Healing Through Exercise Part 1

Healing Through Exercise.

Jorg Blech.

To Anke, Hannah, Antonia, and Leo, with love Our nature consists in motion; complete rest is death BLAISE PASCAL.

PREFACE.

Many diseases can be cured with abstinence and rest, the famous physician Hippocrates decreed more than 2000 years ago. Lately, however, his p.r.o.nouncement has been called into question. In study after study, physicians now prescribe physical exercise for a whole range of different illnessesa"and they see much better results than doctors using conventional medicine.

These results are novel, and exercise hasnat yet been granted the attention it deserves. The marvelous therapeutic effects achieved with exercise are described only in scientific papers scattered throughout the medical literaturea"and have thus been hidden from many doctors and most laypeople.

This lack of awareness results in poor and often downright bad treatment because patients and physicians alike far too often try to fix medical problems with drugs, high-technology procedures, and simply resting in bed.

This book aims to change that. Itas my goal to present the new science of healing through exercise for a wide audience. Iave researched and written this account in the United States, but have added material from European researchers whenever it was insightful and important.

The new research presented in the following chapters applies to healthy readers as well as to people who have already fallen sick. It turns out that we profit from physical exercise to a much greater degree than doctors have previously believed. In particular, individuals who are middle-aged or elderly are able to stave off illnesses and ailments with dramatic results as soon as they get in motion.

My first research on this subject dates back to the summer of 2005 when I began to work as the science correspondent in the United States for Europeas largest weekly news magazine, Der Spiegel. The more I learned about the benefits of exercise, the more I felt the urge to get off my chair, go outa"get moving. It became clear to me that it was time to change my life. I started to commute to work using my own muscles. Whether I ride my bicycle or simply walk, I cover eight miles on the local bike path every day. It would be great if the facts and stories I present here moved you in a similar way.

1.

The Healing Power of Exercise.

AT FIRST GLANCE, THE OFFICE OF THE CALIFORNIAN PSYCHIATRIST Wayne Sandler looks just as one might expect: pictures of Sigmund Freud on the wall, tomes on brain anatomy in a gla.s.s cabinet, and of course the requisite couch.

But there is one thing that seems rather out of place: two treadmills.

aPatients were always telling me how well they felt when they took proper exercise,a says Sandler from his practice on the ninth floor of a building in the affluent Century City district in Los Angeles. But they complained that they never found time or just felt too unwell to practice sports. Thatas why Wayne Sandler decided to combine his standard therapy sessions with physical exercise.

Around half of Doctor Sandleras depressive or phobic patients bring their sneakers along to appointments. The wiry psychiatrist, who lifts weights or pedals away on a cycling machine every day himself, changes into his black tracksuit. Sandler has set the treadmills up facing each other so that he can look his patients in the eye. All he has to do is switch them on, and the therapy in motion can begin.

Sandler still prescribes medications, such as the fas.h.i.+onable Prozac antidepressant, for some of his patients. But he is convinced that in many cases exercise can deal with chemical imbalances in the brain better than drugs. His clients-c.u.m-jogging partners are very enthusiastic, he reports, and he now prescribes exercise just like a drug: aMovement will be your medicine nowa"and you need at least 30 minutes of it every day.a1 Carolyn Kaelin is another believer in the healing power of exercise. A mother of two children, she lives in Boston. In the summer of 2003 she fell ill from breast cancer, at the age of just 42. A course of chemotherapy and five operations including a dual mastectomy couldnat stop Kaelin from going to the gym as often as possible and walking to work every day: aItas the one thing I can do for myself that I know is useful.a Kaelin knows what sheas talking about. She is one of Americaas best-known breast cancer surgeons and runs the Comprehensive Breast Health Center at Brigham and Womenas Hospital, part of Harvard Medical School. Seeing her bright smile and sensing her vitality, itas hard to believe the suffering sheas been through. But thatas what nourishes hope now in the audience of women attending her lectures, with headscarves or a new crop of very short hair.

A growing number of studies, Kaelin tells her fascinated audience, shows that physical exercise can prolong the lives of breast cancer patients and reduce the likelihood of relapses. If diagnosed with breast cancer, the professor recommends women should start a fitness program as soon as possible: aI know it may be the last thing you feel like doing, but I believe it can honestly save your life.a2 EXERCISE AS MEDICINE.

Until now, doctors have usually recommended physical activity and sport as a preventive measure to avoid the outbreak of disease and disorders. But recently, exercise has found its way into the heart of medicine. Psychiatrists and oncologists, orthopedics specialists, dementia researchers, and cardiologists are realizing that physical activity can help people even after they fall ill. In many cases, carefully administered exercise accompanies standard therapies. According to a growing body of evidence, exercise often works better than these therapies. It can make health-promoting cells grow in diseased tissuea"and literally turn a disease around.

It is the mind itself, according to the poet Friedrich Schiller, that builds the body. For many years, the medical community thought the opposite was not possible. Neurology textbooks stated that muscle activity could not influence the brain in any way: A mysterious organ, called automatism center, kept the brainas circulation and metabolism at a constant level, the books said, regardless of whether the body was climbing a mountain or dozing in a shady orchard.3 Compounding this error was the belief that an adult brain could never rejuvenate itself; no new nerve cells were thought to grow after birth. The medical profession held that the brain could only stand still or decline.

Todayas brain researchers are correcting that devastating view. The body builds the mind as well as itself. If you exercise your muscles, you practically flood your gray cells with fresh nutrients and growth factors. These make new nerve cells grow. The new cells are easily stimulated and particularly capable of learning. But if we donat make use of them, they die after a few weeks.4 aExercise is the strongest known stimulus to grow new nerve cells,a says Henriette van Praag, an expert on neurogenesis at the Neuroplasticity and Behavior Unit of the National Inst.i.tute on Aging in Baltimore.5 Once nerve cells are produced, mental activity is needed for these newcomers to survive. When used, the neurons are permanently integrated into the brain and able to increase its ability to learn.

That means we can train the brain just like a muscle, at any age. aFitness training improves neuronal efficiency and performance,a says the psychologist Arthur Kramer at the University of Illinois in Urbana-Champaign. aOlder brains are a lot more flexible and plastic than we have been led to believe.a6 No one has to work up much of a sweat to benefit from the healthy effects: People who exert themselves physically for half an hour three times a week, as researchers at Duke University discovered in a comparative study, protect themselves just as effectively against bad moods and attacks of depression as those who take mood enhancers every day.7 A study led by the University of Melbourne showed that walking for two and a half hours per week improves memory for older people and may stave off dementia.8 These encouraging findings are being made because doctors around the world are starting to study and measure the actual effects of physical exercise and evaluate its benefits. Many of these studies show that moderate training can be seen as a form of medicine in its own right, which can be confidently prescribed like a tried and tested drug. Medicine has reached a turning point, say researchers at the University of Copenhagen: The acc.u.mulated knowledge on the blessings of exercise ais now so extensive that it has to be implemented.a9 This paradigm s.h.i.+ft to advising activity rather than rest involves the major diseases in particular. Osteoporosis, asthma, osteoarthritis, chronic back pain, and type 2 diabetes, for example, can all be improved and even overcome by exercise. In addition, hyperactive schoolchildren are being prescribed physical activity at playtime instead of pills. Tablets like v.i.a.g.r.a can be replaceda"by moderate exercise. A long-term study carried out on more than 500 men led researchers to conclude the only behavior that helps impotence patients is regular physical activity.10 Exercise also has a therapeutic effect on heart patients. If you raise the number of calories you burn, you reduce the probability of blockages in your coronary arteries. The cardiologist Rainer Hambrecht from the Bremen Heart Centre is studying this phenomenon at the level of single cells. aPatients with stable coronary heart disease,a he sums up his findings, acan increase their life expectancy by taking up a sport.a Yet many doctors still recommend rest for various illnesses or even advise patients against any kind of physical activity. Especially for metabolic diseases such as diabetes and osteoarthritis, doing nothing can worsen the patientsa quality of life. The more researchers are finding out about these effects, the louder theyare calling for a change to the traditional advice for sick people to stay in bed.

aWe are getting better, but there is still a long way to go,a says Robert Sallis, a family doctor in California and a past president of the American College of Sports Medicine. aPhysicians increasingly acknowledge that exercise is good, but I do not think they are trained to think about it as a remedy. They much more quickly pull out their pad and write prescriptions for drugs, and they donat have the training to help their patients to get more active.a11 Cancer patients in particular are still often advised against physical activitya"because doctors believe that that helps them to cope better with the strenuous treatment. But it appears that the opposite is the case.12 Some physicians are now placing stationary bicycles next to the sickbeds of even seriously ill patientsa"and they find exercise cheers patients up and gives them back the energy they thought they had lost forever. Physical activity can strengthen the bodyas own defenses against cancera"and even prolong the life of cancer patients.13 Strangely, these exciting findings have hardly made the rounds. The therapeutic value of sport in aftercare for cancer patients appears comparatively unknown and is often rather neglected. Melinda Irwin, a researcher at the Department of Epidemiology and Public Health at Yale School of Medicine in New Haven, says: aThe leap has not been made that physicians recommend exercise for cancer patients.a14 Unfortunately, doctorsa advice for patients to rest is often likely to shorten many of the patientsa lives. Take heart failure, for example: The physiological processes that cause the problem of weak heart muscles are only made worse if the patient stops taking exercise, on their doctoras advice. Well-informed physicians are now recommending the opposite: According to recent studies, sport can reduce the likelihood of dying from stable chronic heart failure by about 35 percent.15 KEEP MOVING TO LIVE LONGER.

Researchers have also taken a new look at the effects of inactivity on healthy people. They have shown that office workers who make only minimal use of their muscles put themselves at almost as much risk as smokers. The mortality rate of inactive people is up to one-third higher than that of people who take regular exercise. A 65-year-old who walks less than one mile per day might die seven years earlier than a neighbor of the same age and the same risks otherwise who walks more than two miles per day.16 The rule is the same for everyone on the planet: If you engage in regular physical activity and push your muscles, you trigger adaptive processes that have a positive effect on your health. That doesnat just go for sports that revolve around top performance, winning, and losing. Itas true for any way we bestir ourselves, including walking and such everyday activities as climbing stairs, cycling, weeding the garden, and cleaning the house. Itas this kind of healthy exercise that keeps us young and lengthens our lives, if we keep doing it in later life. The reward for burning an extra 500 to 2000 kilocalories a week is living longer; the mortality risk is 28 percent lower for 60- to 69-year-olds, and 37 percent for 70- to 84-year-olds.17 Evolutionary physiologists like Frank Booth from the University of Missouri in Columbia say itas a fallacy to believe that physical inactivity does no further harm, as long as you keep a steady weight and eat sensibly. Modern human beings are still genetically programmed for life as hunters and gatherers because our genetic composition has hardly changed in the 10,000 years since the Stone Age. Back then, our ancestors were in top athletic form every day, looking for food, hunting wild animals, and building shelters. Those who werenat able to keep up simply died out. Those who survived pa.s.sed down the biological equipment needed under these conditions over the millennia. That means we all have perfectly functioning bodiesa"but only as long as we take exercise on a daily basis.

Presently, however, a large part of the worldas population makes a living in ways for which their genetic inheritance was never designed: Billions of people spend most of their lives sitting, at work and after.

We do of course live much longer lives than the cavemen, thanks to improved hygiene, obstetrics, and antibiotics. But athe average office worker would be much more healthy,a according to the American evolutionary biologists Randolph Nesse and George Williams, aif he or she spent the day digging clams or harvesting fruit in scattered tall trees.a18 Because the biochemical cycles get sluggish in inactive bodies, fats in the blood tend to form gallstones more often, for example. People who donat take exercise have their gall bladders removed more often than the rest of the population. And because digestion slows down in bodies that donat move much, the period of contact with carcinogenic substances in our food is lengthened; inactive people have a 50 percent higher risk of contracting bowel cancer. Even the genes became affected because being lazy appears to make us genetically old before our time. Researchers in Newark, New Jersey, and London found that pieces of DNA called telomeres shorten faster in physically inactive people, making them p.r.o.ne to quicker cellular aging.19 Frank Booth puts most diseases of modern life down to the fact that our metabolisms are going off course because of chronic lack of activity. He and other scientists recommend a minimum of 30 minutes of moderate exercise a daya"walking or swimming, for example. Everything below that is defined as inactive. aWithout that threshold of physical activity expected by our genomes,a says Booth, aphysiological dysfunction is likely to occur from pathological gene expression, eventually leading to chronic health conditions.a20 If this sounds gradual, and not that threatening, put it this way: The body of anyone who doesnat take at least half an hour of exercise every day is in a state of emergency. Pathological processes are constantly taking place in the cells and tissues, and itas only a matter of time until irritations and complaints break out.

According to the evolutionary biologists, we have to rethink the old view of exercise: movement is by no means just a useful added way to improve our health. In fact, it is absolutely necessary for the human body to work normally. That goes for all ages: Children can develop their mental abilities properly only if they do enough running, jumping, and physical playing as well. Motor and cognitive skills develop in unison and stimulate each other within the brain. Researchers in the field of neuroanatomy at the University of Bielefeld sum up what that means for parents, children, and teachers: aLearning needs movement.a The new findings suddenly put what we think of the aging process in a different light: many of the changes are to a great extent the result of inactivity.21 We spend vast amounts of money on the products of the antiaging industry, but so far all the pills, hormones, live cell injections, vitamin cures, and orth.o.m.olecular procedures have been an abject failure. But donat despair: A fountain of youth is at handa"but it just takes a little effort. Only regular physical activity can slow up the biological aging process. In other words, being active is the only way not to look old.

We donat age chronologically but biologically. If we keep our bodily functions vital, we can slow down or stop the biological aging processa"over decades. Thatas practically a law of nature, and you and I can make it work for us.

Of course, physical exercise can never guarantee that an individual wonat get sick. The author James Fixx remodeled long-distance running as ajogginga and popularized it around the worlda"only to collapse and die at the age of 52 while out on a jog on a lonely country road. However, atherosclerosis was running in his family, and he might have died earlier without picking up the habit of exercising.

No one is claiming we can literally run away from sickness. The Norwegian Grete Waitz won the New York City Marathon nine times and has recently been battling cancer. The cyclist Lance Armstrong contracted testicular cancer after becoming the world road race champion. These stories ill.u.s.trate that fate and bad luck also play a role in disease, especially tumors.

We all know the feeling: whenever we come down with an illness, we always look for explanations, for reasons why it got so far. But doctors have long since found evidence that the course of health disorders is influenced by not only genetic and environmental factors, but also by pure coincidence.22 By the time Lance Armstrong was diagnosed with cancer, he had metastases in the whole of his body and brain. The doctors estimated his chance of survival at below 50 percent. Armstrong himself puts the fact that he was still healed and made a spectacular recovery down to aa lucky coincidence.a But at the same time, the likelihood of many healthy decades of life can be improved by living an active lifestyle. Epidemiological studies indicate one factor again and again: Daily physical activity is linked with a lower risk of cardiovascular diseases, strokes, loss of memory, depression, type 2 diabetes, obesitya"and with a longer life. It also reduces the risk of breast and bowel cancer. There is no doubt: If we could put the positive effects of moderate exercise in a bottle, wead all take a good swig from it every morning. Canadian doctors reported that the elixir is even stronger and more effective than previously a.s.sumed. aRecent investigations have revealed even greater reductions in the risk of death from any cause and from cardiovascular disease. For example, being fit or active was a.s.sociated with a greater than 50 percent reduction in risk.a23 Ninety percent of over-50s would benefit from regular traininga"and the good news is, it works just as well if we take it slowly. It doesnat always have to be jogginga"even brisk walking has proven effective.

OUTDATED ADVICE.

While part of the medical community is now hailing a new era of aactive medicine,a many doctors remain skeptical about exercise, as physician Annette Becker from the University of Marburg remarks with astonishment. There is now ahighest evidence for the effectiveness of exercise in the prevention and treatment of chronic diseases, and for the ineffectiveness or even detrimental effects of bed-rest,a she comments. aBut many doctors still often advise their patients to stay in bed for long periods, which cana"as in the treatment of chronic paina"worsen the patientsa prognosis.a24 Experts at the University of Hamburg also find it aamazing how little many doctors know about these things.a25 Because of this ignorance, patientsa"possibly in the thousands at any given timea"are simply being wrongly treated. Letas look at patients with back pain. Physicians are all too keen to carry out expensive diagnosis procedures such as computer tomography and MRI scans. These rarely produce pathological findings but do mean high income for the doctors. The patients are sent away with prescription drugsa"and often do not receive the physiotherapy they actually need or, more important, any help for changing their lifestyles in the long term. Patients diagnosed with mild high blood pressure are usually prescribed expensive medication; aDoctors seldom think of prescribing a program of moderate stamina training.a26 In defense of the physicians, all this is the exact opposite of what must have been learned at medical school. What we now know is wrong was considered right back when current doctors were students. Sending sick people to bed made everyone happy. The whole way of thinking, the medical practice of the time, was founded on the basic conviction that patients would find salvation in physical rest.

Many of the experienced doctors who now run large practices or hospital departments went to medical school at a time when heart attack patients were still ordered to spend four to six weeks in bed. Some older doctors may remember a time when patients were even strapped down to keep them still. Not that long ago they were of the opinion that our hearts only had a limited number of beats, according to the motto: aUse up those beats by racing your heart with exercise, and you shorten your life span.a27 In his cla.s.sic book The Structure of Scientific Revolutions, the American historian Thomas Kuhn describes why itas always so hard for new findings to take the place of old ideas in science.28 Fundamental new ideas are initially disdained because they undermine scientistsa previous work and reveal that this work is wrong or even foolish. Eventually some scholars adopt the new theory, whereas others stubbornly refuse to alter their positions. The latter gradually die out until their views are entirely forgotten.

When it comes to exercise as medicine, we have not yet reached that turning point: aThe paradigm s.h.i.+ft is in flux, but has not yet been realized in this short period of time.a29 There are signs that it might take a while yet until the breakthrough. Even now, medical training barely addresses the links between regular activity, fitness, and disease.

But itas not just the medical profession that hasnat caught on to the healing power of exercise. We laypersons have also failed to recognize its benefits. When our grandparents were growing up, most people in industrial societies never reached old age, worn out by dangerous physical labor on the factory floor or relentless household labor. Their grandchildren now live in what we could call sitting societies. We are the first generation to face the opposite challenge: We may grow old before our time and die young if we donat get enough exercise.

2.

The Dangers of Going to Bed.

A MEDICAL TREATMENT OFTEN BEGINS BY PUTTING A PATIENT TO bed. Many of us have already had this experience: having barely arrived at a hospital, we are asked to remove our street clothes, put on a skimpy gown or pair of pajamas, and go to bed. The size of a hospital is measured by the number of beds it has, and the severity of an illness is determined by the number of days a patient stays in bed. And whether or not we like a physician depends on that doctoras abedside manners.a A good doctor sits down by the patientas bed and listens.

An example of such medical tact is depicted in Pablo Pica.s.soas painting Science and Charity from 1897. A bearded doctor is taking the pulse of an exhausted patient; he represents science. On the other side of the bed, a nun faces the patient; she represents charity. Pica.s.soas creation shows a vision of how bed rest should be, says the general pract.i.tioner Annette Becker, of the University Hospital in Marburg, Germany. She believes that rest means anot only immobilization but also care, gentleness and protection for an individual who is burdened by disease.a1 A DANGEROUS PRESCRIPTION.

Over the years, bed rest has been prescribed in far more coercive ways. The American neurologist Silas Weir Mitch.e.l.l (1829-1914) introduced something he called the arest cure.a For Mitch.e.l.l, the best treatment for individuals suffering from neurasthenia as well as hysteria was to confine them to bed for six to eight weeks. During this agonizing period, some patients were not even allowed to turn their bodies without support. This type of immobilization soon was taken up by virtually the entire medical world, especially for individuals said to be hysterical. During their detainment, these poor souls were not allowed to receive visitors and, in order to avoid any distress, they were always cared for by the same nurse. The patients were forbidden to use their own hands for was.h.i.+ng, and their nurses fed them a diet consisting of especially fatty dairy products. Mitch.e.l.l actually reported many recoveries: as soon as he allowed his patients to go back into everyday life, they were usually more than willing to flee this sickbed.

The perils of bed rest, however, have been known to more enlightened physicians. Richard Asher (1912-1969), who worked at the Central Middles.e.x Hospital in England, was making his rounds one day when he came across a remarkable case of bed rest. aIn a chronic ward of which I once had charge I found a lady who had been in bed for 17 years with a diagnosis of nervous debility and whitlow,a Asher reported in the British Medical Journal. aShe had survived this remarkable hibernation with little damage, and though she was very upset when I ordered her up she became a different person when she was fully ambulant.a2 There is a long tradition of doctors exercising power over individuals by confining them to bed. In the novel The Magic Mountain, soon after the young Hans Castorp arrives at the International Sanatorium Berghof, where he wanted to visit his cousin, he is ordered to bed. aNow, Castorp, weall stick you into bed and see if a couple of weeksa rest will sober you up,a the physician Herr Hofrat Behrens tells him. aAs if alie downa isnat just as good a word of command as astand upa!a3 The French writer Jules Romains recounts in his satire on medical quackery, Knock, the story of a country doctor named Knock who, by inventing outlandish diseases, turns a whole mountain village into a hospital. This disease-monger tells his first patient, a lady in black, aGo to bed when you get home. In a room where you can be alone as much as possible. Close the shutters and draw the curtains so the light wonat bother you. Donat let anyone talk to you.a The doctor orders a full week of this isolation, after which he will reconsider the case. Knock says: aIf you are strong and full of life it will mean that things arenat as bad as they seem. If, on the other hand, youare weak and drowsy, have a hard time getting up, then thereas no doubt about it and weall have to start the treatment.a4 Over the course of the story, the woman falls sick and confirms Dr. Knockas case for treatment. Findings from real-life research explain why this outcome is likely. After spending just a few days in bed, our muscles start to waste away and a whole range of undermining effects sets in. Being immobilized can bring more harm to our health than the ailments, which sent us to bed in the first place.

aBed Rest: A Potentially Harmful Treatment Needing More Careful Evaluationa: this is the t.i.tle Australian doctors chose for a paper they published in the medical journal The Lancet.5 They had carried out a review of the scientific literature on the use of bed rest in treating various illnesses. In 24 trials that looked into bed rest following a medical procedure, the review revealed that none of the outcomes improved significantly. In eight of these trials, bed rest actually worsened the outcomea"for example following lumbar puncture, cardiac catherization, and spinal anesthesia.

Fifteen of these trials examined bed rest as a primary remedy, and in these studies the results were even more sobering. While not a single group of patients got better, in nine diagnostic groups the health of the involved patients on average actually got worse. This was the case after acute low back pain, childbirth, high blood pressure during pregnancy, heart attack, and acute infectious hepat.i.tis.

The authors of the review article were amazed that so many members of the medical profession were clinging to the ritual of putting patients to bed, even though the bed-rest trials they reviewed had been published for quite some time. aIdeas about bed rest seem so entrenched that medical practice has been slow to changea"even when faced with evidence of ineffectiveness.a6 Researchers at the Yale School of Medicine have come to the conclusion that the effect of bed rest is especially detrimental to people age 70 or older. According to their study in the Journal of the American Medical a.s.sociation, the risk of developing a disability within a month of hospitalization was elevated more than 60-fold.7 In many cases, the physical condition of older people staying in a hospital deteriorates so dramatically that they never return home and instead must be transferred directly to a managed-care facility.

There are only a few researchers studying the phenomenon of being bedridden. The nursing scientist Angelika Zegelin at the University Witten/Herdecke in Germany is one of them. In an unusual study, Zegelin went into an elderly care home and conducted interviews with 12 men and 20 women who dwelled there. These residents were of sound mind but had been bedridden for up to four years. Zegelin wanted to find out: Why did they end up in such a sad situation?

According to her findings, the disastrous scenario leading to the state of being bedridden unfolds in five distinct steps.8 It often begins when a person develops what Zegelin calls a aphysical instability.a The individual is actually healthy, but at one point in the life refrains, for whatever reason, from physical activity. This voluntary inactivity may not appear harmful but can have such a deep effect that some people will eventually end up in a nursing home. A survey among 50 residents in one such residential home revealed that 75 percent of its occupants never played sports in their adult lives.9 The conversion from being sedentary to being totally immobile, the second stage, is then usually triggered by an accident or a similar event. This incident can be a falla"but it may result solely from the fear of falling. In many instances, a stay in a hospital became the starting point for further physical decline. At least, this is what Zegelin heard time and again during her survey interviews. Many of her subjects stated they ajust stayed in bed during their hospital stay, and after one week they were already unable to get up.a10 This triggers the third phase, which is the one of continuous immobility. The individual in question walks only a few steps and for most of the day is simply lying in bed or sitting in an armchair. If he or she still lives at home, then he or she is looked after by a nursing service.

At this stage, some exercise would still be very helpfula"but typically no one is around to help mobilize the ill person. According to a survey among 70 residents in one nursing home, 66 percent of them had fewer than two hours of physical motion per week, and a third of the residents did not move at all. The situation was partly worsened by an unfortunate misunderstanding. Some of the older persons refrained from leaving their beds because they did not want to cause more work for the nurses who appeared to be overburdened, especially on the weekends. Conversely, many nurses a.s.sumed they were being kind to the frail residents by not disturbing their rest. Thus, unsurprisingly, the survey concludes that there is awidespread physical inactivity in nursery homes.a11 Many older people and invalids who are looked after in their own homes are also hardly able to leave their beds. A caregiver from a nursing service might show up two or three times per day, but they usually are in a hurry and leave again after only 20 to 30 minutes. The ailing individuals may ask to be guided to a chair, but once the nurses are gone, they must sit there for hours, until the next nursing s.h.i.+ft arrives, at which point a caregiver can help them back to bed. Thus, most people interviewed by Zegelin vowed not to leave their beds in the first place.

By now, the fourth stage of the decline is reached: confinement to only one spot. Patients resign themselves to the dim prospect of spending every minute in the same spot, with the exception of using the bathroom, for which they need a.s.sistance.

This physical decline is usually a.s.sociated with a cognitive one. At the beginning of their immobile existences, these ailing individuals tend to watch television, but that becomes too boring after a while. Reading often becomes impossible because they lack the muscle strength to hold books. Visitors are rare, creating a condition of mental vacuity. aThe immobile patients are caught in an eventless world and subsequently they lose their sense for time. Months and years dwindled, being fixed to one place all the time made the concept of time meaningless,a observes Zegelin.

Eventually, the patients slide into the fifth and last phase: they are permanently bedridden. They depend on diapers, and they will never again use their legs.

One would like to believe that physicians take measures to avoid such dramatic declines. However, according to Zegelinas survey, it was both well-intentioned advice, as well as medically motivated arrangements, that contributed to these unfortunate circ.u.mstances. In the interviews, many of the residents reported being admonished by doctors and nurses to take it easy and to rest their bodies: aIf you have another fall, itas all over for you!a Furthermore, the transfer into a special nursing bed added to the patientsa physical immobilization. These beds are often fenced with bars and, because of very thick mattresses, are grotesquely high. When Zegelin asked the residents of the retirement home, aSince when were you actually confined to bed?a too often she heard a revealing answer: aSince they put me in this special bed.a WASTING AWAY IN OUTER s.p.a.cE.

Scientists first became aware of the importance for patients to keep moving due to an accidental finding from the Second World War, when beds in sick bays and nurses were scarce. Acting from necessity, doctors released the injured and the sick earlier than usuala"often resulting in better healing successes and fewer complications. After the war, this approach lived on in U.S. military hospitals, and medical personnel were taught that the consequences of bed rest are often worse than the original injury.12 The next hint came from s.p.a.ce research. When the United States decided to send astronauts to the moon, it became crucial to understand how zero-gravity conditions would affect a human body confined for many days to a tiny s.p.a.ce capsule. Thus, in 1966, the National Aeronautics and s.p.a.ce Administration (NASA) initiated a remarkable endeavor that became known as the Dallas Bed Rest and Training Study.13 In a Dallas hospital, five young and healthy men were ordered to stay in bed for three weeks. Like the unfortunate patients in Dr. Silas Weir Mitch.e.l.las ward, these human guinea pigs were not allowed to move their bodies at all. To avoid weight gain, they were kept on a low-calorie diet. They were allowed to take one shower the whole time and were pushed to the bathroom in a wheelchair. After 21 days, the five men were examineda"and it turned out they were physical wrecks. Their ability to consume oxygen was reduced by 28 percent, and when two of the subjects were asked to run on a treadmill, they fainted.

WHILE THE BODY RESTS.

We donat fully understand the effects of immobilization on the body, but the findings doctors have gathered in the past 50 years show a broad physical decline. As soon as we spend too much time under the covers, almost every part of the body starts to waste away.

Connective Tissue and Joints The flexible parts of the bodya"like joints, tendons, ligaments, muscles, and skina"ordinarily move often, allowing them to function properly. When the freedom of these movements is constrained, these parts shrink. This reaction, known as contracture, can be seen within eight hours of rest: After a night of sleep, some joints and muscles are stiff. While stretching intuitively in the morning, we reverse this early symptom of rest.

Bones.

Our bones might appear stable, solid, and hard, but bone tissue is a dynamic structure constantly changing itself. After each stimulus from outsidea"if we carry a weight or perform push-upsa"bone tissue is added, reorganized, or broken down. But as soon as a person takes to bed, bones start to lose calcium, which shows up through increased levels of calcium in the urine after only a few days of bed rest. Scientists have measured this loss and found that 1.54 grams of calcium are excreted per week. This flus.h.i.+ng, in turn, increases the risk of kidney stones and of calcification in tissues. This loss of calcium affects the stability of bones. An underused skeleton can soon become crumbly and fragile. People confined to bed for three weeks double their risk of breaking a hip.14 Skin.

Resting in bed curtails blood flow in the skin tissues. In those areas where the skin does not cover soft tissue but spans directly across a bone, it gets highly compressed. This compression restricts the blood flow in the skin tissue, which is incrementally dissolved, dies off, and turns into a festering sore p.r.o.ne to inflammation.

Muscle.

A given muscle is only as strong as it needs to be and is highly adapted to its usual tasks. Thus, given nothing to do, a muscle will start wasting away, losing roughly one-eighth of its strength during one week of physical inactivity. Such atrophy also occurs when we have to carry an arm or leg in a cast; after the plaster is removed, it is amazing to see how stiff and short the unused muscles have become. The voluntary disuse of our body has a similar effect. When a muscle exerts less than 20 percent of its maximum strength, it starts to shrink. In the case of absolute bed rest, the body loses eight grams of protein every day. The back pain that often appears after a few days of bed rest is actually triggered by the fact that stomach muscles, as well as the muscles lining the backbone, are wasting away. Thus the medical tradition of prescribing bed rest to heal back pain seems downright absurd.

Urinary Pa.s.sages.

The renal pelvis drains because of gravity. If a person is lying in a horizontal position all the time, the acc.u.mulating urine cannot properly run off, and the fluid is retained in parts of the kidney, in the calyxes. This in turn poses a risk of developing kidney stones and infections.

Lungs.

Another problem for people who remain immobile for long periods is that mucus starts to acc.u.mulate in certain areas of the lungs, leading to a condition called local atelectasis. As a result, air cannot move properly through the affected areas and, subsequently, the number of deep breaths a person can take decreases. Even people initially in good health before becoming bedridden risk developing atelectasis and lung infections.

Cardiovascular System.

Like every other muscle in the body, the heart shrinks as soon as it lacks sufficient work. The Dallas Bed Rest and Training Study15 revealed that after three weeks of rest, the heartas stroke volume decreases by 25 percent, and the size of the heart shrinks by 11 percent. In addition, the risk of suffering an embolism rises, as the blood cannot circulate as usual. A thrombus can emerge and can cause a sudden death by blocking a vessel.

s.e.x and Reproduction.

Physical inactivity decreases the production of the male hormone testosterone and dampens the libido. Also, fewer sperm are produced in the testes.

Digestion.

When a person lacks movement, the peristalsis usually needed to move the food through the guts slows down. This can lead to digestive problems and constipation.

Psychological Effects of Immobility At one point, NASA also kept young male test subjects in bed for as much as five weeks, which caused a whole range of mental and sensory problems. These brave men developed sleeping disorders, anxiety, and hostility to the people around them. In addition, there were hints that the physical pa.s.sivity impaired their senses. Their capability to hear, see, and taste diminished.16 Another long-term psychological effect is commonplace in hospitals. As soon as people are admitted, many of them abandon their autonomy and slip into the role of the pa.s.sive patient. Whenever a doctor or nurse appears, patients act in a servile way and readily abide to every procedure. Other people now control many aspects of their life: what they eat, when they sleep, and when visitors are allowed. The lack of intellectual stimulation leads to a dull state of mind. A stay in a clinic can thus mark a sharp decline in cognitive abilities. Nursing scientists aptly call it athe downswing of the IQ in the hospital.a17 Consequently, after being released from a hospital, a surprisingly high number of people must struggle to go back to their normal lives. As the American physician Paul Corcoran concluded: aSmall wonder that many patients have trouble resuming independent management and decision making after prolonged bed rest.a18 Pain and Rest: A Vicious Circle Patients being treated because of neurological injuries suffer more often from chronic pain when theya"or their affected body parta"are immobilized following the treatment. Less well-understood disorders like fibromyalgia and fibrositis also appear connected with the level of physical activity a person maintains. Attacks of pain tend to start during periods without exercise, when the body is in a depleting mode called adeconditioning.a Often a person experiencing pain gets caught in a vicious cycle, cautions Annette Becker: aAs soon as the patients feel the pain they start to take it easy. In the beginning, the rest admittedly leads on to some pain relief, but in the long run it gives rise to deconditioninga"which, in turn, makes the pain worse. This increase of pain adds to the urge to take it easy. Eventually, the rest becomes the reason for being sick and the sickness becomes the reason for the resta"the pain is likely to become chronic.a19 PREMATURE AGING.

The decline a person suffers in the course of a bed rest of several weeks is, in effect, occurring right now in wide sections of the larger population, albeit distributed across many years in the lives of people. In middle age, around their 40th birthday, many people adopt a pa.s.sive and sedentary way of life. They never walk their children to school and always use a car for simple errands. The more they sit, the faster their bodily composition changes. While muscles shrink, fat cells get bigger.

In 1988, the physician Irwin Rosenberg of Tufts University in Boston came up with a name for an eerie phenomenon: asarcopeniaa (from the Greek words sarx, meaning aflesh,a and penia, or adeficiencya). People suffering from sarcopenia usually walk extremely slowly and have a reduced bone density. They have a weak grip, are p.r.o.ne to falls, and are often unable to control urination and defecation. Their condition is, in a word, tragic. As Rosenberg states: aThe more [the potential sarcopenia victims] sit around, fail to exert themselves, and are waited upon by others, the greater the amount of their bodyas muscle ma.s.s that is replaced by fat. This insidious weakening of body structure and gradual loss of functional capacity then becomes a good excuse for continuing the pattern of immobility.a20 But those affected may think it perfectly normal that they hardly have any physical strength. This, they may declare, is nothing but a natural symptom of old age.

This att.i.tude could not be more dangerous. Such a decline of fitness and bodily control is caused by the fact that muscles havenat been used properly in years. Gradually, the physiological changes mimic the rapid degeneration caused by complete bed rest. In both instances the bodyas ability to process oxygen, its aerobic capacity, dwindles. While the stroke capacity of the heart decreases, blood pressure increases. The concentration of red blood cells decreases, but that of cholesterol increases. The ability of blood to coagulate, thus healing wounds, is hampered. Sarcopenia and complete bed rest shape the body and the metabolism in strikingly similar ways: The proportion of fat grows at the cost of the muscular system. Calcium is flushed away, and the outer substance of the bones thins. The capability to utilize blood sugar is impaired, and the average body temperature drops. The level of male s.e.x hormones drops, the production of sperm slows down, and the libidoa"the desire to have s.e.xa"is also impaired.

With both long-term physical inactivity and short-term bed rest, fewer neurotransmitters like dopamine and serotonin are active in the brain. The sense of hearing fades, as well as the ability to sleep. The sense of taste is slowly desensitized. Memory becomes worse.

For most people, all these changes arrive over the course of years. For the most part, however, this decline is not caused by the phenomenon of aging but simply by the permanent disuse of the body in the course of those years.

Every sedentary person can demonstrate that this is true because these multiple symptoms of degradation and decomposition will be reversed as soon as a person gets in motion again. That is the good news of this sobering chapter: Even degenerating cells, organs, and tissues can recover. If they are stimulated to move, they will renew themselves, and will do so at every age of a personas life.

3.

Unemployed Bodies, New Diseases.

IN 1961, PHYSICIANS HANS KRAUS AT NEW YORK UNIVERSITY AND Wilhelm Raab at the University of Vermont College of Medicine wrote of an alarming trend:1 We as physicians, have come to accept as normal what even a century ago might well have been looked upon as below normal, abnormal, or even sick. We blandly accept the fact that men and women in their late thirties cannot run, that they are overweight, that they might have to awatch their hearts,a that they need diets, and that they have an a.s.sortment of minor or major orthopedic aches and pains. . . .

On the other hand, we consider as supernormal or as freakishly exceptional people whose physical activities approximate those of past generations of less mechanized countries. We consider the low pulse rate of an athlete as something unusual. . . . We are surprised at the relatively low muscular tension, the spontaneous weight control, the better muscle strength and flexibility, the greater breathing capacity and the high fatigue level of the well-trained, not over-trained, athlete, and we settle back comfortably to our daily sedentary routines after having declared such people unusual, as indeed they are.1 Kraus and Raab described an emerging ailment produced by lack of exercisea"the hypokinetic diseasea"at the same time such revealing terms as adisuse atrophya and auntrained hearta entered medical dictionaries. Doctors initiated studies asking whether there might be a correlation between physical inactivity and the rate of heart disease. Their conclusions: people with physically demanding jobs were three to four times less likely to die from a heart attack. Forty years ago, this outcome caused a sensation: aIt is not labor that damages the coronary arteries and the hearta"but the lack of labor.a2 Lack of exercise was found to upset crucial bodily functions and to turn asleep disorders and impairments of digestion into the most frequent ailments of our time,a said Harald Mellerowicz, a sports physician in Berlin. In a blend of cynicism and wrath, he cautioned: aThe muscles of the torso are no longer able to give it natural support. Weak and bad postures, degenerations of the spine and of the ribcage develop, with impact on the bloodstream and the respiratory system. This bad posture is not only unattractive but also triggers a whole chain of additional impairments affecting development, health and performance.a3 STUCK IN OUR CHAIRS.

These harsh words, published in 1967, had little effect. No generation has ever moved as little as todayas inhabitants of the United States and other Western nations. Experts at the World Health Organization have cla.s.sified 60 percent of the worldas population as sedentary; 41 percent do not even have two hours of moderate exercise per week; 17 percent are completely inactive. It is estimated that 2 million people die from illnesses caused by lack of exercise, among them cardiovascular disease, breast cancer, and type 2 diabetes. In the United States, treatment for sedentary citizens costs 75 billion dollars every year.4 However, most people do not consciously decide to be lazy. In general terms, they are yielding to the manifold temptations of the modern world. Though we do not act to avoid them, the hazards are well known. In the 1950s, television sets conquered American households, and gasoline was so cheap then that families, instead of walking, took to road trips on the weekends. Today, there is less need for physical exercise at work, at home, or during recreation, to the point where, as William Haskell at the Stanford University School of Medicine puts it, we can speak of its anon-existence in industrialized and urbanized societies.a5 Haskell himself is deeply worried.

In the United States, children grow up in a world that leaves no time and no room for physical activities. For most of the baby boomers, it was common either to walk or to ride a bicycle to school. In these days, kids are moved around in mini-vans, and teachers have a hard time advocating walking days. Once in school, students will rarely be challenged physically because many school systems struggle to finance a physical education program worthy of the name. At recess, video games and other gadgets have taken the role b.a.l.l.s and skipping ropes used to occupy. The idle members of generation XXL spend their youths indoors, and they would rather travel online than by foot. Granted that some ten-year-olds design impressive Web pages, but many have difficulties climbing, jumping, or pitching a ball. According to Nielsen Media Research data, the average child or adolescent watches an average of nearly three hours of television per day. This figure does not include time spent watching videotapes or playing video games; one 1999 study actually found that children spend an average of six hours and 32 minutes per day with various media combined.6 No wonder there is literally no time left for playing outdoors.

The abandonment of exercise is a global trend affecting not only kids growing up in American suburbia but also youngsters living in walkable areas of Europe. Wilhelm Niebling has a doctoras office in the idyllic Black Forest. As he puts it: aMany children in our town are not able to balance backwards.a We hardly realize the subtle ways in which digital technologies reduce the amount of exercise we get at work. To start with, often workers no longer have a real need to leave their houses in the first place. Thanks to cell phones, Internet access, faxes, and e-mail, more people can work from their home. And even if an employee finds her way to the office, there she need not leave her cubicle. She can communicate by phone and e-mail with every colleague. Writing, copying, and sending a doc.u.ment can be done without leaving her chair. The automatic redial function on phones reduces even the amount of energy needed to hit the numbers. Over the course of days or weeks, these effects seem to be negligible for our well-being.

In the course of months and years, these small effects make a big difference. To ill.u.s.trate this point, William Haskell offers the example of an initially slim white-collar worker weighing 60 to 70 kilograms (130 to 150 pounds).7 Imagine, says Haskell, that the worker had the following choices: He could print all his doc.u.ments; pick them up at the printer; and personally bring them, like an office boy, to the relevant colleagues. In this case he would rise from his chair once per hour and walk slowly for two minutes. Alternatively, he could send all his doc.u.ments by e-mail, and he would thus sit all the time. In the latter case, the energy consumption would be decreased by an amount equaling 500 grams of fat per year. That is to say sending e-mails gives rise to an insidious obesitya"after ten years the worker will be five kilograms fatter. If the same man walks one kilometer every morning, he may make up for this. However, if he keeps his food intake, but stops his morning strolls, he will gain two kilograms within one year.8 OFF THE CHARTS.