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.

Is a Knee Replacement Worth It?

This was the subject of a recent New York Times column. I like the Times columns on health topics; they’re generally smart and well-balanced and backed up by good studies.

The author of this one was no less than Jane Brody – former (and presumably reformed) glucosamine enthusiast – who had both knees replaced. She has no regrets, though is quick to note that there are some limitations with artificial knees.

The upshot of the article is that more people are undergoing this major surgery, and at a younger age – and it’s not always medically justified:

One recent study conducted by Daniel L. Riddle, a physical therapist at Virginia Commonwealth University, and two medical colleagues, for example, examined information from 205 patients who underwent total knee replacements. Fewer than half — 44 percent — fulfilled the criteria for “appropriate,” and 34.3 percent were considered “inappropriate,” with the rest classified as “inconclusive.”

A knee replacement is definitely major surgery. If you don’t believe me, Google it and check out some images. And that new knee doesn’t come with a lifetime warranty. On average, artificial knees apparently last only from 10 to 15 years.

But for some people, it will make sense. I think though, like much surgery, it should be looked upon as a last resort. That's my opinion. I’d be interested in hearing below from people who have had the surgery, and finding out whether the experience was good or bad.   

(By the way, thanks for all the good thoughts in the comments section regarding my hand. I still have a splint on my ring finger, which was turning into a mallet finger – ugh – so I’m not a full-fingered typist yet. Hopefully I’ll get there in a few weeks. Patience! Not as much needed as when healing from knee pain, but still, a displaced fracture is no picnic.)

How Would You Treat a Torn Meniscus?

I’m still in a hand cast (with my right thumb, index finger and thumb wriggling free, but my pinky encased and my ring finger barely visible, like a pig in a blanket). So I’m going to keep this short.

I figured I’d try something different. Often you ask me questions, which I spin into blog entries. This time I’m going to ask all of you a question.

My brother, who loves to hike and work out at the gym, has a torn meniscus. Apparently he injured it when shoveling snow. He turned to pitch a load of snow, and the torque on his knee and weight of the loaded shovel must have combined in a bad way to tear his meniscus.

In the immediate aftermath of the injury, he had difficulty walking for a couple of weeks. Since this happened, the knee has never been the same.

He has scheduled surgery for November. Now you probably know where I stand on that. In the world of knee studies, you can throw a stone and hit three or four clinical trials that say surgery for a torn meniscus is no better than physical therapy.

However, that’s fine in the abstract, but when you’ve got the torn meniscus, and PT hasn’t done you a lot of good, surgery starts to look very tempting.

So here’s my question for all of you out there: Anyone have a torn meniscus that they recovered from? What kind of rehabilitation program worked for you?

Okay, all from me for now. This cast (fingers crossed) should be history next week, as long as the bone healed properly. Because of the nature of the break, that’s not a given. Still, my doctor seemed fairly confident.

(Oh, I’m still riding my bike, only indoors. If any of you are on Zwift, that’s me in the blue-and-white jersey, trying to hold 240 watts going up that giant mountain in Watopia.)

Cheers!

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.