Growing Bones.
WHEN THE JOINTS HURT AND THE BONES ACHE, MOST PEOPLE would rather stay in bed. But as with other problems weave discussed, this will only lead to more trouble. Perhaps lying down might spare the cartilage, that smooth and elastic lining of the joints that makes sure bones do not grind painfully on each other when used. Yet it is not only the cartilage that helps your joints. The surrounding muscles also guard and protect joints because they cushion the jolts that damage a moving body. Thanks to muscles, cartilage absorbs fewer shocks.
For that reason, physical inactivity is like poison for the joints. The more muscles waste away, the more b.u.mps and jolts directly affect the cartilage, gradually wearing it down. This way, bones start to ache, people become less active, muscles shrink more, and cartilage gets battered even hardera"not a happy trend. A joint may end up being completely destroyed so that it must be replaced with an artificial one. Or the threat looms of being moved to a retirement home. Neither dementia nor problems caused by arteriosclerosis are the most frequent reason for being inst.i.tutionalized; most people are admitted because they suffer from an ailing musculoskeletal system.
But thereas hope. People canat reclaim lost cartilage, but they can definitely increase muscle ma.s.s. In this way, you can renew the guardians of your joints, preventing future disease, and cure existing ailments.1 STRENGTHENING RATHER THAN REPLACING JOINTS.
At about 120 different spots in the body, two bones are connected with joints. Unfortunately, not all of them are perfect links. The term arthritis covers more than 100 distinct conditions relating to joint problems, and each one can make life miserable. There are two types of arthritis: inflammatory and degenerative. Common osteoarthritis belongs to the latter one; mechanical forces drive the destruction of cartilage, mainly of the knee and the hip. Among 34-year-old people, about 17 percent suffer from osteoarthritis; among people of age 65 or older, the figure is more than 90 percent. Once the cartilage is gone, the disease can progress rapidly, resulting in bulky joints, thickened bones, muscular atrophy, and inflammations that ravage the capsules that cushion the joints.
People notice this degeneration because of the pain developing over time. Initially, the pain occurs only when the affected joints are moved or touched. After a while, the aches become chronic, and the joints swell. At this point, many patients unconsciously cut down on physical activitya"and unwittingly worsen their ailments.
Severely arthritic knees have become a huge and lucrative field within the medical industry: Patients are either instructed to take expensive drugs or to get artificial joints implanted. Yet the researcher Miriam Nelson, at Tufts University in Boston, seems to be convinced there is another way: The best remedy may be for stricken patients to help themselves by strengthening the affected leg muscles.
Nelson and her colleagues have developed a 16-week training program that can be done at home with a stool and light ankle weights.2 The researchers tested their program with 46 volunteers who were in virtually constant pain and were hardly able to walk or climb stairs. The researcher Kristin Baker, part of the Tufts team, visited the patients at home and told half of them how to do the exercises. The other patients also received house calls, but during these visits, Baker just talked in broad terms about the disease and tried to lift the patientsa spirits a little.
Subsequently, the researchers compared the outcomes of the two groups. The patients of the training group reported they had significantly less pain and could perform 17 different physical tasks much better than the inactive patients. The average pain level of the exercising group had plummeted by 43 percent, compared to 12 percent for the inactive patients. The physical performance of the first group improved by 44 percent, nearly twice as much as in the placebo group, which the researchers attribute to muscular resilience; the strength of the thigh muscles increased by 71 percent.
aAll of a sudden, people who had founds lifeas daily activities more and more challenging and painful as a result of arthritis pain were able to partic.i.p.ate in life in ways they hadnat been able to for years,a states Miriam Nelson. aThe exercisers were able to walk, climb stairs, sit, and stand more easily. And they slept more easily.a3 By now, these landmark findings have been confirmed many times. A large survey of 786 patients with worn-out knee joints has also shown that people who exercise the muscles surrounding their affected knee are rewarded with significantly less pain. In order to reap this benefit, it was necessary to work out only 20 to 30 minutes per day with elastic straps.4 The training does more than reduce pain. People adopting an exercise regimen can use their joints much better than before. In a trial of 250 patients aged 60 or older, the partic.i.p.ants had chronic pain but were still mobile. They could get up without support, went to the bathroom alone, and dressed themselves. In the study, they were randomly a.s.signed to three different groups. The members of the first one were asked to walk briskly three days per week. After three months, the first part of the program ended, but the volunteers were encouraged to keep their newly acquired walking habit.
The members of the second group were instructed to do nine different exercises at a weight-lifting machine. They, too, were asked to continue after the initial three-month period. Finally, there was a control group who received general information about osteoarthritis but were not prescribed any exercise.
One year later, all partic.i.p.ants were examined to see whether they could still keep up with the activities of daily life. The result: In the control group, 53 percent of the people had lost the ability to live without a.s.sistance. In the other two groups, that was true only for 37 percent, no matter what type of activity they did. The more diligently a person trained, the better the result. Overall, the success rate could have been even larger had all the volunteers lived up to their resolutions. But after 10 months, only 54 percent of them continued the exercises. The dropouts altered the outcome of the study and, worse, their own health.5 A review of the literature on osteoarthritic knees and exercise suggests that the type of exercise is less important than being active in the first place. Even moderate activities, like doing the Chinese martial art tai chi three days per week, bring promising results, Jean-Michel Brisme and colleagues at the Texas Tech University Health Sciences Center, in Lubbock, Texas, have found.6 In those cases, patientsa pain was relieved after only nine weeks, and the mobility of their joints improved. A recent study in the prestigious New England Journal of Medicine showed that arthroscopic surgery for osteoarthritis of the knee aprovides no additional benefit to optimized physical and medical therapy.a7 The results are remarkable, given that mainstream medicine strongly favors more aggressive therapy options like drugs or surgical procedures. About 300,000 knee replacement operations and more than 193,000 hip replacement surgeries are performed each year in the United States.8 Even though these interventions are often necessary and a pain-killing G.o.dsend for some patients, experts question whether so many are justified. aIf we look at the age and objective discomforts of many patients who were advised to get an artificial hip, we cannot resist the impression that this operation was suggested very prematurelya"long before the treatment with pills and other means like exercise and physiotherapy would have hit the wall,a says the physician Klaus-Michael Braumann at Hamburg University, Germany.9 There are continuing concerns about the high rate of surgical joint replacement in Germany and in the United States because in both countries these interventions are costly for patients and insurers, and lucrative for doctors and hospitals.
RUNNING WITHOUT REMORSE.
Another dangerous myth that keeps people sedentary is that running leads to the premature degradation of knee cartilage. Yet an increasing number of published medical articles indicate the opposite. According to these findings, all these women and men jogging through Central Park in Manhattan or along the Charles River in Boston are not ruining their knees. Actually, it is the large number of sedentary and often obese Americans who sit and lie around whose cartilage is more likely to be in decay.
However, it is very important which type of exercise one chooses. Soccer and downhill skiing are certainly not very good for knees. This is not because of the exercise as such, but because of the high risk of injury to key parts of the knee, such as the capsules under the kneecap, the kneecap itself, and the key ligament in the knee known as the cruciate ligament. Playing compet.i.tive sports does indeed increase the likelihood of suffering from osteoarthritis rather early in life. In one survey, doctors examined the knees of 117 men who formerly were elite athletes and found a lot of injuries: 14 percent of the examined soccer players had osteoarthritis, as did 31 percent of weight lifters.
But running is not among the sports with a high risk for getting injured. According to a study of 27 long-distance runners, the human body is capable of running 20 to 40 kilometers per week for 40 years without damage. Compared to 27 non-runners, these endurance athletes did not show any arthritic signs at the joints of hip, knee, and ankle.10 A similar result was found among runners with an average age of 63 who were monitored for five years, again with no sign of increased cartilage loss.11 By contrast, inactive and obese people have a higher incidence of osteoarthritis, and there seems to be a direct correlation. More than 45 percent of patients with severely osteoarthritic knees carry around above-average weight. Obesity triggers the problem. At first a person becomes fat, then subsequently develops ailing knees. The same connection was found for the hip. Being overweight at age 40 significantly increases the risk for developing osteoarthritis of the hip.
We set our course in middle age, around 40. People who stop exercising by this age in order to protect their bones may actually cause the opposite effect. Jogging helps to reduce weight, which then relieves the joints.12 Arthritis patients who are extremely overweight should be a little cautious, however. Instead of running, they should start out with bicycling and walking.
BEING RESTLESS, FIGHTING RHEUMATISM.
While osteoarthritis is triggered by physical abrasion, so-called rheumatoid arthritis is a chronic inflammatory disease that at first usually affects one particular joint or a few of them. By the time patients see a doctor, about 50 percent of them are no longer able to use their wrists normally. Within the first two years of the disease, big joints usually become affected, and many patients experience severe symptoms. Pain, swelling, and stiffness make it extremely difficult for them to be physically active. This leads to predictable consequences; people with arthritis frequently lose muscle ma.s.s and are 30 to 70 percent weaker than healthy people. Their heart and lungs function worse, and their endurance is reduced by 50 percent.
Physiotherapy under supervision was for a long time the only physical activity that doctors allowed people with rheumatism. These cautious exercises helped the mobility of arthritis sufferers but not their fitness. For this purpose, aerobic training would have been neededa"but physicians were reluctant to prescribe it to their patients because they were afraid it might bring even more damage to inflamed joints. However, it is turning out that this fear was unfounded. Many studies have shown that aerobic as well as strength training soothes the pain from rheumatism without showing any aincreased disease activity or additional destruction of the joints,a says the orthopedic specialist Stefan Gdde at the University Hospital of Saarland in Hamburg.13 Most of the trials included patients with mild to severe symptoms.
Dutch researchers followed 300 patients with arthritis over the course of two years. One group of the partic.i.p.ants received the standard treatment, whereas another group was prescribed exercise for two days per week: 20 minutesa training on a stationary bike; 20 minutesa strength training; and 20 minutes of games like soccer, badminton, basketball, and volleyball. The patients were reexamined every six months. Not only had their rheumatism not worsened, inflammatory processes in the joints were apparently soothed. Loss of bone density had slowed down, and overall fitness had improved, which in turn made the patients happier and more satisfied with their mental well-being.
FITNESS FOR FIBROMYALGIA.
Fibromyalgia is still a medical mystery. Although some physicians doubt its very existence and think of it as a psychiatric problem, others regard it as a widespread disease that is dramatically underdiagnosed. In the United States, 3 to 5 percent of the population is allegedly affected, mostly women. The patients suffer from fatigue, low muscle strength, insomnia, headaches, and a lack of attentiveness. These symptoms might mean that the affected people need exercise. But it is also conceivable that this feebleness is a consequence of the disease. Fibromyalgia is diagnosed on the basis of 18 so-called tender points on the body. These points cannot be recognized anatomically but apparently hurt a little bit when you press on them.
The therapy options for fibromyalgia appear as arbitrary as the cause is mysterious. In Europe, some doctors put their patients in a warm mud bath, others try a medical cold chamber, but neither approach seems to work. Yet one treatment is emerging: in four studies looking into the effects of endurance training, physical exercise appears to allay the symptoms appreciably. As the fitness became better, the unusual fibromyalgia pain eased. Apparently, getting active helps the patients overcome their sickness because the newly gained muscle strength chases off fatigue, reduces pain, and helps patients handle their daily routine againa"thus lifting up their spirits.14 HOPE FOR CHRONIC FATIGUE.
Another complex of symptoms is known as Chronic Fatigue Syndrome (CFS), and it is also very mysterious. As with fibromyalgia, some physicians do not believe its very existence, whereas others are alarmed and call it a very serious condition. The affected people themselves report severe physical and mental exhaustion. If it lasts for six months or longer, and if it is accompanied by sleeping disorders, headache, and muscle weakness, the criteria for a CFS diagnosis are met. CFS was once thought to be caused by viruses, but no one has ever proven this.
This peculiar disease has attracted the interest of exercise researchers. CFS patients may simply be in poor physical shape. On the other hand, MRI imaging indicates that CFS patients have a defective muscle tissuea"the oxygen consumption seems to be hampered.15 The findings encouraged English doctors to a.n.a.lyze the impact of exercise on this illness. During the course of 12 weeks, CFS patients were asked to walk, bicycle, or swim regularly. Fatigue levels were indeed reduced as the patients got in better shape. Even a year after the study, these positive effects still lasted.16 INACTIVITY AND OSTEOPOROSIS.
Of all women age 50 or older, about 20 percent are said to have fragile bones. This statement is based upon bone densitometry, a procedure that pharmaceutical companies, medical instrument-makers, and some pharmacists and gynecologists recommend.
The densitometry is usually carried out through X-rays. The denser the bone tissue, the more the X-rays are attenuated, which can be a.n.a.lyzed with a computer. The results are then compared to the standard bone density of a healthy 35-year-old human. An individual is said to have osteoporosis when her or his readings are 20 to 35 percent below an arbitrary threshold value (which equals 2.5 or more so-called standard deviations under the norm). This measuring system produces results thata"if universally applieda"would turn the vast majority of older people into osteoporosis patientsa"and at the same time into consumers for drugs that allegedly increase the density of the bones.
This whole concept would be a great idea, if it reached the actual goal: cutting down the number of broken bones. Alas, there is no reason to believe that that would be the case. Day after day, older people suffer from fracturesa"even when their bone density measurements produce perfectly normal values. Fifty to 70 percent of the osteoporosis-like fractures actually occur in women showing only a small deficiency in bone density.17 There is an abundance of studies indicating that women who partic.i.p.ate in bone densitometries do not benefit at all. Researchers in Sweden, Germany, and the United States have come to this conclusion in independent trials. Over ten years ago experts at the British Columbia Office of Health Technology a.s.sessment, in Vancouver, presented a thorough report on the question of whether diagnosing osteoporosis makes sense at all. Their conclusion: aResearch evidence does not support either whole population or selective bone mineral density (BMD) testing of well women at or near menopause as a means to predict future fractures.a18 Consequently, health providers in countries like Germany have stopped paying for this useless procedure.
Drugs for osteoporosis have been shown to have no noteworthy clinical effect. The blockbuster is a substance called Alendronate, with annual sales of about $3 billion. The productas molecules migrate into the bone tissue and raise its density. In one study, women with an average age of 68 took the drug for four years, and the risk of hip fractures was allegedly reduced by 56 percent.19 Yet the American physician and author John Abramson took a closer look at the study; he was curious about what this number actually meant.20 How many fractures of the hip were actually averted? The older partic.i.p.ants who did not take the drug had a 99.5 percent chance of living one year without a hip fracture (among 1000 women, 995 would stay healthy). Among the women who actually took the drug, that chance was 99.8 percent (among 1000 women, 998 would stay healthy). In other words, the daily consumption of the drug changed the risk for a fracture from 0.5 to 0.2 percent. In the study, this modest result was boasted as a relative risk reduction of 56 percent.
Translated into real life, the drugas benefit looks like this: 81 women with low bone density must take the drug for 4.2 years (at a total cost of $300,000) in order to avoid one hip fracture. 21 Not only is this effect dearly paid for, there are also indications that it vanishes with time anyway. While a ten-year trial with the substance showed that the value of the bone density was increased, there was no proof that the risk of fractures had gone downa"although that was the reason for this pharmacological intervention.22 But if the drug increases bone density, why is it not preventing fractures? Alendronate may increase bone density, but the bone density is, at best, only an indirect indicator of stability. The basic method for measuring the bone density, densitometry, targets the surface of the bone (the cortical bone). However, it is the inner structure (the trabecular bone) that mainly determines the stability of the big bones. Unfortunately, substances like Alendronate have a much greater effect on cortical bones than on trabecular bones. Thus, the pharmacological effect increases the reading for the bone densitya"yet the stability of the bones is not considerably increased.
In reality, there are other factors that influence the risk of fracture to a much greater extent. More important, for example, are the motor functions of older people and their ability to walk safely. Ninety-five to 98 percent of all fractures among older people occur because of a fall. In fact, it might be more suitable to talk about a afalling-down diseasea rather than osteoporosis. Other key factors are the ma.s.s of the bone and its geometrical shape. In the United States, one out of three adults 65 years old or older falls each year, with hip fractures resulting in the greatest number of related deaths and serious health problems. Women account for 80 percent of the 300,000 hip fractures that occur annually.
In contrast to the bone density (which is weight per volume), the absolute bone ma.s.s indicates how much bone substance a human actually has. The bone ma.s.s peaks in young adulthood, and thereafter declines with age. In rare cases this loss is, for genetic reasons, extremely p.r.o.nounced and hard to stop. Those affected may become hunchbacks relatively early in life.
Ordinarily, bone density is most determined by an environmental factor: exercise. Whenever we use our muscles, they, by exerting strain, increase the bone ma.s.s. Thus, in most cases osteoporosis is not a fateful disorder of bone metabolism but simply the direct result of decades of physical inactivity. And where gynecologists and employees of pharmaceutical companies blame menopausal changes as the cause of osteoporosis, they divert attention from the more important reason for the problem and conceal the most efficient remedy.
The muscular system has been found to determine 80 percent of bone stability. It was the German anatomist and surgeon Julius Wolff (1836-1902) who proposed this in his alaw of the bone transformation,a now known as Wolffas law. This law says that bones in a healthy person will adapt to the strains they are placed under. If loading on a particular bone increases, the bone will remodel itself over time to become stronger.
In the 1960s, the American orthopedist Harold M. Frost expanded this theory by emphasizing that muscles and bones comprise a single physiological unit: He proposed that the body must have specific sensors capable of recognizing mechanical forces and of relaying this information so that the bone grows according to this load. Whereas strain during muscle training triggers the growth of bone tissue, physical inactivity leads to loss of bone tissue.
Eckhard Schnau at the University Hospital in Cologne, Germany, along with colleagues, recently confirmed this hypothesis using CT imaging. The researchers put 349 healthy children and adolescents in CT scanners and determined precisely the composition of their bones and muscles. The data from this high-tech measurement fitted nicely into the old law of muscle transformation, and indeed suggested that the muscular system had determined the makeup of the bones. The sensors that Harold M. Frost had proposed as the reason for this were also discovered: bone cells are connected to each other by dendrites, and the resulting vast network can sense physical strain and adapt to it.23 The process of bone development begins early. An unborn baby, kicking away inside his motheras womb, gives his bones the mechanical strain needed to grow properly. Children need no advice to run and tumble and play; all that perpetual activity promotes the development of robust and healthy bones.
Neither milk nor calcium pills can subst.i.tute for exercise. A normal diet does contain enough calcium, but the body will flush it out swiftly if a person is not in motion. If you want the calcium to become part of your bones, you just have to heed Wolffas law and start using your muscles.
Actually the situation with osteoporosis drugs is quite similar. They can be beneficial for patients with severe loss of bone substance because they alleviate pain. Yet unless the consumption of the pills is accompanied with physical activity, they cannot compensate for the consequences of letting the body waste away.
Time and again, trials of menopausal women have confirmed that moderate aerobic and strength training make the spine stronger. And in order to reduce hip fractures, walking seems to be the best medicine. A study at Brigham and Womenas Hospital in Boston, which included investigators from the Harvard School of Public Health, showed that women who walked at least four hours per week had approximately 40 percent fewer hip fractures, compared with women who were mostly sedentary. Higher-impact exercise provided greater protection. Exercise equivalent to about three hours of jogging per week reduced the risk of hip fracture by approximately 50 percent. aThe news about walking continues to be positive, and our study contributes further evidence that regular physical activity is a womanas key to prevention of hip fractures,a said Diane Feskanich of Brigham and Womenas. aTo reduce risk, women should know that any amount of activity is better than none.a24 A team of researchers at the University of Freiburg, Germany, were curious whether they could make frail people more sure-footed again and tested this idea with a specific exercise for balance and agility.25 Twenty volunteers from ages 60 to 80 practiced standing on one foot as they walked over wobbly planks and balanced on a rope on the floor. In their childhoods, these individuals would have laughed about how easy these tasks werea"but now, after decades of nonuse of their bodies, they had to relearn these movements from scratch. At the end of the trial, the balance of partic.i.p.ants was tested with clever tricks. They stood on a mat that would suddenly be pulled to one side and ran on a treadmill that was suddenly stopped. In comparison to those who had remained sedentary controls, the rate of tripping and losing balance was significantly reduced. This regained control over the motor skills is a good protection against falls.26 A survey in the United States compared the effectiveness of exercise with that of osteoporosis drugs. The study included 10,000 women over 65 and followed them for five years. The a.n.a.lysis of the data revealed that women who had trained for at least two hours per week had 36 percent fewer hip fractures than sedentary women, according to the journal Annals of Internal Medicine.27 In the course of one year, there were six fewer fractures per 1,000 women among the active group of women than among the inactive ones. This effect is actually twice as big as the one reported in the aforementioned study on Alendronate.
The only effective way to keep bones in good shape is to stay active for life. Research shows it is never too latea"getting started at age 80 is better than never. Mobilizing of a body also improves balance and makes one sure-footed, which is very important because falls, as we saw, are the main reason for bone fractures among elderly people. Moderate strength training, for example, is a good way to avoid falls. Tai chi creates awareness and body control, thus also reducing the likelihood of falls in older age.
The trial results discussed here have led to a turning point in orthopedics that would have seemed unthinkable just a short while ago. Physical motion was traditionally believed to be the worst thing one could inflict on an aching jointa"until the opposite turned out to be true.
Unfortunately, the new knowledge about the healing power of exercise has not reached all people suffering from aching joints and bones. At the same time, in a sedentary and aging population, the number of muscular-skeletal diseases is increasing to the extent that physicians wonder if treating all the resulting ailments is financially possible. But when orthopedists gathered recently at a conference in Berlin, they agreed on the culprit of all of these maladies, saying that physical inactivity is the number-one public health problem of the third millennium.28
8.
A Sporting Cure for Back Pain.
JAMES WEINSTEIN REACHED FORWARD TO LIFT A HEAVY BOX. SUDDENLY, he felt an extraordinary pain shooting through his back. Weinstein, a silver-haired professor, was unable to sit down, but somehow he managed to lie on the floor and rest. When Weinstein tried to get up after a while, it took a tremendous struggle.
Thousands of individuals all over the United States are in a similarly miserable situation at any given moment. From one second to the next, the world is a different place. Itas as if a glowing dagger were prodding the lumbar vertebrae. Happy people turn into creatures of misery.
But Weinstein immediately knew what to do. He is one of the most renowned back specialists in the United States and teaches at Dartmouth Medical School in Hanover, New Hampshire. Weinstein took an anti-inflammatory drug, put ice on the aching spota"and went jogging.1 This approach borders on heresy. People suffering from acute pain are usually asked to rest at least until the pain has markedly abated or completely disappeared. Yet the ailing professor merely heeded the advice he gives patients in his own back-pain program at Dartmouth: Hurt does not mean harm. aIn other words, one can have pain and still function.a2 Weinstein is not the only physician to discover that exercise is the key to overcoming lower back pain and triggering the bodyas power to heal itself. Increasingly, doctors encourage back-pain patients to stay active and to soldier on with their daily routines.
What a complete turnabout this is! Just a few years ago, people with lower-back pain were prescribed strict bed rest lasting one to two weeks. Afterward, they were ordered to take it easy and to avoid everything that would cause discomfort. However, a few physicians started to rebel against the common wisdom and demanded exactly the opposite. Patients suffering from lower-back pain, they thought, should stay physically active.
The British doctor Gordon Waddell was one of the first to question these contradicting approaches and tried to determine which one was right. He and two of his colleagues carried out a unique survey, a.n.a.lyzing all the scientific papers they could find that studied the effects of either bed rest, or an active recovery, on lower-back pain. It turned out that bed rest led to terrible outcomes. Consequently, Waddell and his colleagues wrote a paper demanding a radical reversal of the traditional bed-rest treatment: aA simple but fundamental change from the traditional prescription of bed rest to positive advice about staying active could improve clinical outcomes and reduce the personal and social impact of back pain.a3 In the wake of this revelation, medical guidelines and official recommendations gradually dropped the principle of complete rest.
Yet in many consultations, these revised recommendations are forgotten. This is particularly worrisome given that the mind-set and advice of a physician profoundly influences the development of an individual sickness. The general pract.i.tioner Annette Becker, of the University Hospital in Marburg, Germany, writes, aThoughtless remarks or putative explanations like ascribing problems to awear and tear,a recommending rest, or repeated pa.s.sive measures like ma.s.sages and giving sick notes to exempt patients from certain obligations trigger, especially among fearful and dramatizing patients, only more worries about their well-being, like: aI must be careful with my back, Iave worked too much in my life, I must think about myself now.aa This type of thinking can lead to a vicious circle. Individuals with chronic back pain stop using their bodies and slide into complete inactivity. Their backs continue to waste away, which triggers new waves of pain.4 SORE BACK TODAY, DISABLED TOMORROW?.
At any given time, about 35 to 40 percent of the adult population in the industrialized countries suffer from back pain. Fortunately, in most cases these aches disappear by themselves. But about 10 percent of the time the pain stays, and becomes chronic. And about 5 percent of all back patients turn into problem cases: following their back spasm, alumbago,a or a slipped disk, they never become fully functional people again. They are unable to work, are deemed disabled, and their back pain governs their lives.5 The sad fact that millions of patients have suffered through all this is caused in part by an incorrect view that still persists in the medical world. Traditionally many doctors regard back pain as a mechanical problem: If there is pain, there must be a physical problem. But this way of thinking can have adverse consequences: The patients are examined over and over with increasingly aggressive methods, until the doctor makes a diagnosis and starts a treatment that, in reality, is not related to the pain.6 The mechanical trigger of back pain is a phantom that has been chased by medical professionals for more than 100 years. During this hunt, many theories have become dominant, only to be quickly abandoned. Once, flatfeet were thought to cause back pain. In turn, gout, festered maxillary sinuses, syphilis, colds, and varicose veins have all been said to be the culprit. And because the prevalence of back pain seemed to rise during the nineteenth century, when the first railway networks were built, the so-called railway spine syndrome became the disease of the day. According to this idea, back pain was triggered not only by severe injuries but also by the minor b.u.mps and shaking caused by the speed of moving trains.
In 1934, the American physicians William Mixter and Joseph Barr developed the theory further and announced that slipped and damaged disks caused back pain. By 1945, this dogma held that disks caused 99 percent of all back-pain cases. Subsequently, back surgery took off, and continues booming to this day. Medical historians coined the term adynasty of the disk,a and the surgical removal of a disk (discectomy) is today one of the standard procedures in orthopedics.
At first glance, this all makes perfect sense. The processes going on between the disks of our spine seem designed for disaster. Surprisingly early in life, disks are p.r.o.ne to fissures, wearing down, and loosening. By the time we are 20, the tissue of the disk has become worn down and tends to protrude or prolapse. When the orthopedist Jrgen Krmer headed the International Society for the Study of the Lumbar Spine, his presidential address was on the natural course of disk diseases: aThe degeneration curve starts at the age of one when humans begin to squeeze their discs in the upright position. Disc degeneration is progressive and almost universal in the human spine. The curve ends up with 100 percent disk degeneration in the aging spine.a7 This decline is caused by the biological composition of the disks. Made of a gelatinous type of tissue, they are not supplied by blood vessels and absorb nutrition as a sponge does. While we are sitting and standing, these disks become squeezed, so that fluids containing waste material can leave the disk tissue. Yet while we are lying down, disks take in fluids and become saturated with all the nutrients they need. aThe disc,a says Krmer, ais an osmotic system that lives on motion. Because of the human sedentary nonmoving lifestyle, disc generation is progressive.a By now, all these degenerative processes in the spine can be detected by CT and MRI scans in greater detail than ever before. But that is not necessarily good for the patient. When doctors examine individuals who have no pain at all and consider their backs to be healthy, they usually come up with alarming results. In one trial, 67 volunteers with no history of back problems were scanned by MRI.8 Among the subjects under the age of 60, it was found that one in five actually had at least one disk prolapse. In one out of two cases, there was a protrusion of at least one disk. The results for the subjects at age 60 or older looked even worse: More than 30 percent had a disk prolapse, and nearly 80 percent had a protruded disk. And yet all those people were not in pain. The renowned specialist Richard Deyo at Harborview Medical Center in Seattle states: aDetecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.a9 As long as an individual with a disk prolapse is free of pain, he or she will not usually have surgery. However, if doctors encounter a person with pain and a herniated disk at the same time, both physician and patient are convinced they have found the reason for the pain. The orthopedist Steffen Heger says: aTwo events happen at the same time in a patient, consequently a casual relation is postulated.a10 Yet in many cases such a correlation is not a given. When a person has a slipped disk, it is not necessarily the cause of the pain. Nevertheless, such a patient is very likely to have surgery, says Heger: aOne must a.s.sume that in many cases something was operated on that wasnat the cause of the back pain.a Small wonder so many patients feel little or no real alleviation after surgery. According to various studies, 10 to 60 percent of all operations fail in this way. These unnecessary procedures are so numerous that they have given rise to a new medical condition: the afailed back surgery syndrome.a When patients suffering from lower back pain are examined, in 85 percent of the cases the resulting diagnosis does not actually reveal what causes the pain. The a.s.sociation between symptoms and the results of the imaging is weak, and many doctors like to say strain or sprains were the trouble-makers. Yet astrain and sprain have never been anatomically or histologically characterized, and patients given these diagnoses might accurately be said to have idiopathic low back pain.a11 The still-widespread belief that physical damage to a disk is behind all back pain is the main reason so many doctors continue to regard bed rest as a therapeutic measure. The well-intentioned result is often that a person suffering from back pain takes time off work and goes to bed. Yet more up-to-date experts agree that it is just this immobilization that can turn aches into chronic pain. aBed rest doesnat only weaken the muscular system but it also leads on to inactivity osteoporosis,a says Heger. Psychologists also believe bed rest is dramatically underestimated as a trigger of sickness and that athe prescription of too long bed rest is one of the princ.i.p.al reasons for physical deconditioning.a12 Here again we see the danger of going to bed: Only 50 percent of all back patients who have been off work longer than six months ever make it back to their jobs.
THE CULPRIT: DETERIORATING MUSCLES.
Cartilage, ligaments, and bones are not the only components that help to keep the back in shape and give us good posture; muscles also play a key role in stabilizing the body. Although they enable our back to move, they also restrain it, like a corset, with the flexibility needed in our back to absorb shocks. This way, jerky movements and falls usually do not result in slipped or ruptured disks.
There are two parts to our musculature with different tasks. The global system consists of long muscles usually located at the surface of the body. They make possible the movements of the body. By contrast, the muscles of the local system are short, run transversely to the body, and are close to the joints. This way, they support the joints and protect them against sudden movements and mechanical overload. This muscle corset is the precondition for a strong and trouble-free back. The stability of the lumbar spine, for example, is 80 percent due to muscles.13 Losing this stability is a major reason for acute and chronic back pain.
Despite the key role of muscles, the standard diagnostic tests for lower-back pain almost always involve the disks and the vertebrae. The shape and the composition of the muscle system, on the other hand, are often not examined at all. Fortunately, some physicians have developed a model that takes all the components into account. This includes the pa.s.sive system, composed of bones, ligaments, and joints; and the active system, consisting of muscles. This comprehensive model is important because the active and the pa.s.sive systems depend on each other, and each is able to compensate for deficiencies in the other system. Also, muscles can be reactivated, even after decades of nonuse, and are a proven remedy for overcoming back pain.
An example for a stabilizing muscle is the Musculus trans-versus abdominis, lying in the deepest layer of the stomach muscles. Another one is the Musculus multifidus, which connects the transverse processes (Processus transversi) of the vertebrae with the spinous processes (Processus spinosus). It straightens up the back and gives us good posture. This and other muscles, as well as bones and ligaments, act together and usually keep the spine from being twisted and destabilized.
Yet itas important that the muscles of the global system also remain in good shape. There are some muscles that act as aglobal mobilizersa and are needed to carry heavy weights, like the rectus abdominis muscle (Musculus rectus abdominis) and the extensors along the spine. The better they are at this job, the more they help the system of local muscles. Consequently, the local muscles can be used more exclusively to protect and stabilize the spine. This means that people suffering from back pain should make sure their system of global muscles systems is in adequate shape, especially if they have to lift heavy weights at work or at home.14 The more the muscles waste away, the faster bones, ligaments, and disks lose their protection. Trials measuring the muscle strength of people suffering from back pain have confirmed that both aspects are closely related. The longer the pain persisted, the weaker the back extensors became. One study compared patients who had gone through back surgery with healthy people: The average maximum strength of the back patients was 40 percent lower. Furthermore, individuals with ailing backs were found to have below-average strength leg muscles as well as an asymmetric distribution of muscles along the torso, a recipe for more back spasms. In the end, a spine can end up downright twisted.
The back muscles of patients with chronic back pain are not only feebler than those of normal people; they also tire more quickly. This becomes clear when patients are asked to work out: after a fairly small number of repet.i.tions, they are simply unable to keep up. In several studies this failure was shown to be caused by degenerative processes on the cellular level; these individuals have more type-II muscles than usual, which wear out rapidly.
MENDING THE MIND, MENDING THE BACK.
Often, the sore back and the decline of muscle strength are accompanied by a decline in mental health. Some people even become accustomed to the idea of living the rest of their lives as a disabled back patient.
The physician Jan Hildebrandt and the psychologist Michael Pfingsten have examined many severe back cases at their center in the University Hospital in Gttingen, Germany, and have noticed that the amount and intensity of pain is not determined by pathological changes in the back and its muscles. Rather, the way a patient thinks about his sickness predicts how much pain he will feel. Many back-pain patients are deeply convinced they are handicappeda"even when doctors and therapists offer a good prognosis.15 Many patients even stop working and try to live on disability benefits because it appears to all to be the most convenient solution. The employer gets rid of the employee who is always sick and complaining; the doctor has one less whining patient.
Yet this is not the way things have to end. The new science of healing through exercise shows that even the most desperate patients have reason to be optimistic. To start with, disk material that slipped into the epidural s.p.a.ce is recognized as a foreign body and is often attacked and destroyed by the bodyas own enzymes. Physical exercise also seems to promote the healing of damaged tissue.16 Degenerative changes affecting the back and stomach muscles can be systematically reversed. Regardless of how neglected and atrophied muscle cells are, training can awaken these sleeping beauties and give them new strength and endurance.
In order to reap these benefits, patients just have to have confidence in the scientific facts: Exercise and strain do no harm but are needed if the back is to heal. Treating chronic back pain with only pain relievers is not enough, although sometimes drugs might be necessary to help patients start a therapeutic exercise program.17 Patients who stay with it find that seemingly miraculous changes often start to occur after a few days of training. As they begin using their muscles again, their fear of aputting their back outa due to an unfortunate movement diminishes. As a result, their moods brighten and a chance opens up to escape the vicious cycle of chronic pain and physical inactivity.
Hildebrandt and Pfingsten have shown hundreds of patients that it is indeed possible to overcome the pain. They have developed a four-week program consisting of aerobic endurance training, games, swimming, strength training, relaxation exercises, and psychotherapy. They have tested their program among patients who were already medically declared unable to work and given negative psychiatric diagnoses.
Their results? Even the most problematic patients had improvements. Mentally, patients appeared much happier. They had less pain and less depression and looked ahead with more confidence. Physically, measurements showed that their torso muscles became stronger.
Interestingly, most patients did not think the psychotherapy part of the program was crucial to their success. Rather, they regarded their dramatically increased muscle strength and greatly improved endurance as turning points in their medical history. A new awareness of their own bodies emerged, and their fear of hurting their backs was lowered. After going through this program, 63 percent of the patients were able to resume their jobs and daily lives.18 Surgeons would be happy if they achieved such a success rate. There is no doubt that in many instances an injured back needs an operation, for instance, when patients lose control over sphincter and bladder. This usually signals that a ma.s.sive prolapse has compressed the nerves in the pelvic region. When these muscles fail to work, when a foot cannot be moved, or when other body parts become inoperative, most doctors agree it is high time for surgery. In other cases, when back pain and fever occur at the same time, there might be an inflammation rampaging near the spine. Finally, there even might be a tumor growing and compressing nerves in the back.
Although these and other conditions require surgical treatment, most surgical procedures are advised to alleviate pain and prevent further progression of the problem. But what is the outcome of the surgical removal, in part or whole, of an intervertebral disk? The experts James Weinstein, Richard Deyo, and colleagues compared the outcomes of surgical and nonsurgical treatment in a randomized study that included more than 500 women and men in 13 spine clinics in 11 U.S. states.19 One-half of the patients underwent discectomy; the other half received nonsurgical treatments like physical therapy, education with some home exercise instructions, and anti-inflammatory drugs.
After two years, the outcome revealed that patients with herniated disks improved whether they had surgery or not. Though surgery appeared to alleviate pain faster, on average all patients had gotten better, and there was no substantial difference between the two groups.
This is significant because in many cases physicians pressure patients by telling them that, without surgery, their conditions will worsen. Now, the first study about this question reveals this is not the case at all. Eugene Carragee of Stanford University Medical Center in California states: aThe fear of many patients and surgeons that not removing a large disk herniation will likely have catastrophic neurological consequences is simply not borne out.a20 A similarly cautious approach appears appropriate when doctors press for another sort of back surgery, spinal-fusion surgery. During this procedure, which is rapidly increasing in the United States, physicians use metal screws and rods to fuse two or more vertebrae. Though this complex and risky intervention has been performed for 90 years, it was only a few years ago that researchers set out to a.n.a.lyze its success.
The trial, led by Jeremy Fairbank at the Nuffield Orthopaedic Centre in Oxford, involved 349 chronic back pain patients. Of these, 176 were a.s.signed to spinal-fusion surgery and 173 to a three-week intensive program of rehabilitation, involving daily exercises and cognitive behavioral therapy. The rehabilitation aimed not only to address physical ailments but also to help patients overcome fear of pain or exercise, to learn to cope with the psychological effects of pain, and to learn to relax.
There appeared to be a slight advantage to surgical treatment, but the difference was barely significant in clinical terms. Thus, Fairbank states: aThere was no clear evidence from our trial that primary spinal fusion surgery was more beneficial than intensive rehabilitation. Our results suggest that patients eligible for surgery should be offered a rehabilitation program first. We believe it is safer and cheaper than using surgery as the first line of treatment.a21 If a patient, as is so often the case, still feels pain and discomfort after surgery for a herniated disk, these complaints do not necessarily result in self-doubt and restraint among surgeons. Frequently they will recommend a second operation, especially if they are not responsible for the first. In these cases doctors like to say their colleagues have just bungled the operations, whereas the next surgery, usually a spinal fusion, will fix the whole mess.22 But is a second surgery better than exercise? Recently, Norwegian researchers carried out a trial to answer this question.23 The study surveyed 60 patients who were in miserable condition, all with lower-back pain lasting longer than a year, despite undergoinga"or because they had undergonea"disk surgery.
The partic.i.p.ants were randomly divided into two groups. In the first one, experienced back surgeons performed fusions. In the second one, the partic.i.p.ants were taught that ordinary physical activity would not harm their disks. They also received tips on how to use their backs and how to bend and had exercise sessions for three weeks, with three sessions per day. One year later, Jens Ivar Brox of the Medical Faculty University in Oslo and his colleagues measured the outcome by questioning the partic.i.p.ants about their pain and related disability.
Fifty percent of the fusion group reported improvements, compared to 48 percent in the exercise groupa"hardly a substantial difference. The researchers concluded that patients should beware of the scalpel: aOur interpretation of the present evidence is that lumbar fusion should not be recommended in patients with chronic low back pain after surgery for disc herniation.a24 AEROBICS FOR A FIT BACK.
Programs for making disabled back patients fit and mobile again need not be sophisticated and expensive. This is the conclusion of a trial that Swiss doctors carried out with 148 patients who suffered for more than three months from low-back pain serious enough to require medical attention or absence from work.25 The partic.i.p.ants were randomly a.s.signed to three groups: the first had physiotherapy, the second trained their muscles on exercise machines, and the third partic.i.p.ated in ordinary aerobics cla.s.ses. Each program lasted for three months, with two sessions per week. Using questionnaires, at four different intervals, the researchers a.s.sessed how their patients were doing: before and after the program, and 6 and 12 months later.
There were many improvements. In all groups, partic.i.p.ants reported the pain level remained substantially reduced, even after 12 months. This long-lasting effect is apparently because 80 percent of the patients continued with their respective exercises after the official end of the three-month program. Fear of injury was reduced in all three groups and stayed on a lower level up to the 12-month follow-up.
The one exception to this continuing success was in the level of disability. Over the course of the three-month program, the level went down for all groups. However, this effect was soon lost among the patients who had done physiotherapy. Evidently, once they could no longer go to the therapist, these patients were unable to overcome their fear of injury. The researchers concluded: aOne-to-one physiotherapy perhaps promotes a sense of dependence of the patient on the therapist to guide and govern the most appropriate activity level for them in accordance with their declared level of pain.a26 By contrast, partic.i.p.ants in the muscle-training group and the aerobics group fared much better and continued to feel less impaired following the program.
This study, reported in the journal Rheumatology, has important repercussions: aerobics cla.s.ses in an ordinary gym are as effective as weight training for treating back ailments, and in the long term both approaches appear superior to physiotherapy. The latter two procedures are relatively expensive, whereas aerobics cla.s.ses in Europe are cheaper and thus advocated by the researchers: aThe introduction of low-impact aerobic exercise programs for patients with [chronic low-back pain] should allow considerable savings in the direct costs a.s.sociated with its treatment.a27 The aerobics cla.s.ses were likely successful because they cured the patientsa fears of using their bodies. This would confirm the insight of James Weinstein, after he wrenched his own back. When he came back from his run, Weinstein felt apretty good.a28
9.
Exercise and Brain Power.
A HEALTHY BABY IS BORN WITH 160 TO 180 BILLION NERVE CELLS in his or her brain, and in the first four years of life, this lavish endowment will transform into a finished brain, with an average of only slightly more than 100 billion nerve cells. In these early years, while the brain downsizes and develops at the same time, it is extremely important that a child has sufficient physical exercise. Good coordination of the body helps to preserve nerve cells in the brain and promotes their wiring to each other.1 Evidence indicates children need a certain minimum amount of exercise to develop a brain malleable or plastic enough to adapt to ever-changing environments.
Not long ago, this connection between physical and mental skills was disputed. Psychologists and psychiatrists thought that motor activity and cognitive performance resided in two distinct realms. This concept lives on in the terms anatomists use to describe the brain. On one side is the cerebellum, traditionally depicted as the brainas center for motor activity, which is in charge of the learning of movements. On the other side is the prefrontal cortex, long seen as the center for cognitive tasks like planning and behavior in social groups.
The domains for motor activity and cognition were also thought to be separate for chronological reasons. The development of motor skills, it was thought, started early in life and was quickly completed. The development of the cognitive abilities, however, would follow later and would not be affected by physical exercise at all.
For a long time, it was thought that the brain was supplied with blood in a constant mode that could not be changed by external factors like exercise and training. It was not before the availability of novel brain imaging techniques that this a.s.sumption could be experimentally tested. Wildor Hollmann and colleagues of the German Sport University, Cologne, encouraged young and healthy students to train on stationary bikes. Using positron emission tomography (PET), the researchers monitored brain activity while the students were exercising. When the energy expended reached 25 watts, blood circulation in the brain increased on average by 20 percent, and at 100 watts the increase was 30 percent.
BUILDING THE BRAIN THROUGH MOTION.
These data proved the idea of the physiologically separate brain wrong and revealed the opposite to be true: If a person exercises moderately, blood circulation within the gray matter increases substantially. Interestingly, studies of rats running on treadmills showed that this boost does not affect all parts of the brain equally. Although the blood supply is even reduced in some areas, it is greatly increased in othersa"which indicates that the bloodstream specifically transports nutrients and oxygen to certain brain areas. Insulin-like growth factor is among the substances taken up by nerve cells in these areas, making the cells excitable. Also, after just 30 minutes of running, certain proteins are produced in greater numbers within the nerve cells in some brain areas. And after running over a period of three months on treadmills, rats showed a distinct pattern: many genes and proteins critical for the functioning of the synapses between neurons and for the plasticity were activated.2 The proteinsa nerve growth factor (NGF) and the brain-derived neurotrophic factor (BDNF) are also produced in great quant.i.ties in the brain when the body is exercising, and both act like brain fertilizers: if their levels are high, the nerve cells luxuriate. Furthermore, the blood level of the amino acid tryptophan rises in response to physical training. Tryptophan then leads to an increased production of the neurotransmitter serotonin. Finally, endorphins are also elevated by physical activity, and both substances act as mood enhancers. Doctors can use these beneficial brain chemicals by prescribing regular physical activity for depressed patients.
Physical activity not only enriches chemistry in the gray matter; it also alters the structure of the brain. First, exercise promotes the production of new nerve cells in the hippocampus. (Weall see later how much this fountain of youth influences our mental well-being and power.) Second, exercise creates new synapses, thereby establishing and maintaining the vast network of connected nerve cells in the brain. These many effects help optimize the intellectual development of children.
Surveys in preschools and elementary schools have confirmed this direct link. One trial in Cologne included 600 children from 12 elementary schools. The students were asked to run for six minutes, and the researchers doc.u.mented the distance they covered. Another test concerned physical coordination. The children were encouraged to walk backward, to jump on one leg, and to move around a curve using crossover steps. A further test involved sorting and labeling certain symbols according to their importance. This measures the ability to pay attention, a fundamental cognitive skill.
The results: performance in the six-minute run did not actually correlate with results in the cognitive test. However, physical coordination was clearly linked to cleverness. The students with above-average motor activity were also superior in their ability to concentrate. Thus physical coordination and mental ability may reside in the same realm of the brain.
But how could that be? The researchers who carried out the study think it might be because the two skills are represented in overlapping brain areas. Thus activating certain parts of the brain by amotor activities atrainsa them possibly in such a way that they also function better in other situations, for example during work requiring mental concentration.a3 Researchers from the International University in Bremen tested 85 boys and girls ages four to six and asked them to perform seven different tasks involving strength, physical flexibility, speed, and coordination. A further test measured their cognitive skills: the children had to spot certain differences in pictures, which measured their attention spans, memory, nonverbal intelligence, and other cognitive capabilities.
These results also show that cognitive and motor skills are connected. Well-coordinated children achieved above-average results in the picture test. These findings underline that the two kinds of development go hand in hand: The more time spent skipping rope, playing hopscotch, riding bicycles, climbing, walking to school, practicing gymnastics, and playing outdoors, the better. Claudia Voelcker-Rehage, lead author of the study, concludes that, especially among children aged four to five, development of coordination and cognition is linked, meaning that in preschools an aintegrated stimulation for both cognition and motor activity is very important.a4 Findings from brain scans a.n.a.lyzing the functional anatomy confirm that the two domains are indeed very closely connected. When the brain is working on a cognitive problem, areas of the prefrontal cortex are activated, and regions of the cerebellum also light up. A similar double pattern appears when the brain is trying to solve tasks related to languagea"for example, trying to say as many words as possible within one minute that start with the same letter. Conversely, as soon as the individual being tested has solved the problem and does not need to concentrate any longer, the activity patterns in both the prefrontal cortex and the cerebellum fade away.
People with damaged, malfunctioning cerebellums not only have impaired motor activities but often struggle when asked to solve cognitive tasks that involve planning, memorizing, and finding words. There are even speech disorders that are solely caused by pathologically low activity in the cerebellum.5 The process of learning to speak and write is another example revealing that mental and motor activities are linked. Even when babies or small children are unable to speak, they can already grasp the words they hear. But only when children have the motor skills to write by hand can they internalize the concept of scripted language. The motor activities connected with handwriting cannot be replaced by hitting keys on a computer keyboard. Rather, experts recommend children and their parents train the motor skills with activities like drawing, crafts, and also ball games.6 When such training does not occur, the motor skills may not fully develop, which in turn can result in cognitive impairments and disorders. Many children with dyslexia and related problems often also struggle to coordinate their movements. Adele Diamond, a neuroscientist at the University of British Columbia in Vancouver, states: aChildren who are dyslexic, like children who are clumsy, have difficulties with continuous tapping tasks compared to same-aged peers.a7 Among young people suffering from autism, impaired motor activities are also frequently seen. Interestingly, researchers believe autism is linked to a narrowed cerebellum as well as to a delayed maturation of the prefrontal cortex. The two areas seem to be so closely related that impairment in one area can cause a malfunctioning in the other.