Saturday, May 30, 2009

Patellofemoral pain, arthritis, and exercise

First off, an explanation. What's Martha Raye with her toothsome bedentured smile doing in a post on aging knees? If you have patellofemoral arthritis, I think you can relate.

The patella (kneecap) sits in front of the lowest part of the femur (thighbone) at the knee joint. Patella slides over femur as we bend at the knee, and when all is young and working correctly, the cartilage-covered surface of one slides over the cartilage-covered surface of the other.

So with age, cartilage breakdown, misalignment, and saggy old quadriceps (large muscle on the front of the thigh in charge of getting us off chairs and toilets), the patella starts slamming into the front of the femur, and the cartilage frays, tears, and wears away down to bone. So as we squat, plie, rise up, and sit down, one bone grates on the other bone, and...just like Martha Raye fielding a seed between denture and gum...we wince with pain.

Well, that's me. Deep knee bends are yesterday's move, squats out of the question, and I channel Martha Raye during lunges. The first thing I told a personal trainer during a trial session is "I don't do lunges. Period." But she is not taking no lunges for an answer, noting as I have that flexing the weight-loaded knee to heave the rest of me up and down (assuming I'm not in a wheelchair) is what I must do for the rest of my life if I care to remain independent. Is this all about being under 30 and not appreciating how it feels to work-out on aging knees, or is she on to something?

She will feel smugly vindicated when I show her a Dutch study(1) that indicates exercise beats other strategies for relieving patellofemoral pain. The sports medicine practitioners at Erasmus University Medical Center in Rotterdam signed up 131 patients with up to twice that number of painful knees to undergo a 12 week supervised exercise program directed at quadriceps strengthening, flexibility, balance, and coordination or an equal number of weeks under 'usual care' from their physicians. The latter, I'm guessing, means this control group was told "You should do leg lifts and take Advil (or whatever the Dutch equivalent is) and get over it. Next."

On comparing the exercised group with those who motored on without supervision, the researchers found significant improvement in pain and function scores in the former not only at the end of 12 weeks but also on follow-up 12 months later. One can assume that diminished pain means improved alignment and quadriceps strength have improved the tendency of bone to grate on bone and, as a result of this supervised exercise program, wear-and-tear degeneration has been halted.

My trainer has cleverly disguised lunges as other exercises where I hop from bent leg to bent leg as she throws things at me (well, a ball actually), or stand on one bent leg while I do distracting maneuvers with weights in hand, and, well, I hate to admit it but my knees feel better.

So I guess I'll channel Erma Bombeck instead and let Martha Raye rest in peace.
1. American College of Sports Medicine (ACSM) 56th Annual Meeting: Abstract 570. Presented May 27, 2009

Wednesday, May 27, 2009

I'll be doggone!

I was scribbling away on my patient's chart during the initial part of her annual exam. As I wrote her latest information, she began to pant.

My first doctorly thoughts before I looked up: "Good heavens, she's in metabolic acidosis," "She has a sucking chest wound," and finally "She's lost her mind!"

As I turned my gaze towards my patient, I noted that she looked neither distressed nor hypoxic. And...the panting was coming from near her feet!

"What on earth is that noise?" I asked.

She leaned down sheepishly and unzipped her large bag. A small silky-haired dog popped out and made my day by sitting in my lap for the remainder of the interview.

Friday, May 08, 2009

A biological reprieve from life in a shoe

There was an old woman
who lived in a shoe,
she had so many children
she didn't know what to do.
She gave them all broth
without any bread;
she whipped them all soundly
and put them to bed.
--Mother Goose

Have you ever considered that menopause may be a biological boon to get us out of such sticky shoe situations? Seriously though, what is Mother Nature's point with this mixed, menopausal blessing?

Craig Packer, a professor of ecology at the University of Michigan, considered the evolutionary advantage to animals of such programmed senescence, where the ovaries quit years before the rest of the body. He first looked for a 'granny effect', a survival advantage for those young animals with living grandmothers capable of assisting in their care. Baboon grandkids survived just as well whether grandma was dead or alive. Lion cubs only benefited from Grandma Lioness's attention if granny could nurse the little darlings because she herself remained fertile (heaven preserve us from that!).

So why don't the females of various species just keel over at menopause? Packer concluded that the answer could be found in ''prolonged maternal investment," the dependence of young mammals on the presence of a mother who's neither frail, shoe-bound, nor dead. Baby baboons need that mother's touch through their second birthday, and it is fortunate then that a baboon mom typically lives five years past her final birthing.

On the other hand, lion cubs are independent and good to go after just one year, so mama lionesses live less than two years past the end of ovarian function. Packer then assumed that human children need their moms until age ten (what kids has he been around??), and guessed that our maternal ancestors ideally would have lived until age sixty--ten years past the end of reproductive cycling--in order to see the last little darling out the door.

And now, with current advances in medical care and nutrition, we can anticipate successfully nurturing our children until they themselves are sixty!*
*Or more. My 90 year old patient spent the first half of her annual exam appointment two weeks ago fretting over her 70 year old son who still walks from his house next door to hers each evening for her home cooking. Gad.

The oriented-in-space place

Drawing a mental blank is a drawback of a busy day; being unable to draw a mental map of your current location is a red flag for trouble. While getting lost in your work rates high performance reviews, getting lost while driving maybe a sign of dementia.

Arriving safely at home at the end of our day requires the proper functioning of an oriented-in-space place in our brains located just behind and above the ear. This medial superior temporal area (MST) is charged with personal global positioning, providing our brain with continual updates on our current location in space.

Unfortunately, the MST is particularly vulnerable to the cellular destruction associated with Alzheimer's Disease(AD), leaving its victims unstuck in their once familiar world. This deficit has been dubbed 'motion blindness'; the the resultant inability to navigate, even through one's own home, leads to a tragic loss of independence.

Here's another scary consequence. While early AD victims may remember street names and the basic rules of the road, there are certain driving skills that lapse early in the course of the disease based on MST dysfunction. I remember an office visit where my elderly patient arrived slightly late for her appointment. She sat down in the chair with a sigh, then proceeded to recount her harrowing drive over during which, per her report, she sideswiped several cars on both sides of the narrow streets near my office while trying to guide her car down the middle of the road. She had no sense at all of where her car ended relative to those parked by the curb.

I don't know what was more disturbing--her zigzag navigation of a potentially lethal weapon or her relative indifference to destruction that she left in her path.