Open Comment Forum: What’s the Greatest Achievement of Your Recovery?

I’m going to throw the blog open for comments for a few weeks (popping in to clean up spam comments on weekends, as usual).

I’m having trouble typing right now because I crashed my bike on Aug. 11. I broke two bones in my hand. The money break, as the ortho put it, was the displaced fracture of the fifth metacarpal. It’s in my right hand, which is my dominant one, so that’s unfortunate.

But it will heal, and hopefully be close to what it was.

Okay, enough about me. Below feel free to post comments, solicit advice, provide updates ... all those great things that the open comment forum is good for. In short, talk to and help each other. There’s a lot of accumulated wisdom in this blog’s readership.

If anyone wants a subject to discuss: What about something upbeat? Try this: What’s the greatest achievement you can point to during your recovery? And to what do you attibute it?

Okay, all from your left-handed typist for now. Cheers!

Do Bad Bugs in an Obese Gut Cause Knee Pain?

So just when I thought I had formulated the authoritative take on why obesity causes knee pain (namely, that the excess weight places too much force on vulnerable knees), along comes this study:

The gut microbiome could be the culprit behind arthritis and joint pain that plagues people who are obese, according to a new study.

Hmm. Interesting.

The study appeared in a relatively new publication called JCI Insight. You can find it here. The subjects were mice (so, possible objection number one: mice aren’t humans).

One group of mice ate high-fat foods similar to a “cheeseburger and milkshake” diet for a few months. The other group consumed low-fat, healthy meals. After 12 weeks, the chubby mice were carrying nearly twice the body fat of their lean counterparts.

Researchers noted:

Pro-inflammatory bacteria dominated their colons, which almost completely lacked certain beneficial, probiotic bacteria, like the common yogurt additive bifidobacteria.

Here’s the money paragraph of the article:

Changes in the gut microbiomes of the mice coincided with signs of body-wide inflammation, including in their knees where the researchers induced osteoarthritis with a meniscal tear ... compared to lean mice, osteoarthritis progressed much more quickly in the obese mice, with nearly all of their cartilage disappearing within 12 weeks of the tear.

The researchers discovered they could prevent the destructive effects of obesity on gut bacteria, inflammation and osteoarthritis by adding oligofructose to the diet of the fat mice. Interestingly, the mice didn’t lose weight – they remained obese – but this additive preserved their knee cartilage, so it looked the same as that of the skinnier mice.

Before my heavier readers make a dash to the store, hunting for foods containing oligofructose, a word of caution:

The bacteria that protected mice from obesity-related osteoarthritis may differ from the bacteria that could help humans.

Apparently, studies using people will be forthcoming. The future studies are worth keeping an eye on. I still think the mechanical effect of obesity on knee cartilage is significant, but this at least introduces the possibility that another mechanism may be an equally big – or bigger – culprit.

Musings on Complex Systems

No, not primarily my own musings. I’m linking to this essay, which someone pointed out recently. The title is “A Systems Perspective on Chronic Pain.” The piece is nicely done, with cool visuals and some observations that will make you stop and think.

A few parts I liked:

Some pains are more simple and local while others are more global and complex.

This is very true. But there’s a deeper truth here too.

I think a lot of knee pain starts simple, then becomes complex over time. This leads to much frustration. Often knee pain sufferers wonder if they have an immune system disorder, such as rheumatoid arthritis, as chronic knee pain seems to “wander” around their body, afflicting other joints.

Unless you do have a verifiable immune system problem, doctors tend to scoff at such theories (mine did anyway). But after I developed issues with multiple joints, and I heard story after story of similar problems on this blog, I’m convinced this is really a thing.

Because complex systems often change in a non-linear fashion, we can expect progress to be non-linear as well. That means getting better is often a question of moving two steps forward and one step back. In the short term, this makes it difficult to discern positive change. But over a larger timeframe, a pattern of progress may become clear.

 Ha! This almost feels like it could be a direct quote from my book (or blog). Yes, healing is definitely nonlinear, with little steps forward, then little steps backward, then repeat. It can drive you crazy. That’s why it’s best to take the long view. Once into your recovery program, ask if you’re better this month than a month ago, or two months ago. Try not to get too hung up on the day-to-day details.

Changes are often nonlinear, which means that small perturbations to the system can produce large changes, or that large perturbations might produce very small changes. A significant non-linear change is called a phase shift.

This is also an interesting point. As an example of a phase shift, he cites water suddenly turning from a liquid to a solid at 32 degrees Fahrenheit.

I discussed a similar kind of thing in two posts: one on breakdown points, and the other mending points. These remain two of my favorite posts, though I’m not sure they got much attention.

To me, a sort of phase shift may occur between pain and no pain. On a continuum, there may be a point where these two states lie very close to each other. In other words, you can have pain but be very close to a non-painful state. Or the converse could be true.

So let’s say you’re not in knee pain, but you have subjected your joints to repeated stress and are close to being hurt. It may take only a small stressor to nudge you over the edge. That, to me, is the idea of a “breakdown point.”

The example I give in the post involves a ceramic cup. You drop it from x inches, and it makes a loud thud, but doesn’t break. Yet if you drop it from two inches higher, suddenly you’ve got pieces of a cup. You’ve broken it.

Hurting yourself may involve sudden, catastrophic breakdown points. Sometimes, it’s clear what precipitated an injury. But other times you may lurch into a painful state despite not being able to pinpoint an obvious cause.

Similarly – and this is a good thing to know when trying to heal – there may be analogous mending points. You work for months on getting better, with seemingly disappointing results, then suddenly experience a big gain almost overnight.

Above are some of my thoughts on this essay, but I invite you all to read it for yourself and leave comments below.

Review of the Schwinn 170 (MY17) Exercise Bike

I’m doing something different today. I’m reviewing an exercise bike I bought recently, with a section at the end especially for people with knee problems.

First, cycling can be a great activity for bad knees. However, a few things are important before you make cycling your knee rehab activity: (1) Your knee must have good range of motion, so that you can go through the full pedal stroke without discomfort during or after (2) Your knee must “like” cycling – different knees like and don’t like different activities (3) You need to be able to control the effort expended so you don’t overdo it.

Number three is why you should consider using an exercise bike as opposed to cycling around the neighborhood, especially if the neighborhood happens to be hilly, or has a lot of traffic lights that cause you to stop and go a lot. Generally, cycling steadily at a low resistance (or backwards for no resistance at all) is much easier to do on an exercise bike.

Now a short lead-in, explaining how this Schwinn wound up in my basement’s exercise room:

The death of my old stationary bike, a Bodyfit 90x (that came with the house that we bought in April 2014) made buying a replacement necessary. The drive belt frayed apart. (As I had a little free time, I disassembled the bike, scavenging interesting-looking bolts and other pieces. There was a beautiful cast-iron flywheel inside, but even thinking creatively, I could see no future use for it, so reluctantly placed it curbside with the trash.)

On to the review:

The Schwinn 170 (MY17) plugs into the wall and has a detailed console. A user can choose from a selection of rides, from mountains to light cruising through the park (or you can just start spinning away on a flat course, if you wish). The Schwinn is Bluetooth enabled (for geeky super-connectivity). It also supposedly syncs with some virtual reality devices (which I think is cooler).

The seat adjusts for varying heights (warning: it’s a bit limited on the top end – a proper cyclist sets up a seat for a near-full leg extension, and following that rule of the thumb on the Schwinn will only get you to a 6’ 2” or 6’ 3” person, it appears. I’m 6’ 0”, and my seatpost setting is only one hole above the safety warning.)

Set up: It comes in a heavyish box. I set up mine in one hour forty minutes and easily could have done it faster, had I needed to. Unpacking the pieces and laying them out on the floor (always your best strategy) took a good fifteen to twenty minutes of that assembly time. The nice thing is there aren’t too many parts to deal with. Some negatives on the assembly: the included Phillips-head screwdriver on the multi-purpose tool isn’t a good fit for the screws, so be careful not to strip them (I used a smaller screwdriver from my toolbox). Also, like most exercise bikes in this price range, it has its share of cheapish molded plastic. The main shroud, for example, isn’t designed particularly well and doesn’t fit as well as it should.

Pros:
* Very quiet and smooth.
* Value: It was $324 on Amazon with free shipping (when I bought it). I would call that a good value for an exercise bike that has all these features. 
* The resistance spans an impressive range: 1 is very easy (my wife, a non-cyclist who gets little exercise and who kind of has a bum knee, thought 4 was fairly easy). At the high end, level 25 will grind even a Tour de France rider into dust in short order.

Cons:
* The pedaling speed measurements are terrible. On a regular bike, I can sprint at 30 miles per hour or higher; if I crank up the resistance and put forth the same effort, this bike registers about 24 mph (my old Bodyfit was much more accurate). On the low end, I can barely pedal and still get credit for 10, 11 mph. Because the speed is close to useless, I wouldn’t put much credence in the reported distance (as distance is a function of time multiplied by speed, and we already know the speed is off).
* The seat is spongy and looks ample for the largest of derrieres, but not that comfortable. I did gradually get used to it.
* The “media tray” is friendly to the iPad user or DVD watcher; it is not very good for physical books.
* I think the console could be better laid out. For example, the right side is devoted to showing what percentage of your maximum heartrate you’re at, in 10% increments. To save space, just put that number in a box. Also, a better system would allow the user to input their own maximum heartrate, as there can be high variability here (I know a 56-year-old who has a max heartrate of 185, when “normal” for a man that age is about 165!)

For the knee pain sufferer: Yes, you can pedal backwards with no resistance, if you want to. If you can handle the lowest level of resistance, or 1, you should be able to get in a nice, easy ride. Also, the bike’s smooth ride is favorable for knee rehabbing.

So that’s my take on the Schwinn 170 (M17) – and if you’re wondering why the “MY17”, it apparently signifies the later edition of the bike.

Hopefully I’ll be able to do a few more cycling-related reviews in the months to come. I’d love to review Zwift, which is kind of like an immersive cycling world, but the monthly fee of $15 has put me off. If I’m going to spend money for indoor cycling equipment, I really don’t want to be shelling out for montly subscriptions on top of that, unless they’re really cheap.

When You Lose the Thread Between Cause and Effect

Knee pain is often a strange, baffling thing.

I tried to figure it out. I eventually healed my own hurting knees, and learned enough that I was motivated to write a book about my experience.

But at the same time I knew there was a whole lot I didn’t understand (and neither did the smart people out there who study the origins and treatment of knee pain).

One thing I always tried to do: draw lines between cause and effect, especially when I had a setback on the long road to getting better. For me, setbacks were like small teaching moments: my body teaching me something, very important, about how I should go about healing.

Sometimes it’s easy to draw that line. If you carry a heavy backpack up six flights of stairs, then have knee pain the next day, or a couple of days later, what caused it isn’t much of a mystery.

But what’s frustrating are those setbacks when you can’t point to a likely culprit. What then do you do? What if your knees hurt worse then ever, out of the blue, and you can’t figure out why?

These are the good, hard questions. I’ve thought about them more since I started the blog, as a stream of readers have confronted me with issues that weren’t always ones I had to deal with, but that usually made me think.

My gut feeling – and this may work for you, or may not – is to hit the reset button and scale back your activity significantly. Maybe try returning to your activity level from a couple of months before?

But I would be reluctant to go “full couch potato.” I’m not saying it doesn’t work for some people, because apparently it does. But I’d rather find a way to get in some motion, even if I’m seated and resting my feet on a wheeled dolly that I slide back and forth, back and forth.

It can be maddening to be racking up small wins over three or four months then have a weird, sudden, inexplicable setback. But they happen. I think there is a reason for all setbacks, because I’m that kind of logical “things happen for a reason” kind of guy.

But let’s face it: the human body is a very complex stew of chemicals and cellular processes, all interacting in complex ways. It shouldn’t surprise us that the results of some of these interactions are close to unknowable. And some of them probably lead to unpleasant knee pain symptoms.

So, even if you can’t figure out what caused your setback, carry on. Don’t get too discouraged. Try to figure out what you can, but I think there will always be mysteries.

On Experts, and a Growing ‘Antipathy to Expertise’

A recent article in Harvard Magazine, “The Miracle of Knowledge,” gave me occasion to reflect on my ordeal with knee pain. A political scientist by the name of Tom Nichols has noticed in American public discourse “a new and accelerating – and dangerous – hostility toward established knowledge.” The article refers to it as an “antipathy to expertise.”

The article caught my eye, because in a sense I suppose my knee pain recovery can be construed as an “antipathy to expertise.” Ultimately I rejected what my doctors and physical therapists – the true experts – told me about my prognosis for healing, and about what my treatment should consist of. I became a Google’ing omnivore, devouring all I could find about knee pain similar to mine, and sifting for clues about how I could beat this condition.

In the end, I think I proved the experts – at least those in my immediate circle – wrong. I healed, when I was told I couldn’t, and did so by rejecting the core muscle-strengthening advice of my physical therapist. If there were a parade of “don’t trust the experts” activists you might expect me to be right up front.

Except I wouldn’t be. Not at all.

In fact, I pretty much agree with Nichols. I'm also worried about the erosion of belief in experts, which is all too often replaced by the conviction that an ignorant opinion, or a private consensus reached after consulting the Google hive mind, works just as well. “Who needs doctors, climate scientists, whatever?” This attitude frightens me because today, more than ever, a cavalier disregard of facts and truth is becoming acceptable.

So to be clear (and some of you have heard this before):

* If you have knee pain, I would always start by seeing a doctor. In comments on this blog, I’m careful to say that. At the least, a doctor can order imaging and other tests that can shed light on what’s going on in your joint. But more than that, a doctor will typically have the intelligence, breadth of knowledge, and experience (gained from examining scores of patients like you) to make a better diagnosis than Mr. Google.

* My rejection of the experts wasn’t knee-jerk and immediate. It arose from three main things:

(1) Doctors never gave me a plan for getting better. A plan – “do this, then this, then this” – I would have respected. A fatalistic shrug, or the tepid suggestion to avoid activities that bother my knees – that feels like a dereliction of duty.

(2) In other cases, the plan I was given failed. At some point, when confronted with repeated failure, you have to wonder, “Is it just me or could the advice I’m getting be faulty?”

(3) I tried to approach the puzzle of my knee pain in a scientific-minded way. If my doctors knew X and Y, I looked for Z, the thing that perhaps clinical trials had discovered, but that wasn’t commonly accepted when my doctors were being taught in medical school, five, 10, 20 years ago. An example: I located a clinical study where cartilage defects improved, at a significantly high rate. This is part of what informed my optimism about my knees getting better. And I also looked for smarter, out-of-the-mainstream experts. I was lucky to find a few.

So with experts, I would not reject their opinions out of hand. Experts are experts for a good reason. But there are times when they are wrong, and that possibility, no matter how small in a given instance, can’t be overlooked. They are not some monolithic, omniscient body. They are people. And people are fallible.

Open Comment Forum: Anyone Want to Discuss Setbacks?

So I got this comment recently, and thought the writer made a good point:

I have not seen much detail on setbacks in the book and here. You and others mention them, but I am always hungry for more detail to help manage my expectations (do they last days or weeks for others? What works when they happen? etc.) I wonder if another Open Comment Forum on this topic would be useful at some point.

Yes, setbacks are incredibly frustrating for someone working to rehab bad knees: you're slowly getting better, getting better, getting better ... then all of a sudden, you slide backwards. Healing then becomes something like a cruel mirage. Will you ever be pain-free?

So, below, I invite all of you out there to discuss setbacks. It would be especially useful to hear from those people who successfully battled through them: How frequently did you find yourself dealing with setbacks, how long did they last, what did you find was the best approach to overcoming them (regarding state of mind, reduction in movement, etc.)? What caused your setback in the first place (if you know)?

Or, again, feel free to talk about whatever. Open comment forum! I'm out!