Sunday, July 15, 2018

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.

16 comments:

  1. This is so true Richard:

    "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.”

    In my case, my double knee meltdown was triggered by a sudden tear of my left medial meniscus which required surgery.

    But in hindsight, I now realise that surgery was the small stressor that nudged me over the edge. My knees were already starting to approach the point of meltdown. A friend recently reminded me "remember when you use to come to our place for drinks and pinch our ice packs for your knees". This was while I was still training hard and before the surgery & subsequent knee nightmare stopped me.

    The warning signs were a sort of full/stiff feeling in my knees while running. After the meltdown, this became a chronic burning/tingle/stiffness/ache/loss of function (which I now think is the No.1 symptom that your synovial lining is chronically inflamed and you need to stop what is making it so).

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  2. I've got a question for Richard, TriAgain or anyone else that can offer input. I've been fighting a nagging pain in my left knee since Feb 2nd and even took almost three months off from cycling to heal. When I started riding again it was better and I eased back in to riding a few times per week. The light dull ache is coming back and seems to directly correlate to how much I've ridden. I see a lot of recommendations to get a professional bike fit and curious to know if others have done this and if they've gotten good results. During my time away from cycling, I even went backpacking for a couple of days with a 40 pound pack and walked 10+ miles each day and this didn't bother my knee. I'm starting to wonder if something with my fit could be causing the issue. I'm not excited about the cost of a pro fit considering I have three bikes (road, MTB and fat) but I figure I could try getting a fit done for one of them and see what happens.

    TCB

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    1. You could try a bike fit on one of your bikes and see if that makes much of a difference. I had a bike fit done once. It seemed to help most with creating the most comfortable bike geometry for me; finding that optimal configuration doesn't only involve the knees. I'm not sure the bike fit is the problem, unless the bike fits very badly -- make sure your seat is the right height e.g. It may be more a problem with cycling itself. But it might be worth a try.

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  3. Hi Richard

    I am relatively new to this pain and have been experiencing the burning sensation above my knees since this Jan. However, the cracking noise inside the joint is what bothers me most as this is how most doctors have concluded that I have taken the non-returning path to Osteoarthritis of the knee. Since you are the only person I know who has been able to heal himself, I wanted to know do you still hear the cracking sound in knees when you bend them?

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  4. Yes, there is still some crackling in my knees. It's a lot less than before. I wouldn't get too obsessed with eliminating all of the crackling sounds. You can have good, strong cartilage in the knee and it may still crackle some.

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  5. Hi Richard,

    Maybe my question slipped from under your radar because I was responding to an old post of the good and the bad TriAgaib story.

    Wondering if you can expand on why knee taping is under the "bad" category. Thank you so much for this blog and your book!

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    1. Thanks for dropping by! Actually, I didn't respond to your comment because it was TriAgain, not me, who put knee taping in the "bad" category (the blog posts were dedicated to telling his story). I would probably put it in the "meh" category. I tried it myself. At first it seemed to work great. But then it didn't work at all. So I went from being a believer to a skeptic.

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    2. Thanks Richard! At first I got the impression that you and TriAgain were the same person but then I realized that wasn't the case.
      My journey with Chondromallacia started June last year where I got injured in a partner yoga class while doing a squat back to back with someone who pushed me forward at the 90% angle of the squat! Sadly my R knee took all the slack as my L was just coming out of a previous injury. I started having on and off pain on my R knee but mostly related to walking (I am an avid hiker) and my envelope of function started gradually getting smaller and smaller over the course of the next 6 months. My MRI revealed Type II Chondromallacia, and later a near full thicnkness lesion under the kneecap. Like you state on your book, I also didn't stop in time. I only stopped when my knees where crying for help and pain was constant. It's a sad story but I've been relentlessly working on limiting anything that may aggravate my knees for the past 7-8 months while still being active. Things started moving forward after I got a PRP injection, started feeling better and less pain at the end of May and into most of June. But I had a a big setback after seeing a "gait specialist" who stretched my quad too much...after that I started having pain again daily etc. Very upset to have done this!! (working on forgiving myself)
      But it looks like I'm on my way to feeling better again....as you suggest in your comment on setbacks one may need to dial back activity level to about 2 months ago...it's working! So now I am slowly building up again. Walking distances is still hard for me but I'll be working on graded exposure and graded motor skills to make my nervous system calm down.
      For everyone: I'd like to recommend the Lorimer Moseley books(an australian Neuroscientist and pain specialist) his books *Explain Pain, *The Explain Pain Handbook *The Graded Motor Imagery Handbook are excellent resources for people with persistent pain and how to work with a sensitized nervous system.
      I am really dedicated to heal and will give myself the rest of this year to do so.
      Another recommendation: Collagen Peptides, a powder from cow bone I imagine, that tastes weird but I hear it does wonder in cartilage repair. Ok, that's all for now. Thanks again for this wonderful resource and I'll be in touch,
      Much healing and education to everyone!
      Maria

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  6. Richard and All,

    First, I want to say a huge thank you again for creating and continuing to engage in this resource. It was my lifeline during the worst of my knee pain. The confusion and loneliness that arises once you realize that your doctors and physios don't know what they are talking about is one of the hardest parts of this journey and this platform was a great antidote to that.

    Second, I wanted to come back here to share the good news that I am now pain free and feeling great. Less than two months ago I was struggling with the worst knee pain. Last night, I played intense full court basketball for two hours and felt great.

    My path to recovery was surprising and not something I have seen on this and other fora. I wrote up my story on my blog in the hope that my experience may help others in their own journey to healing, if only in some small way.

    My success story is here: https://inscape489664645.wordpress.com/2018/07/24/my-knee-pain-success-story-a-surprising-road-from-despair-to-joy/

    I'd be happy to share any thoughts or nuances on what I learned from the experience on this forum, though I am still processing it myself.

    Thanks again,

    Oliver

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    1. Hi Oliver

      That's a great accomplishment. Welcome to the happier, peaceful days. Seeing someone beat their pain is an inspiration in itself.
      I read your story and while I am also trying to get rid of this pain I have a question for you and anyone who is on the path to recovery. Everyone here states that they took full rest and started with baby steps. As you said, you tried walking 1 minute first and increased the time gradually. Did you try the Doug Kelsey's "moving the knee while sitting" exercise. I mean we all know that the knees love movement except that this has to happen in a condition which will put minimum pressure on the knees, basically a kind of sub-gravity condition. As per Doug Kelsy and others, movement helps increase the quality of cartilage. Yet no one here mentions this as the starting point or an exercise they indulge in aggressively. I have just started my rehab programme and this is one exercise that I do daily twice without fail. It helps me walk more too. My avg steps without pain and only burning is 8000-10000 steps. But now while reading everyone's success stories and none mentioning this as an exercise and instead talking baby steps is now making me skeptical.

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    2. Great news, Oliver! Congrats. Someone else emerges on the other side. More proof that knee pain sufferers aren't condemned to a lifetime of misery. :)

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    3. Your blog is a great read Oliver. I particularly related to this:

      I finally accepted the truth I had been so desperately avoiding despite the many signs – she and the other experts understood my pain no better than I did. I could no longer trust the map I had been given and had to find my own way in uncharted waters".

      I emailed the Australian OS Assoc a year ago offering to speak at their annual conference about my 5yr journey & how using Dr Dyes approach worked for me. The silence was deafening. I think I'll try again, because as you found, these 'experts' are a complete (and expensive) joke when it comes to PFP (though to be fair, our small-town OS was very honest, agreed they were in the dark about PFP, but said surgery was def not the way to go)

      In hindsight, I think the psychological side of things was probably a signficant part of my knee pain (dissatisfaction with work, triathlon became my escape, and ultimately another source of stress/pressure, the perfectionist & pleasing others personality). And I entirely get the 'fear'thing. At the height of my triathlon obsession, I do recall thinking how lucky I'd been with my knees when all my peers seemed to have knee problems. Maybe I mentally set up a self-fulfilling prophecy!

      Anyhow, the main take away for those suffering chronic, debilitating, diffuse, varying, no rhyme or reason & esp. burning knee pain is to treat the conventional 'experts' with the immense skepticism they deserve.

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    4. Thanks TriAgain! upon your recommendation I googled "Dr. Dye" and found some of his conferences here in the Bay Area. I just have to say, the guy is refreshing in his approach, especially when he mentions how careful and minimalist he is when deciding on surgery and performing it. I admire the guy in a world of "scalpel ready" surgeons out there. It tells me he really cares about people and our well-being and is more of a researcher than a "fixer" like most doctors are. I am a big skeptic when it comes to doctors having myself come from a family of mom and dad doctors, I have a lot of reservations regarding the medical profession...and some with a "God-like" approach.

      Also, I read your story and when I get down I think to myself if other people took 5 years to heal then I really can and will do it..so thanks!
      Maria

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  7. Thanks Richard for maintaining this blog site, and all the rest of the contributors for sharing their stories. I come from a medical background, and had great faith in the system...until chronic synovitis. I still have faith, but I would call it more realistic rather than blind commitment.

    I saw Dr. Dye in person for an examination, and I can attest to his passion for knees. I wish I had known what I know now, when the first tingling symptoms started. Hopefully everyone's stories here, saves others from putting themselves on a track where healing often takes years.

    Well, I'm year 1 into this journey. One year ago, I had nonstop burning at rest, in bed, on a chair, etc. Now for the most part, I feel totally normal at rest (unless I've done something to upset my knees). Currently I am in a setback--and I have no idea why. I was making slow and steady progress, and adding stairs (using handrails) to the daily routine. I started with 10, then made my way up to 50 per day (25 up, 25 down--always using the handrails to support what I guess to be 1/3 of my weight). The only thing I can think of to trigger this current setback, was an ill-fated attempt to "sit" on my knees, for all of 5 seconds. I did support my weight with my arms, but I'm thinking having them bent back all the way, and putting my body pressure on them, got them really angry.

    So I must have been close to the "breaking" point with the stair climbing and THEN the knee sitting. Even though I felt totally fine from the stair climbing--if there was any hint of burning the next day, I'd call it off for the next 2 days, then resume at a lower step count.

    Well, hopefully others can learn from my experience. It really can be such a LITTLE trigger that sends you down the Chute to months back. =/

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    1. Elly

      what did Dr. Dye told you? Has he helped? I have an appointment scheduled with him too. I did an MRI and bone scan, that shows that my kneecap has increased uptake, a finding consistent with his theory of loss of homeostasis.

      Unfortunately, I am now in the constant burning phase that you said you had a year ago. How did you get out of that? How do you go about your normal life with such a limited envelope of function? I simply cannot be bed-bound for weeks, I have a family relying on me and on my job...

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    2. Hi Elly,

      Going through the forum questions I realized you might be in the Bay Area. I am looking for fellow people going through knee recovery. Would you be open to correspond with me? It'd be nice to have someone close by to talk to. My email address is mcrescimbeni@hotmail.com. Please email me! I went to Dr. Dye also and I'm following envelope of function protocols, i'm slowly getting better (i've been doing reduced steps since september). Hope your recovery is going well!
      Maria

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