Part 2 (1/2)
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 cus.h.i.+on 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 cus.h.i.+on 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 Hamps.h.i.+re. 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.