Friday, February 7, 2014

Arthroscopic Knee Surgery No Better Than Sham Surgery

Left knee-joint from behind, showing interior ...
Left knee-joint from behind, showing interior ligaments. (Lateral meniscus and medial meniscus are cartilage.) (Photo credit: Wikipedia)

By Dr. Mercola
Arthroscopic knee surgery is one of the most common unnecessary surgeries performed today—along with back and hip surgeries, pacemakers, cardiac angioplasties, hysterectomies, and Cesarean sections.
Several studies over the past decade have highlighted questions about arthroscopic knee surgery, and now, you can add one more to the pile. The meniscus inside your knee is a thin crescent-shaped disc of cartilage that serves as a cushion between your femur and tibia and helps stabilize your knees.
Over time, your meniscus can develop tears, especially if you have arthritis. The standard orthopedic surgeon's intervention for meniscal tears is performing an arthroscopic partial meniscectomy—trimming the torn meniscus and smoothing the jagged edges of what remains, which assumes the tear is what's causing your pain. However, that may be a faulty assumption.

Knee Surgery No Better Than Sham

This latest study, conducted in Finland, examined 146 patients with degenerative meniscal tears (caused by "wear and tear," not acute injury).1 Researchers divided patients into two groups.
One group received the standard surgery, and the other received a "sham surgery"—in other words, a fake or placebo intervention where no actual surgery takes place. The study excluded people with knee arthritis, because they tend not to benefit as much from meniscus surgery and the researchers wanted to ascertain if the surgery helps under "ideal circumstances."2
The sham surgery involved the physician's making an incision and poking around without any actual cartilage shaving or cutting. Many of the patients were given epidural anesthesia, so they were awake, making it necessary for surgical staff to use their "theatrical talents" to pull off a believable sham surgery.
The outcome? One year later, both groups reported equally favorable responses to the procedure—primarily, reduction in knee pain. In the end, the researchers concluded that the real knee surgeries offered no better outcomes than the sham surgeries.
Arthroscopic surgery on the meniscus is the most common orthopedic procedure in the US, and according to this study, is performed about 700,000 times a year to the tune of $4 billion. Any surgeon who tells you this is the best or only option for your osteoarthritic knee pain will not have a leg to stand on when you show him or her all of the evidence to the contrary.

Arthroscopic Surgeries Have an Embarrassing Track Record

Prior to the Finnish study, there were already three prior studies of note that should have orthopedic surgeons rethinking how they treat their knee patients:
  1. landmark study in Texas set the ball rolling back, over ten years ago, in 2002. The study involved 180 participants randomly assigned to either have the real operation or sham surgery, in which surgeons simply made cuts in their knees. The real surgery turned out to have no benefits over the sham procedure.3 This was a classic multi-center (including Harvard) double blind controlled trial that clearly showed the surgery was a $3 billion waste.
  2. In 2008, a Canadian study compared the benefits of physical and medical therapy to arthroscopic surgery for osteoarthritis of the knee. Researchers concluded that physical and medical therapy provided equal benefit to surgery.4
  3. In 2013, researchers compared the functional outcomes of physical therapy versus arthroscopy for patients with meniscal tears. They found that arthroscopy followed by postoperative physical therapy had no benefit over physical therapy alone.5
See the pattern emerging here? It's hard to miss! Eighty percent of meniscal tears develop from wear and tear over time.6 If you have pain in your knees from ordinary activities or arthritis, you may be better off skipping the surgery and going straight to physical therapy.
Or better yet, get some treatments with an infrared laser that I discussed in detail with Dr. Harrington.
Of course, there are other non-invasive therapies that can be helpful as well. But it's becoming quite clear that a torn meniscus—at least, the wear-and-tear variety—is not going to be helped by a "surgical trim." Surgeries come with all sorts of risks, and there is no point in exposing yourself to these without some clear advantage.
If you have a torn meniscus from an accident or injury, the scenario may be different, but I would still recommend you getting a second or even third opinion before going under the knife.

The Power of Placebo

With TWO studies now highlighting the benefits of placebo knee surgeries, the power of placebo just can't be ignored. Placebos typically have far fewer side effects (if any) than prescription drugs, injections, or actual surgeries—and they often work just as well as the standard of care.

Studies have shown that if you think you're receiving a treatment, and you expect that treatment to work, it often does—even if you know you're receiving a placebo.
This was beautifully demonstrated in the Finnish study—the knee surgery patients knew they might be having a sham surgery, yet they experienced the benefits anyway. But how do placebos work? How can your brain produce healing just because you believe it should be happening?

Although the exact mechanisms of the placebo effect are not well understood, it seems related to changes in your brain in response to different psychosocial stimuli. Areas of your brain associated with expectations, anxiety, and rewards seem to be involved. Scientific American reported:7
"In recent decades reports have confirmed the efficacy of various sham treatments in nearly all areas of medicine. Placebos have helped alleviate pain, depression, anxiety, Parkinson's disease, inflammatory disorders and even cancer.
Placebo effects can arise not only from a conscious belief in a drug but also from subconscious associations between recovery and the experience of being treated—from the pinch of a shot to a doctor's white coat. 

Such subliminal conditioning can control bodily processes of which we are unaware, such as immune responses and the release of hormones… Researchers have decoded some of the biology of placebo responses, demonstrating that they stem from active processes in the brain."
You can tap into your own placebo effect with techniques such as EFT or Emotional Freedom Technique. This is a new way of thinking about healing for most people that can be extremely powerful, especially when combined with a positive outlook and a proactive, disease-preventive lifestyle.

Your Secret Weapon Against Knee Pain: Exercise

Exercise is the real medicine for pain in your joints. Exercise helps prevent and relieve joint pain through a number of mechanisms, including strengthening key supportive muscles, improving flexibility and range of motion, improving bone strength, and helping you optimize your weight. The notion that exercise is detrimental to your joints is a serious misconception; there is no evidence to support this belief. It's simply a myth that you can "wear down" your knees just from average levels of exercise and/or normal activity.
This is not to say that traditional pavement-pounding, like distance running, is going to be of any benefit to your knees—I'm talking about low-impact but effective exercise, such as high-intensity interval training (HIIT), high-intensity cardio, weight training,stretching, and core work. If you find you're in pain for more than an hour after your workout, you should slow down or choose another form of exercise—there really are plenty to choose from.
If you've already developed osteoarthritis in your knees, you'll want to incorporate exercises that strengthen your quadriceps muscle at the front of your thigh. And, rather than running and other high-impact activities, you may be better off with non-weight-bearing exercises like swimming and cycling. Strengthening and stretching the areas around, above, and below your knee is key to reducing most knee pain, which is the goal of the exercises I demonstrate in the video above. Make sure to wear appropriate footwear for all of your daily activities. Spiked heels and very flat soled shoes place unnatural stresses on your knees. Goodposture is important as well.

Tips for Natural Pain Relief and Growing Healthy Cartilage

For joint pain, many physicians commonly recommend anti-inflammatory drugs (non-steroidal anti-inflammatories or NSAIDs) and analgesics (such as Tylenol) to their osteoarthritis patients. I don't recommend the chronic use of these drugs due to significant side effects, which may include kidney and/or liver damage. There are safer and more effective natural options for relieving joint pain. Although popular, I am also not much of a glucosamine and chondroitin fan because studies have failed to demonstrate their effectiveness. However, there are some very effective natural remedies that are truly backed up by science. The following are my favorites:
  • Vitamin D: Cartilage loss in your knees, one of the hallmarks of osteoarthritis, is associated with low levels of vitamin D. So if you're struggling with joint pain due to osteoarthritis, get your vitamin D level tested, then optimize it using appropriate sun exposure or a safe tanning bed. If neither of these options is available, you may want to consider oral vitamin D3 and K2supplements.
  • Sun exposure is your best option, because your skin produces two types of sulfur in response to sun exposure: cholesterol sulfate and vitamin D3 sulfate. Sulfur plays a vital role in the structure and biological activity of both proteins and enzymes. If you don't have sufficient sulfur in your body, this deficiency can create a number of health problems, including negative impacts on your joints and connective tissue. Which brings us to the next item...
  • Sulfur/Epsom salt soaks/MSM: In addition to making sure you're getting ample amounts of sulfur-rich foods in your diet, such as organic and/or grass-fed/pastured beef and poultry, Dr. Stephanie Seneff, a senior scientist at MIT, recommends soaking your body in magnesium sulfate (Epsom salt) baths to counteract sulfur deficiency. She uses about 1/4 cup in a tub of water, twice a week. It's particularly useful if you have joint problems or arthritis.
  • Methylsulfonylmethane (known as MSM) is another alternative you might find helpful. MSM is an organic form of sulfur and a potent antioxidant naturally found in many plants, and is available in supplement form. For more on the benefits of MSM, I recommend listening to this interview.
  • Infrared laser: Infrared laser treatment (also called K-Laser) is a relatively new type of therapy that speeds healing by increasing tissue oxygenation and allowing injured cells to absorb photons of light. This special type of laser has positive affects on muscles, ligaments and even bones, so it can be used to speed the healing of traumatic injuries, as well as chronic problems like arthritis of the knee.
  • Astaxanthin: An antioxidant that affects a wide range of inflammation mediators, but in a gentler, less concentrated manner and without the negative side effects of steroidal and NSAID drugs. Astaxanthin significantly reduces inflammation in many people—in one study, more than 80 percent of arthritis sufferers improved8.
  • Eggshell membrane: The eggshell membrane is the unique protective barrier between the egg white and the mineralized eggshell. The membrane contains elastin, a protein that supports cartilage health, and collagen, a fibrous protein that supports cartilage and connective tissue strength and elasticity.
  • Eggshell membrane also contains transforming growth factor-B, a protein that helps with tissue rejuvenation, in addition to other amino acids and structural components that provide your joints with the building blocks they need to build cartilage.
  • Hyaluronic acid (HA): Hyaluronic acid is a key component of cartilage required for moving nutrients into and waste out of your cells. One of HA's most important biological functions is the retention of water. Unfortunately, as you age, your body produces less and less HA. Oral HA supplementation may improve your joint cushioning in just two to four months.
  • Boswellia: Also known as boswellin or "Indian frankincense," I've found this Indian herb to be particularly useful in treating the pain and inflammation of osteoarthritis. With sustained use, boswellia may improve the blood flow to your joints, which may boost their strength and flexibility.
  • Turmeric/curcuminA study in the Journal of Alternative and Complementary Medicine9 found that taking turmeric extracts each day for six weeks was just as effective as ibuprofen for relieving knee osteoarthritis pain. This is most likely related to the anti-inflammatory effects of curcumin—the pigment that gives turmeric its vibrant yellow color.
  • Animal-based omega-3 fats: Omega-3 fats are excellent for arthritis because they are well known for reducing inflammation. Look for a high-quality, animal-based source such as krill oil.
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