When I had understood, that the inflammation complex is the key to arthrofibrosis, my search went on trying get to the root of everything.
As the inflammation is fueled by something, I will now call this the
Inflammation support compound (ISC).
The inflammation complex which creates AF is by itself only local, not global, however the ISC may also be global! Such an ISC encompasses general hormonal levels, immune system state, metabolic state and sympathetic/parasympathetic activities. The main part of this post will be about dealing with these things.
I believe now, that the ISC is the most complex aspect of the whole story!
Lets summarize the layers of the condition, AF is embedded in, first:
1) Inflammation support compound
2) Inflammation complex
3) Fibrotic tissue (AF)
4) Tertiary effects from changed joint conditions and biomechanic as a result of 2) and 3): e.g. Patella Baja, Cartilage damage (both from abnormal cytokine IL level AND mechanic load changes), ligament tissue necrosis etc.
5) Pain, ROM restrictions as a result of 3) and 4)
What you see and feel is mainly 5) - everything else are more or less hidden variables - you can see 3) and 4) on MRI, though. Peeling off the onion has therefore to take place mainly in the mind.
Concentrating back on 2) and 1): the inflammation complex is certainly triggered by primary surgery. The type of the inflammation complex may vary greatly among patients. Research on molecular factors showing emphasized behavior during an AF points clearly to the inflammatory response factors being crucial stages of the cascade, e.g. Cytokine IL-1 and friends.
Influence on these factors is known to be both local and global. Thus, the ISC must be tackled both local and global.
I will define two dimension, one for local handling and one for global handling.
I) Local treatment
stands on two pillars:
I.A) Joint load relief
- I.B) Joint immobility avoidance
I.A) Joint load relief is probably the most important aspect of ISC handling. Its aim is to minimize stress and irritation on local tissues. Among involved local tissues are cartilage tissues, bones, ligaments, muscles, skin, free joint liquid, capsule, the abnormal fibrotic AF tissue and more.
Load stresses occur as a result of biomechanical forces and torques between tissues. In the AF damaged knee, two factors lower the threshold for load stresses: inflamed tissues are more sensible on the one hand and biomechanical settings are altered because of fibrotic tissue and tertiary joint changes on the other.
Load on the patellofemoral joint is least in full extension, where the patella is relaxed. Load is high during dynamic movements covering a wide range of flexion under acceleration and high "payload" weight. This is especially true for walking stairs up and down, walking slopes up and down and exercises like squatting. These have to be avoided at all costs
until the inflammation and AF have completely
subsided. Cycling provides intermediate load and is better to be avoided - its mobilizing aspect should be substituted by other, less load intensive exercises.
Walking on even grounds is safer, as acceleration and spring-damping is performed closer to full extension. Yet, walking should be avoided at high extension deficits.
Standing is mostly safe at low extension deficits as the patella is relaxed and muscle tension is not very high. Sitting is preferably always done with maximum available extension to minimize patellofermoral load and avoid patella contracture. It can also help to increase extension, although very slowly at most.
I.B) Like with everything, too little is as bad as too much concerning joint stimulus. Joint load relief avoids too much stimulus and accordingly immobility avoidance has to avoid too little stimulus. Stimulus avoids tissue atrophy, helps to keep positive healing processes active, dynamic and can channel the inflammation complex onto more natural paths by liquid influx etc. However, mobility exercise has always to take care not to conflict with joint load relief. Thus, exercises have to be free of load, acceleration and larger forces in general. These exercises have to be performed carefully, slowly and within a pain free range. Examples are manual patella mobilization, supported wall slides, free dangling of the lower leg, passive flexion motions, but also straight leg raises (which are patella neutral) and similar exercises.
The frequency has to be adjusted so that no negative subjective feeling (heat, swelling, pain) arises from these exercises as a distinct source. It has to be remembered that there is no urgency concerning muscle atrophy. Any permanent muscle atrophy is caused by nerve damage, not by long enduring temporary atrophy becoming hypothetically chronic.
II) Global treatment
stands on the three pillars of life hygiene
- II.B) Activity
- II.C) Nutrition
treatment centers around stress levels, affecting both hormonal level and (para)sympathetic level, also leading to secondary and tertiary effects by self-feedback together with activity and nutrition. Stress is an intense inflammation fuel and thus a central aspect of the global ISC share.
Stress levels are controlled by ways dealing with the illness itself mentally, by positive and negative social parameters, by mental load and sleeping patterns.
I.A.1) Confronting and accepting the condition itself - direct condition generated stress
One of the largest hurdles is probably the pain. Pain increases stress levels massively and therefore leads to a vicious circle. If there is no clear tendency of the pain levels to subside, only smart and well adjusted pain medication therapy can help to break that circle, making stress levels manageable.
Beyond the pain, the uncertain outlook concerning both work and leisure life are another piece of condition generated stress. Dealing with that is very personality dependent, thus finding a sufficient method of confrontation has to be adjusted individually. In general, it can be said that active confrontation is important. Trying to arrange everyday life by behavior changes in a way that life could be managed if the condition would not improve anymore indefinitely
can be extremely relieving. An inner coming to terms with the disability can reduce stress levels massively and thus actually help to turn things to the better.
I.A.2) Minimizing external negative social stress
External negative social stress usually arises from being embedded into hierarchical organisations. Most job environments are of that kind. Extensive studies on baboon groups have investigated the stress levels of individuals on all levels of social stratigraphy. Stress levels are highest at the top and at the bottom - which is most certainly also true for human beings. Bosses and peons are under the most intense pressure. From this insight follows that not being strongly involved in a stratified environment is best for the stress level.
While being healthy, one might have only moderate problems living and performing under these conditions. With an active inflammation complex, it is most helpful to retreat as much as possible from the squabbling of human organisations during treatment. "Career" and financial aspects are overrated compared to health. Assuming every reader comes from an economically advanced society, it is those in which financial needs are overrated by cultural pressure.
However, this argumentation assumes, of course, a generalized health care system.
I.A.3) Maximizing external positive social impulse
It is known from both primate and human studies that being embedded into a small, non-stratified, but close social context is beneficial for stress levels. Being around close people is not only practical for physical help in times of disability, but significantly reduces anxiety, depression, stress. That should be very clear, nothing further has to be said about this one.
I.A.4) Mental overload
Reducing mental overload means to thin schedules. No travel, no involvement in intense organisations, no plans. Just relaxing. Mental load is a source of stress.
Good sleep over a long time is important for healing complex inflammations. First, the pain has to be relieved as discussed in I.A.1) and other stress factors reduced as mentioned in the previous points. If the foundation is set, you can further experiment with times, temperature, light, earplugs in case you have not done so previously.
Once, when I was still healthy, I tried all available earplugs from a specialized online shop. I found a type of earplugs that is so good in damping and wearability that I can sleep anywhere now. Setting up the bedroom in a way that it is nearly totally dark even at summer noon does also help a lot. Even the change in temperature conditions induced by a different blanket can help a lot.
Furthermore, the concept of Siesta can help during insomnia. Sometimes insomnia is induced by being tired too quickly during the day and then hanging around for some time which leads to not being able to sleep well a night. A 2h Siesta may avoid this.
I have found out for myself that the need for a Siesta depends on season and overall activity levels. In very active stages in the winter, when I get a lot done, I need a Siesta. I organize the work schedule around the sleeping pattern. I experimented even with two Siestas during the day and a very short night - but that did not lead to good results.
Experimenting with different patterns can help you to find your own best. Do not take given what society tries to impose you, especially in times of need!
targets cardio-vascular conditions but also levels of many hormones. Long-term full body inactivity is very dangerous and a great fuel for inflammation complexes becoming chronic. This is a very well investigated and known fact and has not to be discussed further here.
However, nearly all relevant exercise activities known to man require healthy leg functionality which is definitely not present at the discussed condition.
Yet, there is a great source of ideas for activities which can be performed without leg functionality: the tetraplegic community.
Several sports which do not need leg functionality - and thus do not conflict at all with the joint relief paradigm - can be found there:
Handcycling (there are even mountainbikes with electric support now!), swimming with a buoyant leg pad, cross country ski sledding, sitting monoski and upper body strength exercises (bench press, pull ups, curls etc.).
I am especially a fan of the Handbike (I have a Sophur Shark S racebike), which can fully substitute running and cycling as both a sport and a means of transportation.
Like with every other activity, endurance and strength training should be mixed. As only the upper body is available, it is a bit difficult to schedule enough training of both aspects together with sufficient regeneration. Yet, a lower overall intensity than with full body health activity training should be sufficient.
A recommendation can be (which is exactly my program):
3-5x per week 1-2h endurance (Handbike, pad swimming or cross country sled) exercises
2-3x per week short (20-30 min) intensive sessions for strength, each either pull (bizeps/latissimus and friends) or push (triceps, pectoralis and friends)
influences all types of hormonal activity. Both macronutrients and micronutrients play important roles. Sadly, even in the year 2011, we as a society, are far from a general consensus about what is healthy and what is not. Science is entrenched in deep battles and it is hard to find convincing food advice through the fog of that war.
And still there are some undisputed facts, you will find in nearly any modern dietary recommendation:
- Eat meals from food as basic (unprocessed), as possible (and non-toxic)
- Avoid all kinds of industrial sweets
- Avoid fructose corn sirup or any large intake of fructose
- Eat a lot of colorful vegetables (only legumes are disputed)
- Eat omega-3 rich fish
- Drink mostly tea
Sadly that's it. From potato over chicken to bread and egg, from different kinds of oil over milk to chocolate - it's all disputed! The only thing we know is, it is important to eat right, but what is right depends, on whom you believe.
In the meantime, I believe in moderate paleo diets. Recent studies are very convincing. Some very deep literature:http://www.amazon.com/Perfect-Health-Diet-Youthful-Vitality/dp/0982720904http://www.amazon.com/Food-Western-Disease-evolutionary-perspective/dp/1405197714
If you are not totally convinced, you can still go even a little more moderate. More potato/rice, less beef - there is always a place for your truth, for you not wanting to be too radical. But be conscious, be clear - not laissez-faire - and you have that pillar under control. And if it is just cutting out any sugar. Your joint will thank you a lot.
I believe, that global treatment of the ISC is an underestimated aspect of AF handling. If one really wants to overcome AF, it means to overcome it on all fronts and with all necessary means. It is total war and you are the one who has been assaulted. So mobilise everything
. As long, as there is no targeted medication, directly breaking the inflammation complex, outshining all other means - or to keep to the analogy you are "having the h-bomb" - general purpose global treatment is a promising attack vector beyond and in support of the local treatment.
The summarized message of this post: While being somewhat lax about the three pillars of life hygiene might be ok when otherwise healthy, it is not ok when treating a complex inflammation condition!
from S. Reinhard who has now reached 0/0/125 cold and /137 max, feeling better every week