No Pain No Gain

Every now and then we get patients with chronic pain in our clinic, so I was really interested when I saw this case report about a 71 year old woman who feels no pain. I was hoping to find ways to really help these chronic pain patients.

She was found to have two notable gene mutations, FAAH-OUT  which researchers know to have links to pain sensitivity. The second was a microdeletion in the FAAH gene which reduces pain sensation, accelerated wound healing, reduced anxiety and enhanced fear-extinction memory.

This lady sought treatment for a hip issue and was found to have severe degeneration in the hip despite feeling no pain. When researchers looked into her case file, they found that she never reported experiencing pain or needed pain medication after surgery. Even during childbirth, after broken bones and cuts. She was burnt once, but only realized it after smelling her flesh burning!

I was then thinking, if an elite athlete had that sort of mutation and felt no pain, would that be a real major performance enhancer? That would surely not be considered as doping.

Think of how it would affect you if you were running and attempting to beat your personal best in the marathon. If you didn't feel any pain, nor the burn of accumulating lactate in your muscles when you were clicking out each kilometer at your goal pace. Surely you would be able to keep pace to beat your target time.

After thinking about it for a while, I realized that it is not possible. If you experience no pain while training, it would definitely expose you to injuries. Pain is necessary during training to help provide feedback and modulation and of course for adaptation to training.

During races, your performance is affected because pain impacts pacing. If you can't feel pain, you wouldn't know how to back off, when to slow down. You will purely be running by numbers (time) and not physiology.  That means you wouldn't know when to rest. Over training will become common. Mild injuries will then become severe.

Like what I always tell the athletes that I treat, "make pain your best friend". If you can tolerate pain, you will be able to perform your best.


Reference

Habib AM, Okorokov AL, Hill MN et al (2019). Microdeletion In A  FAAH Pseudogene Identified In A Patient With High Anadamide Concentrations And Pain Sensitivity. Br J Anaesthesia. DOI: 10.1016/j.bja.2019.02.019

Signed by David Butler himself in 2003.

Still Can't Run 6 Months After An Ankle Sprain

R ankle

My last patient yesterday suffered an osteochondral injury in her right ankle last July after spraining her ankle while taking part in a trail running camp. Part of the reason may be wearing a new pair of shoes she wasn't used to.

Almost half a year later, she was still hoping to do a 50 km trail race earlier this month, but she definitely wasn't even ready to be running yet.

Many of her running friends and colleagues (she works in a hospital) can't believe an osteochondral injury can be that serious. In fact, some of the physiotherapists in her hospital don't even know what an osteochondral injury to her talus means. They definitely do not know how to treat her.

Hence, you have a runner who works in a hospital, yet comes to Sports Solutions to get treatment.  Just like the physiotherapist from another hospital who sees us after her microfracture surgery.

In the picture above, you can see where the talus is in the ankle. It is the bone that is below your tibial (shin bone). In the scenario where there is an injury to the articular cartilage (which lines the end of our bones to allow for load bearing and friction free movement), there will be both swelling and pain.

The main goal of non operative treatment is to allow the injured bone and articular cartilage to heal. Since articular cartilage has poor blood supply, this is not going to happen quickly.

Sometimes, crutches or a rocker boot may be necessary to take load off weight bearing. In severe cases, surgery is needed to ensure recovery. After three articles on the operative management on articular cartilage injuries, I think I've covered the topic enough. Just in case you're keen, drilling can be done like the picture you see below to stimulate healing.

Drilling is done

I've told my patient she can still volunteer at the race whether it's manning a water station, handing out medals or directing runners at checkpoints in the race. She can also lend support and cheer for her friends at the race. Meanwhile, she has also found "a distraction" or another way to motivate herself. She's been going to the gym regularly and her upper body is much more muscular than before.

I've told her to keep the long view in mind. If she wants to keep running for the rest of her life it's not worth risking it now. There will be other races for her in future definitely.

Have an osteochondral injury? Come see us in our clinics.

High Intensity Interval Training (HIIT) Reduces Cancer Cell Growth?

Picture by richseow from Flickr

I've written positively before about the effects of running on cancer a few years ago. Now there seems to be more evidence that even a single session of high intensity interval training (HIIT) may significantly slow the growth of colon cancer cells.

Researchers had male colorectal cancer survivors perform either a single HIIT session or do HIIT regularly for a month.

After a ten minute warm up, the single HIIT group did four intervals of four minutes cycling (at 85to 95 percent maximum heart rate) with three minutes of recovery in between. The other group did this same session three times a week for a month.

Picture by jungle jim3 from Flickr

Blood samples were taken from these subjects before and after the HIIT sessions. Blood samples before exercise had no effect whatsoever on the cancer cells. Blood samples after the HIIT sessions showed a decrease in the cancer cells immediately.

While comparing the single session HIIT group with the other, there was no significant difference in the blood samples.

During high intensity exercises, our muscles releases lots of myokines (inflammatory cytokines) compared to moderate intensity exercises.

The researchers attributed the cancer cells reduction to cytokines (or inflammatory markers) found in the bloodstream after exercise.

The researchers suggested that the reduction in cancer cells in the colon is not specific to those who had cancer before. Other studies have found similar reductions in prostate cancer cells in healthy individuals as well.

Every individual tolerates and responds differently to exercises, especially HIIT sessions. Train don't strain is important too.



Reference

Devin JL, Hill MM et al (2019). Acute High Intensity Interval Exercise Reduces Colon Cancer Cell Growth. J Physiol. DOI: 10.1113/JP277648.

Autologous Chondrocyte Transplantation For Articular Cartilage Injuries

In the two previous posts, we discussed the microfracture technique and the mosaicplasty technique for articular injuries. The third major procedure for articular cartilage injuries is autologous chondrocyte transplanatation (ACT) or autologous chondrocyte implantation (ACI). This is also the most invasive of the three. This method is usually chosen if the defect is larger than 5 cm and especially if there's a "kissing lesion" (or touching lesions on two joint surfaces).

Kissing lesions- both surfaces affected

The patient undergoes two surgeries for this. In the first, a small patch of healthy articular cartilage the size of one of two Tic Tacs is harvested (from the knee) and sent to a laboratory. It is subsequently grown in a protected medium to get more healthy articular cartilage. During the second surgery two to three weeks later, these newly grown articular cartilage cells are placed onto the defect (which is cleaned) to restore the surface.

There are of course variations to the three surgical interventions described in these few posts like a cell based, biodegradeable membarnes or scaffolding, stem cells etc.

Return to light sporting activities is usually allowed after six months with full return to sports at around nine to twelve months after the second surgery depending on how the patient recovers.

These have strong implications for physiotherapists in the management of these disorders as physiotherapists take charge of the patient's rehabilitation program after surgery. Successful rehabilitation for a patient requires the physiotherapist to have knowledge of the biology of articular cartilage and the factors that will influence damage and repair.

This requires restoring motion and muscle function while reducing functional limitations during weight bearing activities. Patient education and setting of realistic goals based on the extent of the damage is crucial to a successful outcome.

The postoperative management of patient varies according to the surgery performed. There are different time frames for non and partial weight bearing, specific physiotherapy treatment and use of continuous passive motion (CPM) machines. Other than improving range, CPM machines provide a mechanical stimulus to joints to promote healing (Sledge, 2001).

A good surgical technique is only as good as its rehabilitation. Come and see us if you have articular cartilage injuries as we definitely know what to do.


References

Brittberg M, Lindahl A et al (1994). N Eng J Med. 331(14): 889-95. DOI: 10.1056/NEJM199410063311401.

Vasiliadis HS and Wasiak J (2016). Autologous Chondrocyte Implantation For Full Thickness Articular Cartilage Defects Of The Knee. Cochrane Database of Systematic Reviews. Issue 10. Art. No CD003323. DOI: 10.1002/14651858.CD003323.pub3.

Sledge, SL (2001). Microfracture Techniques In The Treatment Of Osteochondral Injuries. Clinics Sp Med. 20(2): 365-377.

Mosaicplasty For Articular Cartilage Injuries

Last week we discussed the microfracture technique for articular cartilage injuries. Many of my patients who read the article commented that they did not realize it was such a serious condition. Yes, indeed, having an articular cartilage injury is worse than tearing your anterior cruciate ligament (ACL). The lengthy rehabilitation makes it much worse.

Generally, the microfracture technique works well only for the smaller lesions (less than 3 cm). If the size of the defect is larger, the surgeon would usually perform mosaicplasty or autologous chondrocyte transplantation (ACT). The latter procedure works better if there is a "kissing lesion" (defect on both joint surfaces).

I wrote that the microfracture technique was made popular by Richard Steadman. For mosaicplasty, it is Professor Laszlo Hangody from Hungary who has probably performed the most procedures and published the most articles on the topic.

Harvesting the bone plugs

Mosaicplasty is a technique in which small bone plugs with healthy hyaline cartilage are taken and then transplanted to cover the defect in the damaged area. The bone plugs are usually taken from an area that is non weight bearing to cover the defect in the affected area. The end result ends up looking like mosaic tiles, hence the name mosaicplasty.

Here's a closer look

The hope is that the body will not miss the taken parts and it can be used where it is needed. Over time, the holes in that part of  bone that is taken will fill with bone and scar tissue. The bone plugs can be from the patient or from fresh cadavers.

The above diagram shows the procedure done on a patient's knee, but it can be done on the ankle, hip and other weight bearing articular surfaces too.

A similar technique to mosaicplasty is Osteochondral Autograft Transfer System or (OATS). The bone plugs used in OATS are usually larger and usually only one or two plugs are needed to fill the area of damage.

See the gaps in between the bone plugs?

In the above pictures, you can see that there are still gaps between the cylindrical bone plugs. This is the main problem with this particular technique. The defect is not filled completely and the gaps normally fill up with fibrocartilage. There is then a worry about how this holds up over time, especially if the patient is keen on returning to sports.

Recently, there has been an improvement/ modification to this technique. A group of researchers, inspired by the honey comb structure of a beehive of honey bees decided to use hexagonal shaped bone plugs instead of the cylindrical ones used previously.

No more gaps?

This is to eliminate the gaps while performing the procedure. The authors named it hexagonal osteochondral graft system (HOGS). Early outcomes of HOGS seemed comparable to mosaicplasty and promising at this stage although further follow up needs to be done.

Advantages of mosaicplasty  are that only one operation is needed (compared to two in ACT) and hence lower cost and less down time. There is less risk of disease transmission and there is a high percentage of hyaline cartilage for the damaged surface.

These procedures require the physiotherapist treating the patient to have knowledge of the biology of articular cartilage and the factors that may influence degradation and repair. The physiotherapist needs to know the nature, location, size of lesion and the surgical procedure performed.

Rehabilitation should address the patient's impairments and functional limitations without jeopardizing healing of the lesion.

I remember back in 1999, as a young physiotherapist a patient told me he had mosaicplasty done and I had asked him what it was. That piqued my interest in articular cartilage injuries and especially so when I later had to have a microfracture procedure done on my right knee in 2003. That also was why I did postgraduate work in that area as I desperately wanted to compete again.

My next post will be on the autologous chondrocyte transplantation/ implantation (ACT) procedure.

References

Erol MF and Karakoyun O. (2016). A New Point Of View For Mosaicplasty In The Treatment Of Focal Cartilage Defects Of Knee Joint: Honeycomb Pattern. SpringerPlus. 5(1): 1170. DOI: 10.1186/s40064-016-2796-y.

Gracitelli GC, Moraes VY et al (2016). Surgical Interventions (Microfracture, Drilling, Mosaicplasty And Allograft Transplantation) For Treating Isolated Cartilage Defects Of The Knee In Adults. Cochrane Database of Systematic Reviews. Issue 9. Art. No CD10675. DOI: 10.1002/4651858.CD010675.pub2.

Hangody L and Balo E (2011). Autologous Osteochondral Mosaicplasty. In Sanchis-Alfonso V. (eds). Anterior Knee Pain And Patellar Instability, London.