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!