Demystifying Noisy Knees

Demystifying Noisy Knees: A Physiotherapist's Perspective

Noisy knees, characterized by sounds such as cracking, clicking, and popping, are a common phenomenon affecting up to 70% of the population.

Recent research conducted by La Trobe University has shed light on this prevalent issue, highlighting the impact of online misinformation on individuals' health choices.

In this blog, we will delve into the findings of this study, led by Dr. Danilo de Oliveira Silva, and explore the implications for both patients and healthcare professionals.

The Prevalence and Misconceptions of Knee Crepitus

Knee crepitus is a term used to describe the sounds that occur when the knee joint moves.

Despite its widespread occurrence, there is a significant lack of credible information available on the internet.

Dr. de Oliveira Silva and his team at the La Trobe Sport and Exercise Medicine Research Centre have found that many people are influenced by this misinformation, leading them to make poor health decisions.

The Impact of Online Misinformation

The internet is a go-to source for health information for many individuals.

However, the study conducted by La Trobe University reveals that over half of the websites evaluated did not provide evidence-based information.

This misinformation has led to a variety of misconceptions about knee crepitus, with some people believing that these sounds are harmful to their health or a cause for embarrassment.

The Research Findings

The research team conducted a comprehensive appraisal of the top 20 URLs from two popular search engines, Google and Bing. Out of 120 websites, 51 were evaluated for credibility, accuracy, and evidence support.

The results were alarming, with a significant number of websites providing information that was not backed by research evidence.

The study found that many websites suggested treatment options such as exercise, medication, passive treatments (brace, ice, splints), and rest, despite there being no research evidence to support these recommendations. This highlights the need for caution when seeking web-based information about knee crepitus.

Moving Forward

Dr. de Oliveira Silva emphasizes the importance of conducting further clinical studies to explore the impact of knee crepitus on individuals' health.

He advocates for the inclusion of patients and health professionals in designing research questions to ensure that the information provided is relevant and credible.

Take Home Message

As a physiotherapist, it is crucial to guide our patients towards evidence-based information and help them make informed decisions about their health.

The study conducted by La Trobe University serves as a reminder of the pervasive nature of online misinformation and the need for critical evaluation of web-based health information.

Let us commit to providing accurate, reliable, and evidence-based information to our patients, empowering them to take control of their health and well-being.

References:

Study in Science Direct: “My knee is cracking” – What information is available on the internet about it? A systematic appraisal of the credibility, readability and accuracy of online information about knee crepitus. Dr. Danilo de Oliveira Silva, La Trobe Sport and Exercise Medicine Research Centre.

Expanding Your Perspective: The Power of Aerobic Exercise in Alleviating Neck Pain

Introduction

Imagine you're faced with a classic puzzle known as the "9-dot problem” (see below).

The challenge is to connect nine dots arranged in 4 straight lines without lifting your pen.

Give up? See the solution below…

Most people struggle with this task because they attempt to solve it within the confined boundaries of the grid.

But here's the twist: the solution requires you to think outside the box, literally!

Thinking Outside the Box

This concept of "thinking outside the box" translates beautifully to another common problem: persistent neck pain.

Instead of merely zooming in on the neck itself, we'll explore a groundbreaking study that shows how incorporating aerobic exercise – a step outside the box – can lead to significant relief.

The Neck Pain Conundrum

Neck pain affects a substantial portion of the population, and the quest for a solution is often met with frustration.

Individuals dealing with neck pain might find themselves in a never-ending loop of shot term quick fixes that, at best, offer temporary relief.

However, the key to solving this puzzle for good might actually be to stop focusing exclusively on the "pain area."

The Study Setup

In March 2020, a study was conducted to assess the impact of aerobic exercise in conjunction with neck-specific exercises for individuals suffering from neck pain.

This prospective double-blind randomized controlled trial was carried out in physiotherapy outpatient clinics, involving patients with nonspecific neck pain.

The Intervention: Inside and Outside the Box

Participants were randomly divided into two groups:

1. The first group underwent a six-week regimen of neck-specific exercises. This represents the conventional "inside the box" approach.

2. The second group received the same neck-specific exercises, but with an intriguing twist – they also incorporated aerobic exercise (AE). This represents the "outside the box" thinking, looking beyond the neck alone.

   The Aerobic Exercise (AE) program consisted of a moderate cycling exercise x 2 per week (60% of the age-predicted maximum heart rate) for 20 min during the first week, 30 min during the second week, and 45 min during the third to sixth weeks

Measuring Success: Multiple Angles

To evaluate the effectiveness of these treatments, an array of outcome measures was used, including the Visual Analogue Scale (VAS) to assess pain intensity, the Neck Disability Index (NDI) to evaluate how neck pain affects daily activities, the Fear Avoidance Beliefs Questionnaire (FABQ) to assess the impact of fear on pain-related behaviors and beliefs, and an evaluation of cervicogenic headaches.

These assessments were conducted at three crucial time points: at six weeks, then at three months, and again at six months post-interventions.

Astounding Outcomes

The results? They're nothing short of astounding!

• The group that performed Aerobic Exercise achieved a whopping 77.4% success rate at the six-month follow-up, in stark contrast to just 40% in the control group.

• A substantial reduction in VAS scores was observed in the AE group, plummeting from 6.73 to 1.89, while the control group's improvement was less pronounced, with scores moving from 6.65 to 3.32.

• The AE group showcased remarkable improvements in NDI and FABQ scores within the first six weeks. For NDI, scores decreased from 16.10 to 7.78 in the AE group, compared to 17.01 to 11.09 in the control group.

• FABQ scores exhibited a similar trend, dropping from 33.53 to 20.94 in the AE group and from 33.45 to 26.83 in the control group within the same timeframe.

• Cervicogenic headaches, a common issue among those with neck pain, also saw a significant reduction in the AE group from baseline to six months.

The Game-Changing Conclusion

This groundbreaking study concludes that adding aerobic exercise to long-term neck-specific exercises is an effective and promising treatment for reducing neck pain and related headaches in patients with nonspecific neck pain.

The key takeaway here is the power of thinking beyond the immediate problem area and embracing a holistic approach to solving the puzzle of neck pain.

Zooming Out for a Holistic Solution

Much like the "9-dot problem," which demands expanding your perspective to find the solution, neck pain requires a broader approach.

Instead of focusing solely on the neck, a combination of neck-specific exercises and aerobic exercise yields outstanding results, offering hope for those grappling with neck pain.

Whilst this study the participants all used cycling as a form of aerobic exercise - the beauty is you could choose any form of exercise you enjoy - whether it’s jogging, walking, swimming, lawn bowls, hiking, gardening or pickleball.

The key is trying to get your body into a low to moderate intensity - around the Zone 2 mark.

You can measure this with a heart rate, RPE or use the ‘talk test’ as a guide.

The goal is to challenge the heart and lungs to continue to feed muscles with nutrients for longer periods of time (20 minutes to an hour or longer).

By considering a more holistic approach, we can finally connect the dots and find relief beyond the box we've been stuck in.

Always consult a healthcare professional before starting any exercise program, especially when dealing with pain or injury.

Wanting to get started on your journey to find relief from neck pain?

#NeckPainRelief #AerobicExercise #HolisticApproach

Research Link

The effectiveness of an aerobic exercise training on patients with neck pain during a short- and long-term follow-up: a prospective double-blind randomized controlled trial

**Solution - ONE of the possible solutions to the 9 dot puzzle:

Is Dry Needling Safe during Pregnancy?

Pregnancy is a time of numerous questions, especially when it comes to healthcare practices like dry needling.

Many individuals, upon discovering their pregnancy, may wonder whether they can continue or start dry needling treatments during this time.

To provide clarity, we will explore the safety of dry needling during pregnancy, keeping both clinicians and patients in mind.

Understanding Dry Needling during Pregnancy

First and foremost, it's essential to acknowledge that dry needling during the first trimester is considered contraindicated.

Although there is no concrete evidence that it would necessarily create harm, this trimester is characterized by the highest incidence of pregnancy complications.

A Closer Look at the First Trimester

The first trimester, spanning from conception to about 12 weeks, is a critical period of fetal development.

During this time, the risk of complications is comparatively higher, and it's essential to err on the side of caution.

As clinicians, our primary responsibility is the well-being of both the expecting mother and her developing child.

Given the limited research on the safety of dry needling during this phase, it's advisable to avoid it.

There are many other techniques that can be safely administered, apart from dry needling.

The Safety of Dry Needling in the Second Trimester

Conversely, there is some evidence to suggest that dry needling during the second trimester can be performed safely.

As the pregnancy progresses, many of the critical developments have already occurred, and the risks associated with certain complications decrease.

However, even during the second trimester, careful consideration is vital.

Dry needling should only be administered by a qualified practitioner who is well-versed in prenatal care and understands the unique needs of pregnant patients.

Conclusion

The safety of dry needling during pregnancy is a topic of concern for many patients and clinicians alike.

While the practice is generally discouraged during the first trimester due to the heightened risk of complications, the second trimester may offer a more suitable window for treatment.

However, safety should always be the guiding principle, and any decision to proceed with dry needling during pregnancy should be made in consultation with a knowledgeable healthcare provider.

Unraveling the Metabolic Basis for Tendon Pain

Tendon pain, particularly chronic Achilles tendinopathy, is a challenging condition that can disrupt an active lifestyle especially for runners.

In recent years, researchers have delved into the metabolic underpinnings of tendon pain, shedding light on the role of lactate concentrations.

The Lactate Connection

Lactate, a compound associated with muscle fatigue and soreness, has emerged as a crucial factor in the study of painful chronic Achilles tendinopathy.

A study utilizing microdialysis techniques revealed higher concentrations of lactate in Achilles tendons afflicted by tendinopathy compared to healthy, pain-free tendons.

The significance of this finding lies in the revelation of anaerobic conditions within the painful tendon area.

Understanding the Results

The study's results are a piece of the intricate puzzle of tendon pain.

Let's break down what we can glean from this research:

1. Lactate Accumulation: The higher concentrations of lactate in painful tendons suggest that anaerobic conditions prevail in the affected area. This accumulation of lactate reflects a metabolic imbalance within the tendon, which may contribute to pain perception.

2. Tendon Structure: The study noted structural changes and widening of the tendon in cases of tendinosis. These observations are vital in understanding the pathological processes at play in chronic Achilles tendon.

A Holistic Approach to Tendon Pain Management

Understanding the metabolic basis of tendon pain is just the first step.

To effectively manage and alleviate this pain, we must take a holistic approach:

1. Training Load and Periodization: In the world of sports and physical activity, it's essential to adopt a balanced training load. The 80/20 principle, where 80% of training is in zone 2 (aerobic), can help minimize the risk of overuse injuries like tendinopathy.

2. Lactate Clearance: Optimal lactate clearance is key. Encourage activities that enhance lactate clearance, such as low-intensity exercise, adequate recovery periods, and proper hydration.

3. Therapeutic Modalities: Various therapeutic modalities can play a role in tendon pain management. These include massage, dry needling, and foam rolling, which can aid in reducing muscle tension and promoting blood flow to the affected area.

4. Liver and Kidney Health: Metabolic health is crucial. Liver and kidney health is vital for efficient metabolite clearance, including lactate. Ensure a balanced diet, stay hydrated, and minimize excessive alcohol consumption to maintain these organs' well-being.

5. Hydration: Proper hydration is essential to support overall metabolic processes, including lactate clearance. Staying adequately hydrated aids in reducing the risk of metabolic imbalances contributing to tendon pain.

Conclusion

The metabolic basis for tendon pain, as revealed in the study, offers valuable insights into the pathogenesis of chronic Achilles tendinopathy.

However, it's only one piece of the puzzle. To effectively manage tendon pain, we must adopt a holistic approach.

This approach includes optimizing training load, prioritizing lactate clearance, and utilizing therapeutic modalities to promote pain relief.

Furthermore, maintaining overall metabolic health through hydration and balanced nutrition is paramount.

As we continue to unravel the intricate nature of tendon pain, adopting a holistic approach can help individuals regain their active lifestyles and harmonize with their bodies' natural healing mechanisms.

Research link: High intratendinous lactate levels in painful chronic Achilles tendinosis. An investigation using microdialysis technique

Deepening our Understanding of Pain

Whilst at first thinking hard about pain can give you a bit of headache, doing a bit of hardwork now could well save you lots of unnecessary stress and excessive pain later on.

So you may need a nice cup of tea or coffee to get through this blog - but I promise it will be worth it !

Warning - for most people this isn’t an easy read, or easy to understand at first - that’s completely OK!

To learn about these things is not a standard part of physiotherapy currently.

But these are important conversations to have - as having accurate up to date knowledge is a big part of genuine recovery.

So if you are open to learning and being patient - you will most probably end up knowing more about pain that 95% of doctors and health care professionals, who by a large and stuck in the one-dimensional view of pain that is called the Biomedical Model (that states all pain must arise directly from tissue damage in a linear relationship).

OK, here we go….

Re-framing Pain as an Emergent Process

Pain is something we all experience and it often becomes a source of frustration and anxiety when it refuses to subside.

Whether acute or chronic, pain has a way of affecting our lives and pushing us to seek relief.

But instead of trying to attack, suppress or eliminate the pain…. what if we re-framed the pain? What if we changed the way we thought about the problem?

Rather than a simple mechanical response (damage = pain), we could view it as a complex emergent process (sensation + emotion + metabolic heath + past history + past expereinces + anxiety about the future etc = pain

By doing so, we open ourselves up to the fascinating intricacies of pain perception and potentially find new ways to address it. You gain empowerment over the pain.

Pain as an Emergent Phenomenon

The first step in re-framing pain is to understand that it is always an emergent phenomenon.

Emergence, in this context, is a concept borrowed from complex systems theory.

It implies that pain doesn't arise from a single source but rather results from a complex interplay of factors.

Let's break it down:

1. Bottom-Up (Physiological Sensation): The physiological aspect of pain begins with the actual sensation. It's the raw data sent from the site of discomfort to our brains, signaling that something isn't right.

2. Autonomic Nervous System (ANS) and Heart Rate Variability (HRV): Our body's autonomic nervous system, which regulates functions like heart rate and digestion, plays a crucial role. Changes in heart rate variability can affect pain perception and contribute to its complexity.

3. Past Experiences: Our personal history with pain and related emotions can influence how we perceive and respond to it. Past traumas or experiences can amplify or diminish pain signals.

4. Top-Down Influence: This refers to the cognitive and emotional aspects of pain. Our thoughts, beliefs, and emotions can either amplify or dampen the pain experience.

Examples of Emergent Systems

To better grasp the concept of emergence, consider everyday examples like making coffee, baking, gardening, or listening to the sound of an acoustic guitar.

These activities involve numerous elements coming together in unpredictable ways to create a unique experience.

Similarly, pain is not a straightforward cause-and-effect relationship but always a complex amalgamation of factors.

Emergent Complex Systems vs. Linear Mechanical Systems

It's important to recognize that emergent complex systems, like pain, behave differently from linear mechanical systems.

Linear systems produce predictable, proportional results.

In contrast, complex systems exhibit nonlinear behavior, leading to outcomes that may not be proportional to the inputs.

This nonlinearity makes pain a highly variable and individualized experience.

The good news!

Whilst the above few paragraphs may sound very complex, that is actually a GOOD thing!

If you notice yourself feeling a bit anxious, frustrated, confused or overwhelmed - that is a great sign and very normal.

When we start on a new road of learning - there is an initial feeling of resistance as our systems are wired to avoid feeling overwhelmed and would much prefer simplicity.

Amongst the confusion, if you feel just a tiny bit of curiosity to learn more - that’s a great achievement.

The bottom line is - Humans Are Complex Systems.

And that complexity (counter-intuitively) opens the door to non-linear improvements in the way our bodies function (and in particular our pain levels).

In simple words when we stop ‘chasing pain’ at a mechanical level, we can be open to more simple, intuitive natural ways of healing.

You don’t have to wait until you get ‘stronger’ or ‘more flexible’ or ‘looser’ until you get out of pain.

Conclusion

Re-framing pain as a complex emergent system allows us to embrace its intricacies rather than anxiously avoiding them.

By recognizing that pain is not a simple linear response, we can explore more holistic approaches to managing and treating it.

This shift in perspective encourages us to consider the multifaceted nature of pain, incorporating both physiological and psychological aspects into our understanding and treatment strategies.

In doing so, we open doors to more comprehensive and effective pain management solutions that respect the complexity of the human experience.

Has this blog sparked any curiosity? Please feel free to leave a comment and I’d love to hear your thoughts.

For more reading - this is a good starting point

The Complexity Model: A Novel Approach to Improve Chronic Pain Care

Affordance-based practice: An ecological-enactive approach to chronic musculoskeletal pain management