Studies That Probably Didn’t Need to Be Done: Knee Pain Causes Activity Avoidance

Today, we’re on the lighter side.

This just in, from the annals of Captain Obvious:

Patients with early symptomatic osteoarthritis (OA) of the knee avoid performing normal daily physical activities because they are experiencing pain, findings of a large, longitudinal study suggest.

I found this amusing and will bite back on my natural inclination toward sarcasm. I do find rather intuitive the concept that if someone has been banged in the kneecaps with a lead pipe his appetite to weed the flowerbed or climb a set of stairs will rapidly diminish.

There were 828 subjects in the study aged 45 to 65 years (yes, it is somewhat of a shame that this huge sample size went to waste.)

You might say the study helps confirm the vicious cycle that when your knees hurt, you move them less and so your muscles weaken, which leads to your knees hurting more, so you move them even less and etc. You get the picture.

I will say, in this study’s defense, that one admirable thing about scientists is that they don’t take accepted wisdom for truth. Some studies reveal curious, unlikely things, but others simply look at something that we think should be true and confirm it.

In this case:

“The results support the validity of the avoidance model in persons with early symptomatic knee OA,” said study author Jasmijn Holla, from the Amsterdam Rehabilitation Research Center in Reade, the Netherlands.

True. But I’m just not convinced we needed a full-blown study to tell us that.

Comment Corner: ‘To Heal My Knees, How Often Should I Increase Light Activity?’

We get mail. (Well, sort of.)

Recently someone left this comment:

I have been scrolling through your entire blog for the day and reading all of your posts. I even bought your book! I'm a 20 year old female who led a VERY active life. I underwent a bilateral knee athroscopy to obtain a final diagnosis of my knee problems AND fix any issues that are able to be fixed.

The surgeon removed a medial plica, a piece of cartilage the size of a pinkie nail that was floating around the knee joint and another piece of cartilage that was flapping around inside the knee joint from my left knee. However, I was diagnosed with softening of the articular cartilage behind my RIGHT kneecap (chondromalacia patella).

My father (who is a GP) told me it will get better if I do light exercise (e.g. walking to the toilet) at regular intervals throughout the day (e.g. every 30 minutes). I had also undergone physio for several months but this exacerbated the problem. After reading your blog, it has given me new hope in healing the cartilage in my right knee.

The only thing that I'm unsure of, is how do you know when and how much to increase light activity. I understand there is no magic answer, everyone is different. But did you increase your activity slightly when the pain had remained relatively stable or did you slightly increase your activity when the pain had improved slightly? After you had increased your activity slightly, would there be a few days where you experienced a little more pain than usual and persisted for a few days before determining whether to decrease or maintain the new level of activity.

First, note that physical therapy made her knee worse. No surprise there. When misguided physical therapy (strengthen muscles! strengthen muscles!) meets very weak knees, it’s about what should be expected. I know that all too well from my own experience.

Now on to the questions. And they’re the hard questions, make no mistake about it. If they were easy, I daresay there would be many fewer cases of knee pain. I've already tried to answer such questions before (based on my experience), but they’re well worth revisiting.

First, she’s right of course. There is no magic answer. I wish it were as easy as saying, “Do x repetitions of exercise y for 2 weeks, then add 5 repetitions every week.” But you have to figure out exactly what works best for your knees.

However, here are three guidelines that worked for me:

(1) If possible, try to enlarge pain-free, or relatively pain-free, windows. So try to find a place of no pain/little pain, and go from there. This may require a radical readjustment: your knees may be too weak to do much more than walk around your apartment (or house) for short bursts at regular intervals. That then becomes your baseline.

Between the choice of (a) “increase activity when pain was stable” and (b) “increase activity when pain had improved slightly,” I guess -- if I had to choose -- I’d take (b) in most cases, as that’s the least-pain route.

(2) I had success operating on a weekly schedule. Each week I decided on my plan for the following week (based on how the current week had gone). And I tried to stick to the same regimen for at least one week.

Why weekly, not daily?

For me, it reinforced my belief that I had to go slow and get on cartilage time, where progress would be measured in weeks and months, not days. Also though, I found it easier to isolate cause and effect, when troubleshooting little issues with my knees, when I kept my program fairly constant.

(3) Err on the “go slow” side.

Say you’ve spent four weeks doing 2 one-mile walks each day. Your knees feel a little better, but not much, and could the “improvement” be just your imagination? Now you’re thinking: “Week 5. Time to step it up (so to speak)! I need to dial up the intensity. So I’ll start walking 1 1/2 miles twice a day!”

Time out. There’s no rush. If in doubt on increasing activity, I would give that stage of the program (assuming you are active, which is important), another week or two, or month even.

My hunch is that, while you’re going slow and thinking “I really ought to be doing more,” you’re actually building a nice “motion groove” for your knee that will help ensure success when you do step up to the next level.

(Oh, the commenter also asked if, after I increased the level of activity, were there a few days of increased pain? Honestly: not really. I tried to stay at a given level long enough, and increase intensity so gradually, that the transition was fairly uneventful.)

Grapes to Lessen Knee Pain? What About Bee Venom?

The odd things that, um, cross my desk:

New research presented last week at the Experimental Biology conference in San Diego, California, suggests that regular grape consumption may help alleviate pain associated with symptomatic osteoarthritis of the knee, and improve joint flexibility and overall mobility. Researchers attribute these potential benefits to the polyphenols found in grapes.

Hmm.

Well, at first glance, it sounds more or less like a real study.

For 16 weeks, 72 men and women with knee osteoarthritis either consumed whole grape freeze-dried powder, or a placebo powder. The study, conducted by researchers from Texas Woman’s University, found that subjects on the grape-rich diet “had a significant decrease in self-reported pain related to activity and an overall decrease in total knee symptoms.”

Further, at least for the men, there was also “evidence of increased cartilage metabolism.” They had higher levels of an important cartilage growth factor.

Also, the serum marker for inflammation was elevated for both groups, but less so for the grape-powder takers.

Now on to the bee venom:

A study being undertaken in Oklahoma City aims to find out whether bee venom will “take the sting out of knee pain,” as this article reports.

The venom is mixed with the anesthetic Lidocaine so the injection won’t hurt.

Apparently the use of bee venom to treat joint pain and arthritis goes all the way back to Hippocrates, the Greek physician.

So will bee venom work?

Are grapes really worth adding to your diet to treat aching knees?

I don’t know. Honestly, there are so many foods/supplements/substances that are supposed to relieve knee pain that it’s just about impossible to keep track of them.

Of course some may be genuinely beneficial. But I start at a position of skepticism from personal experience: no supplement or herb or fruit or vegetable ever helped me with my knee pain.

But even if they did, in the long run, you want more than intermittent relief of symptoms. You want to cure the problem. You want a stronger knee that doesn’t hurt as much in the first place. If your knee isn’t as painful, you won’t have to worry about taking powdered grapes or getting shot up with bee venom to get through the night. And the best way to get healthier knees, I’m convinced, is through a smart, motion-based program.

Why Saving My Knees Doesn’t Contain a Glossy Photo Section Showing Knee Exercises

One common complaint is that Saving My Knees doesn’t include knee exercises. There are a number of reasons why, and I thought they would be worth reviewing, so readers (or would-be readers) can appreciate that this wasn’t a gratuitous exclusion.

* I’m not a physical therapist or doctor, as I’ve said repeatedly. To me, once you start including pages and pages of knee exercises, that suggests the kind of authority of a professional who knows that exercises X and Y work. I don’t have that confidence, partly because I’m not a specialist in rehabbing bad knees.

* Saving My Knees was mostly my story -- with a lot of information and studies packed in, showing why what worked for me probably would work for a lot of people. And honestly, what worked best for me was nothing that came out of an exercise guide. I did a lot of slow walking -- and most people learn how to do that exercise by the age of 15 months.

* I like simple. I like an Occam’s razor type of approach. What’s the simplest way to achieve a desired result? I get a kick out of seeing physical therapists and personal trainers standing around swapping favorite stretches and exercises. God, there seem to be dozens and dozens of stretches alone. Seems complicated to me.

I’m well aware that the knee doesn’t bend and twist in a vacuum; it’s one piece of a complex biomechanical system. Still -- what if, with knee pain, the most important thing to focus on is your knees (not hips, gluteus, trunk, whatever)? What if your knees deserve 95 percent plus of your attention? What would happen if you just tried to focus on getting in lots of easy, beneficial motion and let your knees sort out the healing part?

That’s basically what I did.

* This may come as no surprise, but I’m not convinced that most knee exercises are that valuable anyway. I could be wrong but:

I remember Doug Kelsey making the statement that the health of cartilage can be improved, but the tissue adapts best under light loads and thousands of repetitions. Thinking about that really opened my eyes. Picture all the pages of knee exercises you’ve ever seen and ask yourself: How many of those could you do 3,000 times in a row? Or even 300 times in a row? I’m guessing roughly zero.

So where does that leave you?

Well, I’d say with a few high-repetition activities you probably don’t need instructions to know how to do.

Walking. Swimming. Cycling.

(All to be done gently, of course, at least initially.)

And if you don’t have the knee strength to do these, you can do modified versions: e.g., cycling backward or swimming with floatbands on your ankles (what I did). The key thing is getting in lots of easy repetitions without further injuring your knees.

Of Book Reviews: Brickbats, Bouquets and Everything in Between

I thought this week we’d have a little fun. Instead of listening to me drone on about cartilage defects, and glycosaminoglycans, and flaws in clinical studies that purport to show a link between X and Y, you can listen to me drone on about ... book reviews.

I’ve gotten 53 now at Amazon, which is kind of cool. A few authors say they never read their book reviews. Personally, I suspect that’s a rare few. I’ll confess that I read all of mine.

The first few were kind, even glowing: five-star raves about Saving My Knees and its message. Great, I thought. Then I looked at another knee book, this one by a doctor, that also had a few five-star reviews.

After the gushing endorsements were comments like this:

Nice try, doc. Five-star reviews by people with no prior history of reviewing anything on Amazon. What do you think we are, stupid?

Uh oh.

A few mouse clicks later, I discovered that my reviewers too, as luck would have it, hadn’t written about any other book or product on Amazon. You might say that only shows the brilliance of Saving My Knees -- that it stirs timid, often unopinionated people into lusty cheers of affirmation and joy. :)

But I realized most people would not arrive at that conclusion. Rather, they’d assume the same as the commenter for the other book: that I was somehow involved in fraudulently obtaining five-star reviews.

Clearly, I needed some non-five-star reviews (“Yeah, a great read, with really good insights into beating knee pain, but I didn’t like his usage of semi-colons and what’s up with the mold in his camera?”)

Soon, my wishes were granted -- almost.

A couple of reviewers, it so happened, didn’t think the book deserved five stars. They didn’t think it deserved even two. Their comments went like this:

No substance. Too expensive. Way too long. Waste of money.

Be careful what you wish for, huh?

Anyway, the good thing about amassing 53 reviews is that the criticism -- agree or disagree with it -- looks authentic.  

Sometimes I do want to disagree. Some comments leave me scratching my head or wanting to scream something like, “Page 37! Reread page 37!”

Then there are those ambiguous comments like “reads like fiction.”

In a five-star review, it comes across as high praise. In a two-star review, it carries an entirely different sense, suggesting I’m a breezy wannabe novelist, sacrificing useful information for the sake of indulging my creative whimsy to create narrative tension or capture the hue of a character’s eyes.

Finally, let me tell you about my favorite review. It’s not one of the most admiring. In fact, when the writer initially posted his thoughts, he gave the book one star or two -- I forget. In any event, I remember kind of shrugging. Can’t win ‘em all.

Then something really nice happened. He changed his review completely. It turned into a sort of mini-journal of his progress, following the ideas in the book.

And here’s what he wrote, over the course of several months: 

6/20/2013 - I am a 57 year old ex-athlete with very serious chronic knee injuries and recently my left knee has taken a turn for the worse, leaving me with crippling pain and difficulty walking. I am still experimenting with the recommendations made in this book for my knee problem. The best way to tell if the advice given here is worth anything is to see if it actually works so I will let you know later what my results are...

8/20/2013 - OK, it is now 2 months later and I used the advice in this book to devise my own knee rehabilitation program centered around a stationary bike. My arthritic knee is definitely improving as I can now walk a lot easier and no longer need to use a cane. I also don't lie in bed every night moaning in pain as I was doing before - it's nice to get a good night's sleep again. I am also completely off pain killers for more than a month. My knee still has a long way to go but I am really hopeful now. I'll update in a couple of more months...

9/11/2013 - The author is really onto something here as my knee continues to improve. Before reading this book I was preparing to do a lot of weight training to rehab my knee and I would have unwittingly destroyed the joint. Glad I found this book just in time to save my knee. The author gives sound advice with undeniable logic behind it. If I don't post here again it will be because my knee has recovered enough where I just don't think about this anymore.

That’s really, really cool. Yeah, there are still some one-star reviews. But there are always going to be one-star reviews on Amazon that say things like “tiresome, tedious,” “disjointed,” “rambling,” “rubbish,” “worst book I have ever read.”

By the way, those descriptions aren’t for Saving My Knees. They were used in one-star reviews of James Joyces’s Ulysses. ;)

Good News: Doug Kelsey Has a New Book

I recently got an e-mail from Doug Kelsey (a pleasant surprise). He wanted to tell me about his new electronic book, The 90 Day Knee Arthritis Remedy. The book is being offered for sale here.

First, I prefer this choice of title to his earlier Runner’s Knee Bible. No, it’s not that I’m a deeply devout Christian who believes the word “Bible” must be reserved solely for The Book. Rather, I see the words “Runner’s Knee” in the title and think that many would-be readers -- in fact, should-be readers -- will turn away, thinking, “I’m not a runner.” And that’s unfortunate because runner’s knee afflicts more people than runners.

“Arthritis” though is more of a catchall word that will attract many of exactly the sort of people who would benefit from Doug’s message about exercising the right way, in the right amounts, to build up your knee instead of further breaking it down (he also addresses strengthening the core muscles, something that I’ve never really gone into).

And for those who didn’t like my book (or liked it less) because of the lack of exercises, Doug includes plenty of those, with links to videos showing you how to do them.

I’ll be taking a deeper look at The 90 Day Knee Arthritis Remedy later, telling you what I like most about it. Doug floated me a review copy, and I’m finding it an inspiring, thorough and well-detailed read: the complete DIY knee repair kit for people with achy, grumbling joints.

One final thing.

The price.

At $28.95, it’s not the cheapest knee book out there certainly. But here’s how I look at that:

* I can find you cheaper how-to-fix-your-knees books that don’t work, or don’t work as well. So the question as I see it boils down to: Do you want to fix your knees or save a few bucks?

* Right now the specialist co-pay under my health plan is $40. So I could spend $40 to see an orthopedist (if I still had knee pain) who would say something like, “Your knees look fine” or “You’re not a candidate for surgery yet” or “There’s not much I can do” -- or some rather unhelpful combination of the above. So which would you prefer -- that or a detailed plan of action (note: of course you should always start by seeing a knee doctor, not by buying a book, but after your first or second doctor, chances are good they’ll start sounding pretty much the same).

* $28.95 is certainly cheap if your alternative is surgery. Now surgery, that’s expensive -- even if you have good health insurance. Start adding all your co-pays for an entire surgical procedure, plus the stuff that’s not covered, plus the bandages, rehab clothes/equipment (some not covered), the co-pay on your pain medication, then the harder-to-value opportunity cost of being laid up for x days ... that’ll make $28.95 seem like the price of a candy bar.

Microfractures Revisited

This post that I wrote comparing whether to get a microfracture or ACI (autologous chondrocyte implantation) got a lot of reads. Perhaps surprisingly, I came down on the side of the traditional microfracture procedure. I partly based that on this study, which said that functional outcomes between microfracture and ACI patients were found to be about the same

I also happened to mention that, in support of microfracture, it’s the less extensive surgery that the NBA pros -- who could afford any kind of procedure -- choose. 

So recently, along comes this article featuring the NBA’s Greg Oden, a superstar talent felled at a young age by a pair of bad knees, that claims that doctors are moving away from microfracture to fix cartilage defects in NBA players. Among the alternatives, besides ACI: OATS (osteochondral autograft transfer, for small tears), platelet-rich plasma therapy and the Orthokine procedures that Kobe Bryant popularized that are similar to platelet-rich plasma therapy.

It’s certainly true that one or even all of these treatments may be superior to the old-fashioned microfracture, but a few points:

* The knees of NBA players take an epic amount of abuse. It’s important to appreciate that from the outset. It’s not just the jumping and running, but also the diving for loose balls, colliding with opponents in the normal course of play, making quick shifts in direction, etc.

* With that in mind, when someone writes, “the history of microfracture, especially among NBA players, has been dotted with success stories ... and failures,” I wouldn’t take that as necessarily an indictment. I’d be surprised if any knee operation ever had a 100 percent success rate, or even close to it, for such a subject population: too-tall men who bang their knees really hard every two or three days.

* The article tells us the problem is that the microfracture process (in which holes are drilled in bone, which creates bleeding that results in a new layer of cartilage) leads to rubbery fibrocartilage, not the good sort of hyaline articular cartilage. True, but interestingly enough, that fibrocartilage after a while can begin to take on characteristics of normal cartilage. In a study published in Arthroscopy in April 2006, researchers who took biopsies to inspect the cartilage that was formed after a microfracture observed that "this healed tissue is a combination, or hybrid, of fibrocartilage and hyaline-like cartilage."

So is fibrocartilage more of an intermediary state on the way to some form of cartilage that, if not normal, is at least much more normal in function and characteristics? Or what does fibrous cartilage created by a microfracture look like after 20 years, in a well-cared-for knee?

I don’t know. But I suspect that the answer may surprise some people who are critical of the procedure.