

So back to the question: What constitutes a spam comment? What gets a comment deleted? Here are a few things I look for:

* Someone I’ve never seen on the site before, who posts once with a link, and that’s it. That's often a red flag.

* A comment that’s blandly approving (“This is a great post”) or that speaks in generalities but doesn’t really address the post above. Believe me, after a while, it gets easy to spot the spam comments where a person probably making $2.15 an hour in some Third World country is trying to engage superficially with the blog, all the time thinking, “Gotta get this link in.”

* A short comment that has a link, either embedded or at the end, to something like “orthopedic supplies.”

Basically, I apply the smell test to a lot of stuff. I hope I haven’t inadvertently deleted any legit comments. But I strongly suspect that if I have, the ratio is something like one good deleted for every 300 bad.

Anyway, that’s the end of the housekeeping stuff. A Happy Fourth to all!

Fake News, Medical Edition

There is something that’s not quite fake news, but possibly more dangerous, in the world of medicine.

First, what would you think if you had chronic knee pain and came across this intriguing item?

High quality (pharmaceutical grade) chondroitin sulfate is as good as a widely prescribed non-steroidal anti-inflammatory drug (celecoxib) for the treatment of painful knee osteoarthritis, according to a British study published in the Annals of Rheumatic Diseases.

Your reaction might be something along the lines of “Sign me up for that!” Especially when, upon doing a little investigating, you discover that chondroitin sulfate is an over-the-counter supplement – much cheaper and easier to obtain than celecoxib. What’s more, it’s naturally found in cartilage.

The problem is, high-quality studies have found it’s basically useless, just like glucosamine.

So what’s going on with this new study? I was curious and tracked down the full write-up here. But I wasn’t looking for details such as the number of people who took part, the methodology, confidence intervals for the results, etc.

This time, I was looking for something different: a certain taint that is increasingly a problem with published clinical studies. It took me a lot of – I mean, a LOT of – scrolling to find it. But at the end, neatly dropped in like an insignificant afterthought, there it was:

The study was sponsored by IBSA Institut Biochimique SA, Pambio-Noranco, Switzerland, a pharmaceutical company marketing Chondroitin Sulfate. The manuscript was entirely written by the first Author (JYR) who received an editorial assistance from IBSA. However, IBSA has no influence on the content of the manuscript. The editorial assistance was limited to the final editing of the manuscript and the submission process through the ARD website.

Which raises a host of questions: (1) If the study happened to find that chondroitin sulfate was useless, or even worse, harmful in some way, would the results have just been quietly quashed? (2) How exactly was this study “sponsored”? How much money did the principal researchers receive? Are we to believe that the knowledge of who is writing their paychecks really has no influence on how this study is conducted and reported? (3) What exactly was the nature of this “editorial assistance” that was provided?

Upton Sinclair once wrote wisely: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

This study is not quite that kind of situation. But it’s a cousin to that kind of situation.

Open Comment Forum, Dive In!

I started scrolling through recent months, and realized we haven’t done one of these in a while. They’re extremely popular, and probably more useful than the regular posts. :)

So I invite everyone to take over the comment section and say what’s on your mind (about your knees, or matters related to your knees).

A suggestion, in case anyone’s looking for a theme: What are you struggling with most right now? What’s the one big single thing? Tell us, and perhaps the wise commentariat (that is, the very knowledgeable people who frequent this blog) can help you find a solution!

Cheers, and hope everyone is having a good spring (or fall, if you’re in Australia).

Those Noisy Knees: Crepitus Revisited

The medical community may be realizing that crepitus is significant after all.

A study of 3,500 subjects, led by a group of researchers from the Baylor College of Medicine in Houston, found that those with crepitus were more likely to develop knee pain.

The findings don’t surprise me at all. Back in December 2011 I wrote about crepitus (the medical term for creaky knees). The first paragraph of this excerpt from the post, below, references an arthritis website that describes the condition:

The site also declares, incorrectly I think, "If it occurs without any pain, it is unlikely to be caused by arthritis or any medical condition, and is usually meaningless." A popular "save your knees" book on the market also asserts that that noise from your knees, unaccompanied by pain, isn't significant. I think that's wrong thinking, and dangerous. 

What if you were a ship's captain and spotted a strong beam of light through the fog? If you continued on your way without incident, you might conclude that the light was meaningless. However, if you strayed too close to the light's source -- and wrecked your ship on the rocky shores that this lighthouse was trying to warn you of -- I think you'd argue the opposite: that the light was quite meaningful indeed.

My thinking about crepitus remains pretty much the same, more than five years later.

First, when you’ve got bad knees, don’t obsess about it. For a while, I kind of did (along with eighteen other variables related to my knees as I tried to figure out how to heal them). But it’s very tricky mapping the amount of crepitus you hear in your bad knees to how well they’re healing, or not healing.

In short: Once you’ve got bad knees, monitoring crepitus probably isn’t all that worthwhile.

But as an early-warning harbinger of trouble ahead, I believe the presence of crepitus is very useful. It doesn’t mean you’ll develop knee pain. For instance, when I was thinking of doing the grueling Mount Washington “Hill Climb” on my bike, I remember a forum full of riders who had done the race, and one guy who said his knees were very crunchy, but he was asymptomatic.

However: anytime the crepitus gets worse and worse, I think you are at much greater risk of eventual knee pain. I often wonder about that rider. It’s been about a decade since I read those comments he left. Is he still asymptomatic, or is he now among the legions of people with knee pain?

Don't Pin Your Hopes on Vitamin D Supplements

When it comes to knee pain, certain beliefs are vampire-like in their resistance to debunking. You find yourself trying to drive a stake into the heart of these beliefs, but in vain.

Basically, even when evidence-based medicine shows certain treatments and supplements don’t work, some people will continue to cling to them.

Glucosamine is one of these. It’s been extensively, thoroughly debunked as a cartilage regrower, as a pain reliever, as a function improver, but you throw a rock at a Bad Knees Convention, and you’ll hit about twenty people who swear by it. Some will say they can’t leave the house before taking their glucosamine tablet. (My standard disclaimer applies here: if glucosamine helps you, and you’re fine coughing up the money for it, go right ahead. But of course, I also believe if taping a piece of pink construction paper to your nose helps with your knee pain, that’s fine too.)

Another belief that is less widespread regards vitamin D supplements, and their beneficial effect on knee pain. When I wrote this post, I was taking vitamin D myself (not related to knee pain, which I no longer have, but rather for general health reasons). Nowadays the vitamin D fad is kind of burning out, and taking high doses has been shown to cause problems.

Yet I’m willing to bet there are still holdouts when it comes to using vitamin D to treat knee pain. So in their honor, I bring you this study, which is about a year old. The lead of this summary about it:

Vitamin D, which can reduce bone turnover and cartilage degradation, did not slow progression of knee osteoarthritis (OA) or reduce knee OA pain when tested in a randomized placebo-controlled trial.

The study included 413 patients who were considered vitamin D deficient. So, if anyone would see an improvement from taking the vitamin, presumably they would. For two years they took vitamin D (or didn’t if they were in the placebo group). Then MRIs were done and pain scores taken.

The authors concluded:

Results showed that even among study participants with low 25-hydroxyvitamin D, supplementation did not slow cartilage loss or improve WOMAC-assessed pain. These data suggest a lack of evidence to support vitamin D supplementation for slowing disease progression or structural change in knee osteoarthritis.

Fun bit of trivia: The lead researcher on this study was Changhai Ding, who also did the very first study I came across that really buoyed my hopes when I had knee problems. I mention that study in the book: it showed cartilage defects were found to improve about as often as they got worse over a two-year period. Fascinating, amazing, uplifting!

Knee Braces: What’s Your Experience?

I dug this article on a new “bionic” knee brace out of the dustbin this morning. Yes, it’s from last year (hence the “dustbin” allusion), but the idea of knee braces intrigues me:

A pair of Nova Scotia researchers are close to producing a "bionic" knee brace that enhances ability and reduces fatigue, and have now landed a lucrative contract to produce a beefed-up version for the Canadian Armed Forces.

The so-called Levitation brace can reduce the burden of carrying heavy weights. But another intended use, the article makes clear, is for athletes going through rehabilitation.

To be fair, this very expensive, lightweight carbon brace probably isn’t the best example for a knee pain blog. It seems to compete more with robotic exoskeletons. So if you have normal knees and want to turn into Super Ant, this may be the knee brace for you. For knee pain sufferers, you can probably find something serviceable for a cheaper price (this brace costs a bit less than $2,000, from my quick Google search).

Anyway, back to the point: What’s the usefulness of knee braces? As I wrote here, the neoprene sleeve braces aren’t probably much good at all. Even so, doctors still recommend them (one advised my wife to wear one for a swollen knee).

So what’s your experience? Knee braces – worthwhile or waste of money? If you want to weigh in, please leave a comment below.

Revisiting Inflammation and the Ghost in the Machine

Amy Stevens left a good comment last week that got me thinking about the simple fact that there are so many things about chronic knee pain that we don’t understand:

I thought I was onto something by leaving work 6 months ago to rest, and I did manage to identify a lot of triggers I never suspected in that time (such as lifting the mattress a bit to make the bed each morning!) but unfortunately I have not improved simply by avoiding certain activities. My comprehensive knee diary isn't revealing any clear patterns at this point either. Interestingly, Coeliac Disease is looking increasingly likely in my case, as is the potential for my synovitis of the knees to be autoimmune in nature due to reacts to certain foods. Perhaps a change of diet will help.

Amy, by the way, often drops in to comment here, and if you haven’t clicked through on the URL embedded in her name, you should. I remember the first time I did and thinking, “Wow, what’s this all about?” She writes a blog about her adventures in Africa with her husband, Austin Stevens, who seems to be part snake wrangler and part naturalist.

Anyway, heading down this autoimmune path to try to understand one’s knee pain feels very familiar. Maybe Amy will find that certain foods trigger problems; that’s possible. Or there could be a harder-to-pinpoint systemic issue; these can be frustrating to chase.

I originally wrote about the ghost in the machine here. I followed up here about a study that showed that, contrary to what you may have been told, osteoarthritis is not the noninflammatory version of arthritis (rheumatoid arthritis supposedly being the inflammatory and out-of-control variety). Inflammation was found in osteoarthritis joints well before changes appeared in X-rays.

Why is inflammation so important? Well, in its chronic form, it can be a very destructive force from what I can tell. I know that in my attempts to heal, I was always fighting to bring that burning flame to its lowest point. I wanted as little inflammation as possible and was able to modify my behavior to achieve that. Luckily, I wasn’t working at the time and had the freedom to experiment and adjust and could reach a safe zone that I then enlarged little by little over time.

Some people can’t achieve that through modifying behavior. So what happens when inflammation sets up long-term? This is a fascinating question with no clear answer. I do wonder if inflammation in the knee may be something akin to a dog of hell on a leash that, if it isn’t brought to heel, might escape and plague your whole body. I had too many odd joint problems along with my knee pain for this to be coincidental, in my mind. When I mentioned my theory to a family doctor, he kind of pooh-poohed the idea, but now I think he was dead wrong.

Why? Not just because of my own experience, but because of your experiences. Too many of you have shared stories that resemble mine. There is something to this malevolent inflammation genie. I’m convinced of it.

Does Your Doctor Really Understand Your Level of "Physical Activity"?

I came across a study recently that came to a not-very-surprising conclusion: that a high level of leisure-time physical activity is good for your knee cartilage.

That’s nice to hear (again), but it’s hardly stop-the-presses news. Nor is it necessarily true without qualifiers. There is an appropriate amount of physical activity that’s good for knee cartilage, but you to make sure you get that amount right for you, especially if you have a difficult case of knee pain. Too much and you’ll further damage your knees.

What I found more interesting was this idea of “physical activity,” taken in its broadest sense. The study focused more on activities such as walking and Nordic walking, but “activity” can be almost anything: it’s crossing the room, kneeling to scrub the floor, walking to the mailbox, carrying your little niece on your shoulders. It’s all of that and much more.

This study got me thinking about something doctors and physical therapists usually don’t do: they don’t take anything resembling a comprehensive inventory of how you use your knees each day. Example: You have really bad knees and your doctor asks what sports you do. You say you don’t run or play basketball, but get in a few miles of slow walking each day.

Sounds great, right? So maybe your doctor writes down, “Sporting activity appropriate.” But what if you’re also lugging your two-year-old around all the time? That could be doing as much damage to your knees as playing basketball a few times a week.

In my book, I went into a lengthy criticism of a knee study that seemed to me to be a bit of a mess. One flaw concerned giving too much weight to how much time your knees spend in a certain kind of physical activity, like running or walking. That’s part of the picture, but it seems to me everything you do from the moment you wake up until you hit the sack at night is part of the picture. And if you’re not being asked about how you use your knees outside of sport, your health-care provider (or therapist) isn’t looking at the whole picture, but only at what might be a small piece.

One point I like to make about conquering knee pain is personal involvement in finding a solution. The experts are good, but they are limited: they only have a short time to spend with you, and there’s no way they can crawl inside your body and feel how your knees feel, and live with those joints for a few days to see how they’re being used, and how they’re irritated, and to what degree.

So I think it falls to everyone with knee pain to do this analysis themselves. Ask yourself, “How do I use my knees each day?” What knee-unfriendly things do I do? How much squatting, lifting, kneeling, carrying, walking? You may find activities in there you’re doing that you shouldn’t be – at least not until your knees are stronger.

Open Comment Forum Again, Your Turn to Speak!

I thought today that once more I'd turn over the mike to all of you. The open comment posts have turned into some of the best read recently!

Again, you're all welcome to discuss whatever you want. If, however, anyone is searching for a topic, here's one that's a bit different: What are some of the best resources you've found online that have helped you with your knee pain (this website excluded of course; I'm not scrounging for compliments :))

Otherwise, hope you're all well, and looking as forward to the end of winter as I am (okay, none of this applies to our friends south of the equator; forgive me for being Northern Hemisphere-centric). I want to ride my bike again but it's hard when the temperature is 16 degrees at six o'clock, like today. Cheers!

Your Bad Knees Are Someone's Market Opportunity

This article recently caught my attention, with its lead:

The global knee cartilage repair market had a valuation of US$1.6 billion in 2014. The market’s valuation is expected to rise to US$2.7 billion by 2023, indicating a [compound annual growth rate] of 5.8% between 2015 and 2023.

That $1.6 billion actually sounds low to me, but still: It’s a considerable chunk of change. The estimate is from a market intelligence company that blames our increasingly sedentary lifestyle for our knee woes. Still, this isn’t an exhort-couch-potatoes-to-get-moving article.

It’s identifying a market opportunity. Yup, that’s right, your bad knees are a market opportunity. So let that sink in a little, what it means to be a market opportunity. That means there’s gold in them thar joints.

Maybe not golden outcomes unfortunately, but gold for the guy who’s wielding the scalpel and for the company that made the artificial knee joint, or that developed a process to grow cartilage cells in a lab dish, or that makes arthritis medication.

So just keep that in mind when you ask your orthopedic doctor: What should I do about these bad knees?

Most doctors are very conscientious, very ethical people, but be aware there’s a little conflict of interest tugging at even the best among them. They have become vested in surgical procedures. What would you think if you had spent many hours perfecting cartilage-trimming operations, investing in equipment for the same, receiving sizable paychecks for surgery – then someone said, “Hey, you know, clinical studies show doing that’s usually a waste of time.”

I bet on some level you’re going to resist that conclusion.

Also, all these companies that have developed drugs and procedures, they have something at stake – maybe stock prices, impatient investors, shiny new facilities. The drug makers employ pretty young representatives (my brother was married to one) who smile their way into the office of your crusty old physician, who takes some samples and maybe later writes a few ‘scrips – and that attractive young woman, she’ll know exactly how many Doctor X wrote, believe me, and she’ll be back later, trying to induce him to write a few more.

So, as a patient, you just need to remember there’s gold in your bad joints -- $2.7 billion by 2023, it appears – and that when there’s money to be made if you do thing X (surgery/medication) but no money if you do thing Y (try to heal on your own or through physical therapy), you have to be aware of that and weigh your options wisely.

With Glucosamine Studies, It Pays to Read the Fine Print

As many of you reading this know, I’m a skeptic when it comes to glucosamine supplements for treating knee pain. Of course my usual disclaimer applies: If it works for you, go ahead and keep taking it. I don’t think the supplements are actually harmful (unless you’re diabetic). For most people, the only damage will occur in the region of their wallet.

Occasionally a clinical study on glucosamine will catch my eye. Here’s one with an impressive headline: “Glucosamine-containing supplement improves locomotor functions in subjects with knee pain – a pilot study of gait analysis.”

First, let’s get right to the researchers’ exciting conclusion:

Our data based on gait analysis using a motion capture system suggest that supplements [containing glucosamine] can increase walking speed through increased stride length and increased force of kicking from the ground during steps, and these improvements may be associated mainly with alleviated knee pain and direct effects on muscle.

Well, this certainly sounds good. But one odd thing you’ll note if you look closely at this study. There didn’t seem to be a control group. In fact, the researchers make a damning admission near the end of their article:

There are some limitations to the present study. First, it was conducted as an open label study.

Hmm. An “open label study.” What the heck is that? Well, the gold standard would be a double-blind study. In such a clinical trial, the patients don't know whether they are receiving real glucosamine or a placebo. What’s more, the “double blind” means that the researchers don't know whether they are evaluating subjects who have taken glucosamine or a placebo.

So in other words, in a figurative sense, it’s like the subjects and the researchers are both wearing blindfolds until the very end. This ensures no placebo effect for patients and also that researchers won’t be swayed when they evaluate the results, because they happen to personally believe, or not believe, in the efficacy of glucosamine.

So what would be the opposite of a double-blind study? A study where both researchers and patients know who's taking the medicine that’s supposed to improve their joint health – thus fairly effectively polluting the integrity of the results? Well, that would be – you guessed it – an open label study.

Well, if the researchers weren’t at all conflicted, this still might work. Maybe. Maybe? Ah well so much for that. Four of the authors, it turns out, work for Suntory Wellness, which made the glucosamine supplement used in the trial.

Now you’re probably wondering: Who would publish such a conflicted study?

The article appeared in a publication of Dove Press, an “open-access” publisher that has taken some heat before for its business practices and has been tarred as a “predatory” open-access scholarly publisher. Such publishers “are predatory because 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.”

I think the very fact this study includes FOUR authors who work for the company that makes the supplement being tested, and was “open label,” should be enough to send any smart knee-pain sufferer running in the other direction. Remember to read the fine print!

Don’t Be Afraid to Question Your Doctor

Warning: this post will be only tangentially about knees.

First, I was going to write about crashing my bike last week. I went down hard at 25 miles an hour after the guy in front of me braked hard and our wheels brushed, and I ended up bouncing and sliding on the pavement. My goodness, the litany of injuries: road rash on my face, swelling over one cheekbone, sprained wrist and finger, scrape on one forearm, bruising on my hip, and then knees banged up with cuts on both and a little swelling on the right one.

I was fully clothed, this being winter, yet still the crash was violent enough that I had bloody rashes under my garments. But the upshot: a week later, I’m in pretty decent shape, and the two knees feel pretty good (the scabs aren’t pretty, but they’ll go away soon). I’m a healer! :)

So that was going to be the post, then my daughter caught the flu, and my wife called me yesterday from the pharmacy to say she had bought Tamiflu for both Joelle (7) and Elliot (three and a half). Elliot didn’t have the flu, so he would be given the Tamiflu in a prophylactic way – to hopefully lessen his chances of contracting the virus.

It cost a heckuva lot -- $78, and that’s reduced from $600 with no insurance. But something else was sticking in my mind as I got off the phone with her. Tamiflu ... Tamiflu ... hmm, what do I know about Tamiflu?

I started poking around on the internet, and immediately started getting a bad feeling about this drug. It sounded a bit controversial. It also sounded like it was of uncertain efficacy. And one side effect I found rather chilling: “neuro-psychiatric events.” So kids can have nightmares, insomnia, delusions. Those aren’t typical side effects of say aspirin or Ibuprofen.

Now for those of you who don’t know me well, let me be clear. I’m not some nutter when it comes to medicine. I’m not anti-vaccine. I’m pro flu shot. I try to keep an open mind, and always consider the scientific evidence and the statistical likelihood of outcomes.

And I have loads of respect for well-run scientific studies. I’ve cited the Cochrane Collaboration before, as they tend to do “meta-analysis,” sifting through a wide range of studies for the best ones, and then combining all the findings to reach a conclusion. Here’s what they reportedly had to say in the BMJ in 2014 on Tamiflu (underscoring is mine):

Compared with a placebo, taking Tamiflu led to a quicker alleviation of influenza-like symptoms of just half a day (from 7 days to 6.3 days) in adults, but the effect in children was more uncertain. There was no evidence of a reduction in hospitalizations or serious influenza complications; confirmed pneumonia, bronchitis, sinusitis or ear infection in either adults or children. Tamiflu also increased the risk of nausea and vomiting in adults by around 4 percent and in children by 5 percent. There was a reported increased risk of psychiatric events of around 1 percent when Tamiflu was used to prevent influenza.

That “psychiatric events” warning bothers me. Now, taken literally, an increase of pyschiatric events of 1 percent may not be much at all. As in, say that among 10,000 people with the flu, there are normally 100 “psychiatric events.” On its face, this statement implies that there would be 101 among Tamiflu takers, an increase of one in a population of 10,000. Not much to worry about there, right? Hardly even statistically significant.

Yes, seemingly, but – the nightmares and delusions appear to have a long anecdotal tail when it comes to Tamiflu. Japan banned its use for teens after a couple of suicides and other incidents, including some kid running into traffic. Now, a hundred anecdotes don’t make a statistic, and it could be just some bad batches of Tamiflu, or the kid was going to dart into traffic anyway – but it is a little disconcerting that these cases pop up with some frequency on the internet.

What’s Tamiflu doing in the brain anyway, you fledgling biologists might wonder. Isn’t there this thing called a brain-blood barrier that effectively blocks most chemicals from crossing into the seat of our reasoning mind? Apparently, Tamiflu normally can’t cross the channel. But when the tissue is inflamed, as with a flu, the barrier may become more permeable.

May be. Perhaps. Some incidents. Anecdotes. This isn’t hard science. Hell, I’d the first to admit that I haven’t done a helluva lot of research. But I did call the doctor who prescribed it. Once upon a time, before my knee pain saga, I never would’ve done such a thing. But I’m a bit bolder now. Doctors don’t always get things right. So I asked her reasoning for prescribing this drug.

She explained that she presented it as an option; she didn’t recommend it. She was very nice the whole time we spoke. My tone was perhaps a touch less friendly. But something she said surprised me: A mother had called her office that very day saying her daughter was taking Tamiflu and having delusions. The doctor, thank goodness, told her to take the child off the drug. (Full disclosure: she did say it was the first case of delusions directly reported to her in 14 years of practicing.)

In the end, I told my wife that it was partly her decision too whether to give it to the kids. Me, I wouldn’t. I’m ready to put the whole $78 of the stuff right out on the doorstep, if someone else wants to roll the dice with it. This anti-viral medicine seems to be powerful stuff. I don’t like giving my kids stuff that powerful unless they absolutely need it.

My daughter had a temperature of 104.7 yesterday. Today it’s about 101 and going down. I think she’s going to be fine.

On Skepticism About Cartilage Healing

Recently I’ve seen some comments popping up questioning the idea that cartilage can heal. So I wanted to devote a post to that. Some of what I’m about to say will sound a bit different from what’s in Saving My Knees, because my thinking has changed somewhat. However, my belief that damaged cartilage can improve remains as strong as ever.

First, what’s changed: I don’t see knee pain through such a cartilage-centric lens anymore. Knee pain sufferers often do fine with some cartilage defects, and curing these shouldn’t become an obsession. I did note in the book that some people with cartilage defects have no knee pain; others that appear to have fine cartilage have lots of knee pain. Cartilage flaws and knee pain certainly don’t correlate perfectly.

Do I still think my problem was my knee cartilage? I think that was at least some of it, yes. My knees made awful crunching noises; they are much quieter now. But how much of that could be from improvements in the synovial fluid and how much from better cartilage? On that, I honestly don’t know. What’s changed in my analysis: I think some of my problem lay in the bone endings and could have been detected with a bone scan.

Again, these are just theories. What I do know is I had knee pain that the best doctor I saw said would never get better, and I smiled outwardly and inside I said, “Screw you, I think you’re wrong.” And I devoted more than a year of my life to proving he was. Recovering from chronic knee pain was the hardest thing I’ve ever done, and the achievement I’m most proud of (getting into Harvard was only about doing well on some tests and writing a good essay by comparison; I am extremely proud of my children, but they are their own accomplishment).

Occasionally – and I must say very occasionally, because this blog has some really terrific followers – I catch a whiff of a newcomer probing, trying to figure out what kind of fraud I might be. “Hmm, cartilage can heal? Curious that this fellow says so, when my doctor says it can’t, and my physical therapist says it can’t. But I bet you can sell a lot of books that way. So let’s see if he can produce some evidence that his cartilage regrew.”

(Please check out this post where I address head on the question “Why don’t you get a second MRI to show all the cartilage healing that you claim occurred?”)

My more expansive reply to a skeptic is: Don’t get distracted by thinking your end goal is to walk out the other end of the tunnel with pristine cartilage. That’s a waste of time. You need for the cartilage to get stronger, more resilient, more capable of handling day-to-day loads. Whether it’s once again as smooth as a baby’s bottom ... that’s not the main issue.

Today, I feel confident that mine is much stronger than it was than when I had constant knee pain.

But let’s backtrack for a moment and tackle the tough question directly. Can cartilage improve? Can it be restored in spots where it’s vanished? On this, don’t waste your time looking at my knees. Just consider the studies I cited in the book. There were two that I recall; they’re in the bibliography for anyone to track down.

Let’s consider one briefly. It’s called “A Natural History of Knee Cartilage Defects and Factors Affecting Change.” You can find it here (at least until it disappears behind a paywall, which I hope it never does, but one never knows).

What amazed me about this study, and I hope this came across in the book, is that researchers found that cartilage defect scores got better at about the same rate they got worse. Also, this was the same for knee pain sufferers as for pain-free subjects. At the time, the implications seemed mind-blowing. Changes in cartilage are a two-way street. You don’t just get worse.

So you may wonder: Well, those that got better, what were they doing differently? Answer: we don’t know. Notice this study is called a “natural history.” That means the point wasn’t to test whether walking or Pilates is better for rehabilitating bad knees; it was simply to observe the knees of more than three hundred subjects over a longish (two-year) period and see how they changed naturally.

Do you get why that’s so great? Think about it for a moment. People who weren’t trying to do anything in particular to “save their knees” saw an improvement in cartilage defects over this period. Imagine what they might have accomplished had they actually been trying to save their knees! I can’t tell you how much this study buoyed my hopes. I drank it down like a thirsty man with a glass of cold water and, once I fully grasped the implications, thought to myself, “Damn, I really can do this.”

And then there's also this other study (“Factors Affecting Progression of Knee Cartilage Defects in Normal Subjects over 2 Years”). It showed five cases where researchers saw bare bone on an MRI and two years later, in four of those cases, some cartilage had appeared (Rheumatology 2006, 45:79-84, page 81). That table I reference is in the upper left; an image showing improvement is below. Check it out.

Could it be that all these MRI readings were wrong, that the researchers are fraudulent, that the whole thing is some lousy hoax? Of course, but it’s also possible that my mild-mannered mother is secretly a Russian agent. Lots of things are possible. But what makes more sense: that we’d be created with bodies containing some tissue that just wears out, and that’s it, or that it have some capacity to heal, at least slowly? (After all, most of the rest of our body can heal; even neural networks can rewire after damage.)

I operated on the optimistic premise – not because I’m some dumb Pollyanna. I actually skew more toward the dark-humored pessimistic end of the spectrum. I operated on the optimistic premise because, at the end of the day, it seemed most rational. And it was.