Healing Through Exercise: Scientifically Proven Ways to Prevent and Overcome Illness and Lengthen Your Life (12 page)

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, “lumbago,” 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.
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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.
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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 bumps 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 “dynasty of the disk,” 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 prone 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 Jürgen Krämer headed the International Society for the Study of the Lumbar Spine, his presidential address was on the natural course of disk diseases: “The 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.”
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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. “The disc,” says Krämer, “is an osmotic system that lives on motion. Because of the human sedentary nonmoving lifestyle, disc generation is progressive.”

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.
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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: “Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”
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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: “Two events happen at the same time in a patient, consequently a casual relation is postulated.”
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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: “One must assume that in many cases something was operated on that wasn’t the cause of the back pain.”

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 “failed back surgery syndrome.”

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 association between symptoms and the results of the imaging is weak, and many doctors like to say strain or sprains were the trouble-makers. Yet “strain and sprain have never been anatomically or histologically characterized, and patients given these diagnoses might accurately be said to have idiopathic low back pain.”
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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. “Bed rest doesn’t only weaken the muscular system but it also leads on to inactivity osteoporosis,” says Heger. Psychologists also believe bed rest is dramatically underestimated as a trigger of sickness and that “the prescription of too long bed rest is one of the principal reasons for physical deconditioning.”
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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.
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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 passive system, composed of bones, ligaments, and joints; and the active system, consisting of muscles. This comprehensive model is important because the active and the passive 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 it’s important that the muscles of the global system also remain in good shape. There are some muscles that act as “global mobilizers” 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.
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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 repetitions, 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 Göttingen, 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 handicapped—even when doctors and therapists offer a good prognosis.
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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 space is recognized as a foreign body and is often attacked and destroyed by the body’s own enzymes. Physical exercise also seems to promote the healing of damaged tissue.
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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.
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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 “putting their back out” 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.