Try To Be Optimistic Because How You Feel Affects What You Feel

Here’s a knee pain finding with a message well-worth heeding.

A South Korean study of 660 men and women, all older than 65, found that being depressed can make symptoms of knee osteoarthritis feel worse.

Researchers used X-rays to measure how severe each subject’s osteoarthritis was. Naturally, those with the most damage reported the most pain. However, some of the subjects with mild to moderate arthritis also reported severe pain.

Now, setting aside limitations of X-ray measurements (and there are many, for conditions that involve soft tissues), what can we learn here?

An Arthritis Today article about this study quotes Jon T. Giles, an assistant professor of medicine at Columbia University:

“Painful sensations are relayed through the brain in a very complex way, and can be modulated up or down,” he says. With stress, poor sleep, anxiety and depression, which are known to influence pain levels, “stimuli feel more painful than they would in someone without the adverse psychosocial factors.”

Now here are a few of my thoughts.

And if you have knee pain, you’ll be relieved to know that none equates to “Don’t worry, be happy.”

Because chronic knee pain stinks.

Of course there’s a good chance you’re depressed. If you’re anything like I was, you’re depressed because you have discomfort and pain most of the time. You’re depressed because merely climbing a set of stairs or carrying your toddler across the room causes a flare-up in your joints. You’re depressed because you know that almost everything you want to do in your life will involve your knees, and you’re doubtful that they’ll ever be normal again.

In short, you have a lot of very good reasons for feeling depressed.

Still.

Negativity levies a real tax on your body. That’s an inescapable truth. So even though you may be perfectly justified in your anger/bitterness/sadness, you have to realize you’re paying a price for it.

What to do? Here are a couple of ideas.

First, consider a de-stressing activity, such as meditation. I did it for a while, during my knee pain recovery (this was a period, by the way, when it wasn’t just my knees giving me problems). I found it useful.

Second, get into a long-term program that has one objective: healing your knees. This will restore something that is essential to getting better: hope.

This brings me to a closing rant.

In the Arthritis Today article, reactions to the study above included this suggestion: that care providers such as doctors screen patients for conditions such as depression and refer them for treatment (drugs, etc.) when needed.

I can imagine, upon hearing this, a gathering of doctors murmuring in approving tones, “Yes, yes, that sounds like an excellent idea.”

Arrrgh.

Here’s what irks me about that seemingly sensible suggestion. One major reason that knee pain patients suffer depression is because no one shows them a path to escaping knee pain. In this regard, doctors are the worst, from my experience.

In many cases, I suspect (again drawing from my experience), patients bounce around among doctors who just kind of shrug and say “You have knee pain, but I wouldn’t advise surgery just yet.” Further, patients are diagnosed with unhelpful, baffling terms such as “patellofemoral pain syndrome” that don’t tell them, in clear, specific terms, what’s wrong with their knees.

And then they’re found to be depressed. Well, no kidding.

Before doctors go about blithely prescribing pills for depression related to knee pain, they might want to ask themselves if they’ve done everything possible for their patients in terms of finding a good, long-term plan for eventually escaping that pain.

Bad Knees, Weak Hips, and the Other Problem With Structuralism

If you’re a runner, perhaps you’ve heard this theory before:

Runners with weak hip stabilizers appear to have tendencies to rotate the thigh inward and to excessively adduct the hip (i.e. run knock-kneed) to create stability to compensate for the weakness of the hip stabilizers. These maladaptive movement patterns put strain on the knee, and over time an injury emerges.

I took that from this article in “Competitor: Your Online Source for Running.” The author of the piece further simplifies the hip-knee relationship to:

Muscle weakness in hip --> bad form --> knee injury

Assuming you believe all that, you should also see a common sense solution:

Strengthen the weak hip muscles.

Easy enough, huh? Apparently not.

20 women (who weren’t injured yet who showed signs of abnormal adduction while running) participated in a study where half went through a six-week program of hip strengthening and instruction in single-leg squats. The other half (the control group) did their normal training.

And the results?

Nothing. Nada. Zilch.

The knock-kneed runners who strengthened their hips continued to run the same way as before.

So was lack of hip strength really causing them to run knock-kneed? Or was it something else?

And, more to the point if you’re a structuralist type (someone intent on tracing problems back to crookedness and muscle imbalances): How fixable anyway is what you think is wrong? (I’ll set aside the question of whether running knock-kneed predisposes you to injury -- let’s assume for now that it does).

This seems to be “the other problem” with structuralism. The number one problem, I think, is that the search for structural deficits is overused as a diagnostic tool. The “other problem” (the depressing one, really): It’s very hard/impossible to correct many structural “faults.”

A great example is leg length discrepancy. Having legs of different lengths, in the structuralist world view, sets you up for all sorts of problems. But what’s the remedy? Unfortunately, you can’t mail order an evenly matched set of limbs.

Have no fear though. In a long, fascinating essay on structuralism (subtitled “The Story of the Obsession With Crookedness in the Physical Therapies”), Paul Ingraham notes a 1984 study showing that leg length discrepancy doesn’t make any difference for back pain (within reason of course -- if a doctor saws six inches off your right leg after a car crash, yeah, that’s going to affect your walking and a whole bunch of other things).

And so it is with other bits of structuralist orthodoxy, Ingraham goes on to explain. Another study looked at imbalances of major muscles in elite players in the Australian Football League. Any structuralist worth his salt can tell you what that should lead to: higher rates of injuries. But researchers found that “asymmetry in muscle size was not related to number of injuries.”

Ingraham’s essay is a terrific read for its bountiful evidence and good insights. For instance, he says structuralists are masterful dot connectors. He gives this as an example of how they think:

A podiatrist might tell you that your fallen arches (dot!) cause greater strain in your knees (dot), which in turn force you to use your hips differently (dot!), which leads to hip weakness (dot), then muscle imbalance in the core (dot!), which finally results in back pain (dot!).

What’s the first thing you notice there? I’ll tell you what I see: the potential for incredible, bewildering complexity. After all, almost everything in our lower extremities can be connected, somehow, to almost everything else. Treating chronic knee pain under such a belief system then becomes like solving some higher order math equation. This suggests your treatment will probably be long and frustrating, as your structuralist, dot-connecting physical therapist explores various hypotheses about what might be “truly” causing your knee pain.

My approach was much simpler. I operated on the assumption that my joints were just injured, or weak, and needed to be slowly strengthened and coaxed back to health.

This approach worked very well for me. I suspect it would work very well for many other people suffering from chronic knee pain too.

What Are You Waiting For? Get Moving!

As I’ve noted in the past, I get regular e-mail alerts from Google about the latest Internet content that relates to knee and cartilage problems. Sometimes a theme will emerge, repeated across a number of alerts. One theme I’ve written about several times before: Lose weight! Another I’m writing about today: Get moving!

If you have chronic knee pain, don’t take it lying (or sitting) down. You need to move that bad joint to have any hope of saving it. All the evidence firmly points in that direction.

Let’s start with the University of Minnesota School of Public Health. Researchers there reviewed 193 studies conducted between 1970 and 2012 that looked at treatments for osteoarthritis-related knee pain that didn’t involve drugs or surgery.

This meta-analysis showed:

Exercise fared the best at improving pain and mobility, as long as subjects followed through with a program, while the researchers found that few physical therapy interventions were as effective.

The favored activities: low-impact aerobic exercise and water exercise (yes!) as well as strength training (eh -- be careful!).

A Wall Street Journal reporter noted the shift in thinking that has occurred, writing “Doctors increasingly are recommending physical activity to help osteoarthritis patients, overturning the more traditional medical advice for people to take it easy to protect their joints.” Exercise reduces pain and improves mobility of the hurt joint.

“The most dangerous exercise you can do when you have arthritis is none,” Kate Lorig, director of the Patient Education Research Center at Stanford University, says in the Journal article.

In fact, the reason you have problems in the first place may be because you’re not moving enough. According to Indian orthopedic surgeon Madan Hardikar, there are two key causes of knee pain: (1) for the old, it’s natural wear and tear of the joints (2) for the young, it’s a sedentary lifestyle (he cites the country’s IT workers, who put in 12- to 15-hour workdays at a computer and who often don’t get any exercise outside work either).

To conclude, here’s a cool arthritis story (even though it doesn’t involve knees, but hands):

Margaret Crowell was an elite tennis player who had osteoarthritis in her thumbs and hands. An orthopedic specialist said nothing could be done to prevent the disease from worsening.

Luckily, Crowell refused to believe him and give up. She discovered the benefits of gentle exercise and movement and managed to reverse her symptoms. Now she gives classes for older adults that emphasize slow stretching and agility movements.

So there you go.

As with the need to lose weight, there’s no debate here.

Move, move, move!

With Knee Pain, What We Believe Influences How We Interpret What We See

This is a famous drawing:

What do you see?

Do you see the dainty, pert-nosed young beauty, her head turned away? Or the large-featured old hag?

If you see the young woman, and your friend sees the hag instead, your first reaction may be to scoff and say, “No way! Look again!”

Now, suppose you are studying cartilage defects in human knees and learn the following set of facts:

* Between 34 and 62 percent of people having knee surgery are found to have cartilage defects.

* Some 50 percent of athletes (from recreational to professional) who have cartilage defects don’t have knee pain.

* The vast majority of people with moderate knee osteoarthritis don’t have functional limitations.

What would you conclude?

Colin Hoobler, a physical therapist, connects the dots thusly in this Q&A:

“... it’s entirely possible that your knee pain isn’t caused by your cartilage defects, but something else (muscle weakness, inflexibility and/or lack of coordination).”

(A quick aside: the “lack of coordination” explanation for knee pain I find a bit odd; I’ve never encountered it before and it seems to make sense mainly if this lack of coordination causes you to fall on your knees a lot. :))

Now, if you remember back to last week, you’ll realize that on the matrix for knee pain treatment and beliefs, Mr. Hoobler probably belongs in the upper right corner (among those recommending treatment that is “Not Joint Focused”). He will work on addressing your muscle weakness, tightness and general klutziness.

That’s because, when presented with the group of facts above, he sees one picture. But might there be another picture here, if we look again?

Certainly.

It might be described like this:

“It’s entirely possible that your knee pain is caused by your cartilage defects, but you don’t have to get rid of them to become pain-free, as they’re actually quite common and don’t always cause problems.”

This is great news! This belief (that I didn’t have to restore my cartilage to a pristine state) sustained me during a long recovery from knee pain.

In fact, this was my thought process as I embarked on the journey:

“An MRI shows I have “mild” chondromalacia, but my knees are really crunchy and always inflamed. Any MRI is imperfect*, so maybe it hasn’t detected what’s really wrong with the cartilage (after all, chondromalacia starts with damage deep within the tissue). I’m betting the problem is with my cartilage. I can either despair -- oh no, it’s damaged and will never be perfect again -- or I can take solace in the fact that lots of people are walking around with defects and feel fine. I just have to strengthen the tissue slowly (and hopefully it will heal along the way, as it’s done in various studies). Yeah! I can do this!”

But why would some defects be painful while others aren’t? Recall that cartilage has no nerves. Hugely significant. So the tissue itself isn’t sending out pain signals, but rather nearby structures are. Pain may result when the cartilage becomes too thin or too soft or too ragged -- but it won’t be a problem with all lesions.

So when you look at your bad knees, what picture do you see?

* Serendipity! As I was writing this, along came this brief article saying that MRI exams underestimated the size of cartilage defects by 70 percent (compared with what surgeons actually found during an arthroscopy), according to one study. So that MRI that suggests you have a small problem, or no problem at all, may not be trustworthy.

What Does Your Doctor or Physical Therapist Really Believe About Bad Knees?

I thought I’d try something different today -- a very basic, bird’s-eye view of beliefs about chronic knee pain and the appropriate treatment.

Hopefully, this will help clarify why I succeeded in my long battle to overcome burning and aching in my knee joints, after a doctor -- the best of the four I saw -- told me in a grave voice that I would never get better. He was very much wrong.

First, take a look at this simple diagram, what I call the distilled matrix of beliefs both about the proper treatment for bad knees and about their capacity to heal:

That first line represents treatment. Let’s start there.

To treat bad knees, you will believe in an approach that's either “Joint Focused” or “Not Joint Focused.” (True, you may adopt a blend of the two, so you may want to think of these as endpoints on a spectrum).

“Not Joint Focused” largely equates to “Muscle Focused.” Every time you hear a doctor or physical therapist say that, to overcome your pain, “you must strengthen your quads, your hips, your glutes” -- you’re receiving “Muscle Focused” advice. (Also, the advice to stretch belongs in the “Not Joint Focused” box -- you can’t stretch a joint, but you can stretch muscles, for example).

So that’s the box on the upper right.

One of my huge revelations was that I needed to be in the upper left quadrant. That is, I needed a “Joint Focused” treatment regimen.

So for months, while trying to heal my bad knees, I didn’t worry about my weakening quadriceps muscles. I didn’t care if my quads turned to butter. I walked very slowly, often for short distances (too short to be of much benefit to muscles). I knew that if I fixed the joints first, I could strengthen the muscles later.

Now here’s the weird thing: Most of the current thinking about how best to fix aching, grumbling knees fits in the upper righthand box. But, if your knee joints hurt, common sense dictates that you focus on fixing them, not some nearby (or not so nearby) structure in your body. So this should make you wonder why that box on the upper right is so darn crowded.

(Of course part of the reason has to do with a preponderant structuralist view that seeks reasons for knee pain outside the joint, in imbalances and misalignments, instead of from injury or normal wear-and-tear inside the joint. I don’t want to get sidelined into a long discussion of structuralism today; there’s more on what I think of structuralism here and here.)

Now move down to the second line. This stands for beliefs about the capacity of bad joints to heal. (Be careful here -- this doesn’t mean “the capacity of bad joints to hurt less.” Someone in the upper right corner may argue that strengthening quads results in “less pain,” because stronger leg muscles better protect the weak joint. At the same time, that same person may argue that the joint itself hasn’t improved because it can’t.).

Now, for this line, two states of the world again exist. You’re either optimistic that knee joints can get better, or you’re pessimistic (or, once more, you may be somewhere in between).

Now here’s an interesting thing: You may think it makes more sense for the second line (beliefs about the joint’s capacity to heal) to be swapped with the first line (beliefs about the appropriate treatment regimen) -- because which logically comes first? But I used this order for a reason. The second line goes a long way to explaining where you find yourself on the first line.

It helps explain the mystery of why that “Not Joint Focused” treatment box in the upper right is so darn crowded. “Not Joint Focused” seems irrational until you drop down one box to the south, into “Joint Pessimistic” territory. Ahah! If you believe knee joints can’t improve (“Joint Pessimistic”), why would you advocate “Joint Focused” treatment? That’s just banging your head against the wall!

“Joint Pessimistic” shows up in many forms. Doctor to patient: “Your knees eventually just wear out and that’s life” or “You’re getting old and your knees won’t get any better.” Scientific literature (and popular medical thinking): “Cartilage has a very limited ability to heal” or “Damaged cartilage can’t heal.” The physical therapy profession (speaking to its members): "Patients should be told that treatment is aimed at structures surrounding the joint, rather than the joint itself" (which is presumably beyond hope).

On the bottom half of this matrix, I lodged myself squarely in the leftside quadrant, “Joint Optimistic.” I did so not from a sense of wild, hopeful desperation. Rather, I did so after a lot of reading, partly of new medical studies from the past decade. I found evidence that damaged cartilage apparently did heal, more frequently and more dramatically (even over bare bone!) than anyone had ever suspected.

Once you’re “Joint Optimistic,” it makes sense to target the joint in your recovery efforts. That’s what I did, and it worked extremely well in the end (though very slowly, and my healing occurred in a lumpy, nonlinear fashion -- but joints are just tough to rehab).

So, to sum up, in this matrix the right-side quadrants go together logically, as do those on the left side.

Now, within the “Joint Optimistic” believers and “Joint Focused” treatments, there can be differences. For example, Doug Kelsey of Sports Clinic was a huge inspiration to me. But he thinks nutritional supplements such as glucosamine are beneficial for joints; I’m a lot more skeptical that they do much good, if any.

Anyway, the point of this matrix is to give you a fuller understanding of the belief system of your doctor or physical therapist, and what it means. You should feel free to ask that person: Are you optimistic about bad joints healing, or pessimistic? (Hardly anyone will say, “Oh, I’m pessimistic,” so you’ll have to read their body language, or carefully parse their answer.) Also, from the exercises you’re given to do, figure out whether you’ve been assigned a “Joint Focused” treatment regimen or a “Not Joint Focused” one.

All this really, really does matter. For me, the first step to beating my chronic knee pain was realizing I needed to be on the left side of this matrix -- and I needed to stop listening to people who were on the other side.

What’s the One Piece of Advice That All Knee Pain Doctors and Experts Agree On? (Part II)

Last week I revealed (to a chorus of groans, I’m sure) that the one, simple thing that everyone agrees on for reducing knee pain is:

Lose weight.

This week, I’m going to provide more evidence (I say “more” because I’ve already visited this topic, here and here, bearing lots of evidence.) But the “lose weight” message is important enough to merit periodic revisits.

So here you have yet more proof, in round-up fashion:

* A report published in the August 2009 issue of the periodical Radiology linked obesity with the rapid progression of knee osteoarthritis and cartilage loss.

All 336 subjects, though overweight, started out with minimal or no loss of knee cartilage. During the 30 months they were monitored, one-fifth of the patients lost cartilage slowly and 5.8 percent lost it rapidly. For every 1 point increase in body mass index, the risk of rapid cartilage loss jumped by 11 percent.

* A 16-week diet that included protein shakes and soups helped people lose weight, lessening joint pain, according to findings published in the December 21, 2011, issue of the European Journal of Clinical Nutrition.

The 175 obese people in the study lost an average of 26 lbs. in the first eight weeks. Dropping all that weight had a significant impact; it “helped more than 60 percent of the participants reduce their knee pain and improved their ability to walk.”

* Another study looked at morbidly obese patients who underwent surgery (such as bariatric) to spur weight loss. A year later, they had lost almost 51 lbs. on average and reported significant improvement in knee function and less pain.

* A higher BMI means more knee pain among women -- whether or not they have osteoarthritis -- according to a study published July 7, 2011, in Arthritis Care & Research.

The 594 women who took part were examined over 14 years. “Significant predictors” of pain were found to be greater initial weight and weight gain. (Curiously, the relationship applied only to patients with pain in both knees, not just one.)

* A study of 20 morbidly obese youngsters, average age 14.2 years old, showed that each had a cartilage lesion in at least one knee region, as indicated by MRI.

The defects (surprising in adolescent children) were similar to those found in victims of “various accidents” or in older people.

It was unclear, at least at the time of this 2005 report, whether the cartilage damage was due simply to mechanical overload or whether metabolic factors might also be to blame.

* And, just in, published December 27 in Arthritis Care & Research:

196 subjects (from 25 to 60 years old) were split into three groups: those who lost 5 percent or more weight during two years, those who gained 5 percent or more and those whose weight remained stable (everyone in between).

Those who put on extra pounds reported stiffer, more painful, worse-functioning knees, whereas those shed weight boasted of the opposite.

So there you have it.

Evidence -- pretty much overwhelming at that -- that losing weight is one of the smartest things you can do to beat knee pain.

What’s the One Piece of Advice That All Knee Pain Doctors and Experts Agree On? (Part I)

Occasionally, as I’ve noted before, I get a taste of how confusing it must be for a new knee pain sufferer seeking relief. Chase a few helpful-looking links on the Internet and your head will be set awhirl.

Stretching should be part of a program to beat knee pain! Stretching is useless! Take glucosamine for proven relief! Glucosamine is a placebo! Ice your knees to subdue inflammation! Inflammation is good; it’s a necessary part of the healing process! Strengthen your quads! Don’t worry about strengthening your quads!

Then you have the many unorthodox methods for overcoming knee pain, from acupuncture to squeezing an inflatable ball between your knees while sitting. And, even when a piece of advice seems to be consistent across practically all web sites (you need to move!), there’s much disagreement on how to interpret this in practice (what kind of movement? how much?)

So, considering the welter of conflicting, confusing signals about how to treat your bad knees, when there’s a bit of simple advice that’s easy to interpret that everyone agrees upon, shouldn’t we sit up and take special notice?

I would certainly think so.

At this point, I hope I’ve piqued your curiosity. The idea behind the buildup of suspense is to engage you the reader in really thinking about, “What can this be? And why doesn’t everyone do it?”

Because, once I draw back the curtain, you’ll probably react with a deflated, “Oh, he means that.”

So here goes.

100 percent of everyone out there agrees, for relief from knee pain ...

Lose weight.

Okay. I’m imagining the hue and cry already. Some of you are probably protesting: But I’m not overweight! Doesn’t apply to me!

My guess, however, is that it does. As I’ve said before, I think more than 90 percent of knee pain sufferers (and maybe more than 99 percent) could benefit from losing at least a little weight. I was skinny when I battled knee pain. Still, I forced myself to shed about three pounds. And I think it helped.

Knees are extraordinary in many ways, but one of the most remarkable has to be how knee cartilage has evolved so many mechanisms for surviving and thriving based on mechanical feedback, i.e., based on forces and pressures exerted on it. And that’s going to be influenced by how much you weigh. That’s not a conjecture on my part. That’s simple physics.

Here’s a quote I recently came across from orthopedic surgeon Ronan Banim that starkly (and effectively) summarizes the problem:

In clinics we are seeing knees that are literally being crushed by excess weight.

How's that for graphic imagery?

Next week, it’s time for the evidence. I’ll provide a roundup that further illustrates why losing weight = a smart way to start addressing that knee pain that’s been bothering you for so long.