Healing Through Exercise: Scientifically Proven Ways to Prevent and Overcome Illness and Lengthen Your Life (13 page)

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.
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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 massive 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.
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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: “The fear of many patients and surgeons that not removing a large disk herniation will likely have catastrophic neurological consequences is simply not borne out.”
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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 analyze 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 assigned 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: “There 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.”
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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.
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But is a second surgery better than exercise? Recently, Norwegian researchers carried out a trial to answer this question.
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The study surveyed 60 patients who were in miserable condition, all with lower-back pain lasting longer than a year, despite undergoing—or because they had undergone—disk surgery.

The participants were randomly divided into two groups. In the first one, experienced back surgeons performed fusions. In the second one, the participants 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 participants about their pain and related disability.

Fifty percent of the fusion group reported improvements, compared to 48 percent in the exercise group—hardly a substantial difference. The researchers concluded that patients should beware of the scalpel: “Our 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.”
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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.
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The participants were randomly assigned to three groups: the first had physiotherapy, the second trained their muscles on exercise machines, and the third participated in ordinary aerobics classes. Each program lasted for three months, with two sessions per week. Using questionnaires, at four different intervals, the researchers assessed how their patients were doing: before and after the program, and 6 and 12 months later.

There were many improvements. In all groups, participants 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: “One-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.”
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By contrast, participants 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 classes 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 classes in Europe are cheaper and thus advocated by the researchers: “The introduction of low-impact aerobic exercise programs for patients with [chronic low-back pain] should allow considerable savings in the direct costs associated with its treatment.”
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The aerobics classes were likely successful because they cured the patients’ 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 “pretty good.”
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Exercise and Brain Power

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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.
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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 brain’s 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 assumption 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 others—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.
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The proteins’ nerve growth factor (NGF) and the brain-derived neurotrophic factor (BDNF) are also produced in great quantities 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. (We’ll 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 documented 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.