KNEE OSTEOARTHRITIS Let’ s talk...
An Introduction Normalising Pathology It’s Not Your Fault Movement Think Sponge! Graded Exposure What if it hurts? Avoidance & Apprehension Flare Ups Sleep & Stress In Summary If Nothing Changes, C Nothing Changes O N T E N T S
AN INTRODUCTION I have worked with people in pain for well over a decade, and I can assure you that pain cares little about age, race, sex, shape or size. I am always saddened when people come into my clinic and tell me that someone (sadly, often a healthcare professional) has tried to justify their pain, or limit their recovery, by placing them in a pigeon hole; “You aren’t a spring chicken anymore” “It’s wear & tear” “You need to lose weight” These fallacies are often presented as if these things alone are the cause of the pain, and that their pain is to be expected and accepted. Unfortunately for us all, pain is an often complex, commonly multifactorial and always unique experience. And so I am not going to approach this as a “self-help guide”, or a one-size-fits-all approach, as that would be foolish and arrogant of me. I appreciate that whatever I “know” about pain may pale in comparison to your experience of pain, and so I want you to know that I am not trying to ‘fix’ your pain in this short booklet. It is simply my humble hope that by providing (introducing to you?) some of the current knowledge and reasoning in a succinct and readable way, you may be able to build some comfort and confidence, and leave with a belief that you may not be destined to be in in pain forever.
Up to 1 in 5 people in the UK will develop osteoarthritis of the knee (Arthritis Research UK, 2013). And this is especially common in the over 50s, with almost 50% of that demographic reporting knee pain annually. However, it is also important to remember that in many cases this joint change is completely pain-free, and that joints go through a natural aging process. Some studies show as little as 15% of those with an arthritic change have symptoms. So as your hair may go grey, your face may get wrinkles; your joints will change. But to repeat; change doesn’t mean pain. Most people have arthritic joints without ever knowing. However, signs and symptoms of an arthritic change can be unpleasant for some – deep knee pain, pain on twisting, giving way, locking, perhaps some grinding - and these changes often develop slowly and are insidious in their onset. And without explanation, they can be scary. So, where there is arthritic change related pain, it is easy to inadvertently develop a self-limiting approach where we become more and more inactive due to pain. But this inactivity can be a key driver in pain development and a decline in all round quality of life – and so begins a vicious circle.
It is very easy when we are in pain to assume that we are “broken”, and that all of those noxious, threatening pain messages are flooding in purely from injured tissues (bones, ligaments, tendons, muscles), which are degenerative, damaged, or ruptured, or torn, or bulging, or any other unhelpful description we generally use. And whilst tissue condition can and does absolutely cause pain sometimes, it is also useful to understand that no body is perfect, and that as we have touched upon, a huge percentage of the population go about their business with pretty horrible sounding conditions, but with no pain, and so completely unbeknownst to them. So many of us have been conditioned by social media, general media, friends and family members to think that these pathologies and conditions – conditions like osteoarthritis - are extremely harmful and life-limiting; but that often doesn’t need to be true. NORMALISING PATHOLOGY
IT’S NOT YOUR FAULT One of the most deeply held beliefs and fears regarding osteoarthritis is that it is a “wear and tear” condition — that joints slowly crumble under the onslaught of years of abuse. And I see this clinically, where joint pain is blamed on years of ”playing football”, or “working on my feet”, for example. This fundamentally mechanical view of arthritis suggests that the heavier we are, or the more we use our joints, the more likely we are to have trouble in them at some point. But that’s just not the case: osteoarthritis prevalence doubled in the 20th Century independent of age and weight/load (1). And there are now mountains of evidence showing that these - seemingly mechanical - conditions like arthritis are much more about metabolic health than physical stresses (2). Knee osteoarthritis has doubled in prevalence since the mid-20th century, Wallace et al., 2017 1. Biomarkers of Osteoarthritis-A Narrative Review on Causal Links with Metabolic Syndrome, Lynskey et al,. 2023 2.
What do we mean by “metabolic health”? Essentially, it is what most of us would know as our risk of heart disease and diabetes — all the signs and symptoms of feeling “out of shape”; high blood sugar, high blood pressure, lots of cholesterol in your blood and belly fat. In practice, what this means is that “wear and tear” is outdated terminology, and that it is not the use of your joints that have caused these joint changes. It also suggests that some of us are predestined to have more - or more painful - joint changes than others. Family history can also matter, though just because you have an arthritic change, that your children will. The suffix “’itis” is Latin for inflammation. And that is the common denominator. Chronic, systemic inflammation can cause harm over time. At worst, it can be a trigger for the formation of arterial plaques (the key mechanism in heart diseases). But that inflammation also chips away at our musculoskeletal system, with that natural caressing of time sometimes likened to “rusting.” It makes problems like arthritis (alongside issues such as tendinitis, and stress fractures) far more likely. It can make them actually worse (more change), but also feel worse (neurological sensitisation). But there is hope!
M O V E M E N T “A ship in harbour is safe — but that is not what ships are built for” John A. Shedd So what do we do? Imagine a drug found to reduce knee pain in arthritis sufferers by 47%; to reduce progression of dementia and Alzheimer's by 50%; to reduce progression of diabetes by 58%; reduce chance of death by 23%; and is the No.1 treatment for fatigue….(1) There is a way that we can utilise the brains drug cabinet – a cabinet full of hormones that mimic the effects of morphine; opioids, endorphins, serotonin. These ‘happy hormones’ are very effective for pain management, and easily (and cheaply!) utilised by doing what your body craves; moving (2). Whilst this may feel like the last thing you want to do when you are in pain, we are built to move, and to utilise the amazing muscular and cardiovascular systems we have evolved with. And this does not mean a membership to an expensive gym and hours a day of intense exercise! Together with your therapist, you can look to set yourself simple goals; a few hundred more steps per day, walking the dog, or taking the stairs for example. Essentially, whatever your fitness level today, a little more can – and often will – offer more protection from the stressors which can lead to pain, and more tolerance of the pain stressors when they do (over?) react. Everything should be sensibly graded – pacing is key, as we gradually build the foundations upon which we can build, where necessary. 1. Understanding Pain: Brainman chooses, www.youtube.com/watch?v=jIwn9rC3rOI 2. Therapeutic Neuroscience Education: Teaching Patients About Pain, Louw & Puentedura, 2013
T HIN K S P O N G E ! The cartilage - the part of the joint which is going through change - is made up of two types of collagen holding together, mostly, water! The mechanical forces of movement help to push that water in and out of the joint. Squeezing, almost, like a sponge. When that ‘sponge’ is not squeezed, the water within becomes dirty, and stagnant (which inside our joint, creates a cellular build up of waste products). When we move, we squeeze out this nasty water, and bring in the fresh water (and nutrients), thus keeping the joint healthy and happy. So less “wear & tear”, and more “wear & repair”.
GRADED EXPOSURE Graded Exposure is a “theoretically appropriate way to reduce chronic pain and disability. The primary goal of graded exposure is behavioral in nature, as it serves as a way to increase the performance of fearful activities” (1) Basically, it starts with what you can do today – sore and frustrated – and works towards what you could do before your onset of pain, training for the ‘athlete’ you are today, not the one you were 12 months ago. I am a simple therapist at heart, and take my rehab inspiration from Goldilocks, whereby everyone has their own “just right”, and it is worth spending time finding your own, either with a professional, or by trial and error. As a rule of thumb when starting to move more: No soreness – too little, do more! Severe soreness – do less! Soreness that settles quickly – just right! Patience and perseverance are key, and initially the road will seem long. It may seem overwhelming or intimidating. I imagine us driving 500 miles in the dark. We may not be able to see our destination, but we can see the 400 yards that our headlights show. And we know that if we follow our Sat Nav (training/rehab plan), that when we get to the end of those 400 yards, we will be able to see the next 400 yards. Eventually, those 500 miles disappear behind us. NOTE: Remember, a cake cooks in the oven at the right temperature. If we turn the temperature up too high to try and cook it quicker, it will burn. If we turn the temperature down too low because we are too scared of burning it, we wait longer than necessary. 1.Physical Therapy Utilization of GradedExposure for Patients With Low Back Pain, George & Zappieri, 2009
WHAT IF IT HURTS? Something which I don’t believe is spoken about enough in Clinics and Therapy Rooms when we are working with pain: We are not looking for a pain score of 0/10 Not today, not tomorrow. Unfortunately, maybe not ever. Things get sore, and that is ok. We know that this is usually an alarm system saying we have done too much, and it ordinarily bears no relationship to damage or worsening of the joint. And as we expose you to more movements - potentially new movements - then we can expect and allow for some muscle soreness as we go. This is your body adapting and learning to tolerate different inputs. The more we adapt, the more we learn to tolerate, the less pain we may feel. Another thing to bear in mind is that the Pain Score alone is not the only thing of importance. Anecdote: A runner came to see me 4 months out from their first marathon, but unable to run at that time for more than 3 miles without knee pain. We discussed the “mechanical” aspects of why the knee may be feeling more force than necessary and agreed to see each other again 4 weeks later. The runner was a bit deflated at their follow up, as the pain score was the same. However, onset of pain was now at mile 8. We agreed to carry on a progressive program, and 4 weeks later, the runner was similarly despondent – but pain onset was now at mile 16! A huge improvement in 8 weeks. So, we see that there are different measures of progress, and doing more for no more pain, is worth celebrating.
AVOIDANCE & APPREHENSION As mentioned at the start; fear and apprehension, often led by a lack of understanding or explanation, can become self-limiting. Fear of a named pathology/condition (such as arthritis) has been shown to be more harmful and limiting than the condition itself (1). Do you feel like you are not as active as you like because you have an arthritic knee? Or have you become an arthritic knee? Whilst sometimes it is ok in the short term to let soreness settle post-injury, prolonged periods of not moving can make you more sensitive and more fearful, which can lead to heightened sensitivity and lower pain thresholds over time. Sometimes, we need to confront those sensitive or painful movement patterns to normalize them and turn down your ‘alarm’. As we have already seen in studies on normal, pain free knees, most diagnosed “conditions” are completely normal variances in the pain-free population, and whilst they can sound scary, they have incredibly strong natural histories of improvement and/or recovery and do not need to cause years long disability. 1. Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories, Nijs et al., 2015
A LIG NIN G E X P E C T A TIO N S We would all love every day to feel better than the last, unfortunately this is unlikely – and this is ok. We would love Recovery to be completely linear, like our red line below – however it is far more likely to look like the blue line. Bumps in the road are normal, and to be expected (frustrating and disheartening as they can feel!). Over time, we aim for more good days then bad days, one day at a time, and we measure in weeks – sometimes months - not days. NOTE: the ‘Road to Recovery’ is rarely linear. Expect bumps in the road and accept that everyday can’t be our “best” day, or they would just be our “average” days.
FLARE UPS ‘Flare Ups’ are completely normal even though they can feel frustrating. They can appear at anytime and sometimes it’s hard to put your finger on anything which may have triggered it, so they can be hard to avoid. It is vital that we remember that with all new or increased movement or exercise, some soreness is to be expected. This is the body adapting and getting stronger. Some management options include; Find some relaxation or distraction Remember – tension makes things more sensitive Set yourself some realistic/achievable goals (5 minutes more walking for example) Resume gentle movements (starting easy, building slowly) It is better to keep moving – albeit at a lower level – than stopping completely and starting again Work up to the pain – not through it Use ice or heat packs – whichever you prefer (there is no right or wrong) Stop activities which feel antagonistic – but only for a short period of time! Our mantra is “Movement is medicine” – there are no “bad movements”, only currently sore ones Be comfortable - think clothing, shoes, siting/laying position Medication (small doses at regular intervals of your prescribed medication – speak to you GP if needed) Rest is fine – but not prolonged rest (a few days at most) Stay positive. Remember, stress worsens pain and slows healing Repeat to yourself: you are sore but safe
SLEEP & STRESS As I mentioned at the very start, this is not a self-help book. But it would be naïve of me to avoid mentioning these two important factors in managing pain. I offer no solution, as such, and there are far better qualified experts in these areas. However, a lack of ‘quality’ sleep has been shown to influence: Memory Cognition Pain perception The Immune system Inflammatory response Appetite Carbohydrate metabolism Protein synthesis Although there are no hard and fast rules as to how much sleep humans need, the consensus seems to be that 7-9 hours is optimum for adults (1). An interesting study was carried out amongst adolescents (ave. age 15 yo; famous for their sleeping ability!) that showed those that slept on average 8 hours or more per night, were 1.7 times less likely to have an injury when compared to those that slept less than 8 hours per night (2). Whilst sleeping can become problematic when pain has made residence, it is of huge benefit to find a way to improve sleep quality and quantity. When awake, our nervous system fights on many fronts to keep us functioning; when asleep, the nervous system can focus on recovery. Managing stress is very much an individual thing, with some finding huge stressrelieving benefits from Mindfulness or Meditation; some in Yoga or Pilates; some in running or gardening; and some in reading or listening to music. Whatever works for you, it is of huge benefit to find a way to manage stress levels. 1. How Much Sleep Do We Really Need? Www.SleepFoundation.org 2. Chronic Lack of Sleep is Associated With Increased Sports Injuries in Adolescent Athletes, Milewski et al., 2014
IN SUMMARY To reemphasise, this not to be seen as a “self-help guide”. Some parts will resonate with some more than others, and that is ok. And I want you to know that I am not trying to ‘fix’ your knee pain – only to look at your pain differently, perhaps, and hopefully with a little less fear, and a bit more understanding of how osteoarthritic pain develops; So, my key points: You are not your pain, or your diagnosis. Pain and damage are not the same thing. Humans are incredibly robust – even when we don’t feel that way. Stress heightens the pain experience (alongside a multitude of other emotions and previous experiences). Stress slows healing. Movement is medicine – when graded and sensible. Learn to sleep well Recovery is not linear – and that’s ok.
NOTHING CHANGES IF NOTHING CHANGES
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