Healing Your Knees With ‘Virtual Reality’ Cycling

Okay, a confession up front: I know this won’t be the most popular post of all time, or even in the top 20. Still, I have been to other (virtual) worlds on my bike, and I want to share what I have discovered, and how it may apply to people recovering from knee pain.

The backstory: On Aug. 11, I crashed on my bike in the rain and broke the fifth metacarpal in my right hand, badly (I also broke the tip of my ring finger, but the orthopedist pointed out that was essentially small potatoes compared to the oblique displaced fracture of the metacarpal).

I was very, very morose about this turn of events, as this apparently meant I would miss the best cycling month in the New York City area: September (as well as August naturally). And I did miss it. I wasn’t cleared to ride my road bike outside until last month.

But I was determined to do something, even while wearing a cast. While encasted, I was advised not to sweat excessively (bacteria flourish on dirty, sweaty skin), but I couldn’t see myself spending Saturday mornings taking leisurely walks to Main Street. I evaluated some options (believe it or not, I had my eye on a fast recumbent bike, and was getting close to pulling the trigger on the purchase, then I found out that basically everyone would drop me on climbs.)

I ended up buying a smart trainer instead and joining the community of “Zwifters” and riding in my basement. The Zwift subscription costs $15 a month. The Zwift setup can range from a few hundred dollars to a few thousand; you can find the breakdown on YouTube videos.

What is Zwift? It’s a virtual world where you pedal on your bike, which is attached to a trainer, which in turn communicates your level of effort to the Zwift software. The software may be on an iPad or a PC (and if you want to add another layer of complexity, that device may in turn be hooked up to a smart TV that shows you cyling in the Zwift world.)

The harder you pedal in real life, the faster your bike-riding avatar goes.

The native Zwift world (called Watopia, which is probably meant to sound like a utopia for cyclists as all the roads are bereft of cars) has a variety of geographical features. There are underwater roads that travel through transparent tunnels, a volcano that can be climbed to the summit, and a rather daunting “hors category” Alpe mountain climb.

The cool thing about using a smart trainer is that Zwift tells the trainer if you’re going uphill or downhill, and how steep that grade is, and the trainer adjusts accordingly. So it’s quite hard to push up a 13 percent incline, but of course you’ll pedal down that grade with no effort at all.

Now for the quick bullet points, to get to the heart of the matter: How well does virtual reality cycling (like Zwift) work for knee rehab?

* First, virtual cycling keeps you engaged. Unlike a stationary bike, where you better bring something to read or have a fertile imagination, the Zwift landscape is always changing. And other cyclists, from all over the world, are passing by (sometimes Zwift feels like a geography test of “name the country that flag next to that person’s name belongs to”).

Also, there are group rides segregated by level. The riders “virtual chat” back and forth (you can see their messages come up on the Zwift screen, even when you’re not part of the dialogue).

* But Zwift worlds are not flat. I’ve noticed that the default route choices in the software never send you up a mountain, but they can still send you up some steep hills. This isn’t optimal for someone healing from knee pain. You do have the choice of making a U turn anywhere to avoid an ugly ascent, and I suppose you could make an effort to stick with flattish roads.

Or, if you’re not on a smart trainer, I guess you could just stick with easy pedaling, even though it’ll take a while to get up that hill.

* One negative is that Zwift tends to bring out your inner competitor. It’s very much geared to more-intense athletes who like to monitor their personal records, and want to see if they can beat their last record on a timed hill climb, or if they can pass that guy four seconds in front of them.

* Another possible negative: A lot of these Zwift athletes are pretty damn good. Example: I began climbing a big Zwift mountain in August, trying to hold 230 watts or so. Then I got better. Recently I was trying to hold 280 or 290 watts on the climb, and I broke my previous record and passed a lot of people on my way up.

Intrigued, I checked my personal record for the Zwift climb, to see how I compared with the others. I felt pretty good about myself until I found out I was about 25,000 out of 176,000. Ugh. Are the others really that fast? Or are some of them “digital doping” (i.e. lying about how much they weigh to go faster). I suspect it’s some of both.

* Another Zwift negative: The software forces you to ride in a certain world anytime you log in. Zwift controls which world everyone will ride in on a given day. I’m surprised that riders have no choice, as Zwift just created a “New York City” world that’s frankly awful.

Anyway, my feeling on Zwift as a rehab tool is it could be helpful, but more for people who are at a more advanced stage of their recovery. It is an interesting world to ride in. I know that I’ve gotten noticeably stronger on climbs. But I wouldn’t want to tempt the Knee Gods with some of those efforts unless I felt pretty good about how my joints felt.

If You Take Painkillers, Opioids May Be a Poor Choice

I spotted this article about a pain medication study a while back (underlining is mine):

A yearlong study offers rigorous new evidence against using prescription opioids for chronic pain. In patients with stubborn back aches or hip or knee arthritis, opioids worked no better than over-the-counter drugs or other nonopioids at reducing problems with walking or sleeping. And they provided slightly less pain relief.

The opioids that were tested included the generic version of Vicodin. The nonopioids they were up against included generic Tylenol and ibuprofen.

So, basically, Tylenol beat Vicodin. Sounds like a good reason to chuck the Vicodin in the trash. After all, as a doctor quoted in the article says, if opioids don’t work better, there’s no reason to use them considering “"their really nasty side effects -- death and addiction.”

In case you’re wondering, the study randomly put patients in either the opioid taker or non-opioid taker groups. Further details:

Patients reported changes in function or pain on questionnaires. Function scores improved in each group by about two points on an 11-point scale, where higher scores meant worse function. Both groups started out with average pain and function scores of about 5.5 points. Pain intensity dropped about two points in the nonopioid group and slightly less in the opioid patients.

Many of you already know my position on medication for chronic knee pain. Personally, I took as little as I could. I wasn’t worried about becoming a drug addict, but rather the fact that the drugs muted the signals from my knees that I was trying to listen to in order to figure out how to get better.