A Balanced Life

Humpty Dumpty sat on a wall,


Humpty Dumpty had a great fall. 


All the king’s horses, 
and all the king’s men,

Couldn’t put Humpty together again.

No one ever said why Humpty fell off the wall. If he’d managed to stay up there, he would have been OK. That’s the way it is with older people with thin bones. Osteoporosis doesn’t make people fall but it makes them break when they do. The real question is why they fall.

Why do older people fall down?
Falling is a risk of age because balance, strength, flexibility and speed decline over time. Even if you have no problems with balance it is worth understanding how balance works – how you maintain an upright posture and adjust to changes in the terrain under your feet, and how you manage to catch yourself and not fall as your foot slips on an icy path. The good news is that “use it or lose it” applies to balance, strength, flexibility and speed. You have some say in their preservation.

The systems that create balance

Your sense of balance comes from the integration of messages from muscles and joints, eyes and ears. Try experimenting and you’ll feel how these sensations contribute to balance. First, stand on one leg. Then try doing it with your eyes closed. Then try doing it after spinning around in a circle, and disturbing the fluid in the inner ear. With each maneuver, you subtract some of the sensory input to your brain and make it harder to control the muscle strength and tone needed to keep you upright. Fortunately, we don’t have to “think” about the actions that keep us balanced. They happen automatically.

What happens when the balance systems go awry?

When some part of the entire balance system goes awry, you feel “dizzy” or “lightheaded” or “off” or “tipsy.” The doctor who hears your complaint will ask you questions related to all the components of the balance system, and to all the medical conditions that can disrupt your eyes and ears, your peripheral nerves, your spinal cord, or your brain. He or she may order hearing tests or brain scans, blood tests or electroencephalograms. Patience, careful observation of symptoms, and systematic ruling out of problems is the best approach.

Vertigo

A sense of spinning dizziness, called vertigo, makes balance almost impossible. Vertigo is most frequently the result of an inner ear problem Three semicircular canals deep in each ear lie at right angles to each other and are filled with fluid that moves when you move your head. The fluid stimulates nerves that add information to the balance system. Viruses can affect the ear and produce profound vertigo with even tiny head movements. Some tumors of the nerve to the ear (acoustic neuromas) affect balance and hearing. A benign condition called Meniere’s disease causes episodes of hearing loss and vertigo. Though acute ear problems are sometimes at fault, very often dizziness that comes from the ears is a result of disuse of the inner ear canals. Ears that are unaccustomed to change in position because body movement has become limited and slow no longer cope well with rolling over in bed or turning the head quickly, and such routine activities can make the room spin. This is called benign positional vertigo and the treatment consists of exercises of the head and neck to re-accustom the semicircular canals to movement.

Muscle and joint receptors keep track of the body in three dimensions

Tiny receptors in the muscles and the joints perceive gravitational stress and muscle tension and movement. These receptors tell the brain where the body is and how much muscle tension is needed to hold you up and to move the way you intend to move. Balance suffers when nerves don’t function properly (neuropathies) because of diabetes, kidney disease, vitamin deficiencies, medications, exposure to toxic substances, or a variety of esoteric blood and autoimmune diseases. Balance also suffers when pain messages from joints and muscles override the compensatory adjustments that have to be made quickly to avert a fall.  Arthritic diseases of the spine, spinal tumors, or diseases that affect the peripheral nerves can disrupt the pathways in the spinal cord that carry the messages from the nerves to the brain.

Vision: an important component of the balance system

Visual input contributes a lot to the brain’s interpretation of the world and to where the body is in three dimensional space. Darkness, by removing visual clues, sometimes uncovers balance troubles before they are apparent in good light. Of course, people who have never had vision have developed balance systems that function perfectly well without visual input and sighted people who lose vision eventually adapt their balance to its lack.
Brain: coordinating the input and determining the output

The brain takes incoming sensory information and converts it to a sense of where the body is in space. It also sends messages back down the spinal cord and out over the motor nerves to the muscles to stimulate them to contract and relax in just the amounts necessary the body where you want it. Interference with these finely tuned functions can cause feelings of dizziness and imbalance that are harder to describe than the vertigo caused by ear problems. These sensations are termed central imbalance and can come from strokes, side effects from medicines, or a fall in blood pressure on standing up too rapidly. Less common causes are a variety of degenerative diseases, like Parkinson’s disease, and cerebellar degeneration.

Keep you balance and you won’t have to retrieve it later

Even if you are young, practicing balance activities that challenge you and maintaining muscle strength, quickness and range of motion are useful habits that serve you well in youth as well as in older age. If you do slip, you will have the best balance possible and the strength required to get your feet back underneath you. Choices abound that give you opportunities to stimulate your balance circuits. Put your pants and socks on while standing. While you brush your teeth! where you can grab onto something if necessary, practice one-footed standing with eyes open, then closed. Do regular head rolling exercises, gently and slowly at first, to get those semicircular canals used to some movement or take dance lessons and get back to spinning movements. Make yourself move briskly at all times to keep speed in your repertoire. Squat completely and rise as often as possible when only bending is required. Try one-footed squats. Use the stairs instead of elevators. Balance on your toes, and on your heels. Walk an imaginary tightrope, frontward and backward. And if you still ride a bike or ski or dance or skate or run, keep it up. Unlike Humpty Dumpy, you’ll have a better chance of staying up on the wall.

Muscle: Designed for Action

“Use it or lose it.”  Jimmy Connors

When the weather turns cold, black bears retreat to their dens. During their period of winter sleep, they occasionally rouse themselves and shiver to raise their body temperatures, but for the most part, they engage in little physical activity. In the spring, the bears emerge from their dens, having lost a lot of body fat, but only a little muscular bulk. They are fit enough to begin the season’s hunt for food. A human emerging from an equivalent period of bed rest, however,  would be in terrible shape, in need of a wheelchair to make it to the grocery store because his muscle mass would have declined nearly 80 percent. He would face a long and arduous period of rehabilitation to regain the muscular strength and bulk he lost due to inactivity. 

Human muscle isn’t bear muscle

The difference between the muscle of humans and that of hibernating mammals lies in the genetic makeup of each type of muscle. Human muscle is programmed for almost continuous activity. During times when it is not called into action to contract or resist the force of gravity, it heeds some mysterious signal to begin closing up shop. In medical terms , it begins to atrophy. Anyone who has ever broken a leg or had surgery that required the immobilization of a limb remembersWhen the weather turns cold, black bears retreat to their dens. During their period of winter sleep, they occasionally rouse themselves and shiver to raise their body temperatures, but for the most part, they engage in little physical activity. In the spring, the bears emerge from their dens, having lost a lot of body fat, but only a little muscular bulk. They are fit enough to begin the season’s hunt for food. A human emerging from an equivalent period of bed rest, however,  would be in terrible shape and would be in need of a wheelchair to make it to the grocery store because his muscle mass would have declined nearly 80 percent. He would face a long and arduous period of rehabilitation to regain the muscular strength and bulk he lost due to inactivity.

The difference between the muscle of humans and that of hibernating mammals lies in the genetic makeup of each type of muscle. Human muscle is programmed for almost continuous activity. During times when it is not called into action to contract or to resist the force of gravity , it heeds some mysterious signal to begin closing up shop. In medical terms , it begins to atrophy. Anyone who has ever broken a leg or had surgery that required the immobilization of a limb remembers the sad, shrunken state of the muscles in the limb that emerged after weeks in a cast. The bone has healed but the muscles atrophied. 
.How does muscle shrink?

Atrophy occurs because, in response to inactivity, the normal balance of protein recycling in muscle cells shifts in favor of breaking protein down rather than building it up. During this process, tiny protein-based fibers called myofibrils, the contracting and relaxing elements in all muscles, begin to shrink and disappear. Unless muscles are called into action, atrophy continues and, within two weeks, the loss of muscle mass is visibly apparent.

Other triggers for muscle atrophy

Muscles also shrink in response to some serious illnesses. In these cases, the triggers that set atrophy in motion are things other than inactivity. One trigger  is a substance called tumor necrosis factor, which the body produces in response to some cancers and infections and which contributes to dramatic loss of weight in cancer patients. Another trigger is loss of nerve supply to muscle cells such as happens when the controlling motor nerve cells in the spinal cord die in diseases like polio and amyotrophic lateral sclerosis (also known as Lou Gehrig’s disease) or when nerves that run from those cells to the muscles are severed by trauma or damaged by diseases or toxins (examples are diabetes and lead exposure). Old age, with its lower testosterone levels, gradually robs muscle of some of its bulk. But no matter what the trigger is, once atrophy is set in motion the result is the same. Muscle shrinks. It becomes weak, fatigues easily, and consumes less energy. The body’s metabolism slows down, sensitivity to insulin declines, and fat accumulation becomes easier.

Atrophy conserves energy

Energy demand is the key to understanding muscle atrophy. All living things conserve energy whenever possible. This bedrock survival principle applies not only to the visible animal world , where animals do little but rest when they are not eating or seeking food, but also to the microscopic world of cellular physiology. Those cells that do not get used get put to rest. Muscle is a heavy consumer of the body’s limited energy resources and it has a mysterious ability to measure the time since it has been called upon to work. Once inactivity has exceeded a few days, muscle cells begin to shrink as a means of conserving the body’s precious energy stores. In a gravity-free environment like the International Space Station, for example, astronauts’ muscles atrophy because the work of moving bones is greatly reduced outside the earth’s gravitational field. Weightlessness is rest for muscles. Astronauts use stationary bikes and other exercise equipment in an attempt to counteract muscle atrophy, but these measures do not make up for the normal and continuous activity of resisting gravity.

Muscle loss with age

Muscle atrophy can also occur more subtly over the course of a lifetime and the patterns of muscle loss are related to lifestyles in different cultures. The human foot,  for instance, has more than twenty muscles that control the motion of its intricate, bony structure. In non-shoe wearing cultures around the world, people have remarkably strong and flexible feet because they demand much of the muscles in them. In some of these cultures, people use their feet to grasp the surfaces of trees as they climb in search of things like coconuts. Activities like these, in addition to the lack of the kind of general support that shoes provide, help keep the muscles in their feet strong. Conversely, people in shoe wearing cultures with smooth walking surfaces demand much less of their foot muscles.Not only do their feet lack strength and flexibility, but they frequently develop bony abnormalities like bunions, overlapping toes and hammer toes. The same principles apply to the muscles of the legs and hips. In cultures where people squat instead of sitting in chairs, the ability to squat and rise is retained better than it is in populations where squatting is not required in the daily routine of life. 

Retrieving muscle

Muscle is very forgiving and will respond to resumed calls for action, even in people in their eighties. When they begin to use their muscles in more demanding and repetitive activities, muscle cells once again begin to make more proteins than they break down. Muscle fibers increase in size and tensile strength. As health returns in someone who has been weakened by a debilitating illness, increasing activity improves strength. Following nerve damage, muscle may recover if the nerve supply is re-established, al­though this recovery is usually limited if a long period of time has elapsed between nerve damage and repair of nerve supply. For instance, if muscle has become weak from pressure on spinal nerves and surgical decompression has been delayed, muscle strength may not fully return. Passive electrical stimula­tion of muscles which have no nerve supply helps prevent atrophy but is never as effective as active use in restoring muscle strength.

Maintaining muscle

The lessons to be learned from muscle atrophy are that humans are designed for motion and that healthy muscle is integral to a healthy overall metabolism. Hence the constant refrain from doctors and health writers that exercise is necessary to prevent chronic illnesses like obesity, diabetes, and coronary artery disease. But how much movement is necessary to keep muscles healthy and prevent atrophy? The easiest way to answer this question is to picture the world in which early humans evolved. There were no cars, no chairs, and no grocery stores. Life involved hunting and gathering, squatting around camp­ fires, climbing trees, running from predators and after prey. In such a world, no groups of muscles were neglected. In the modern world, it takes more effort-such as learning Pilates or yoga-to make sure that the muscles of the shoulders, hips, and torso are used regularly. Still, it is easy to find daily opportunities to squat and rise, to walk without shoes, run a few steps, and add a little bounce and speed to  stair climbing.  If you need to sit for prolonged periods of time, be certain to take frequent breaks and stand up and move around. Mindfulness and willfulness about physical activity are keys to healthy muscles in the modern world. Unlike black bears, humans are programmed for short, regular intervals of rest, not for long months of hibernation. Nature will wait only a few days before moving on with her overriding goal of conserving energy. Use it or lose it is her rule. •

Gout and Girth: A Sweet Relationship?

At Hampton Court, one of King Henry VIII’s sixteenth century palaces outside London, tour guides regale visitors with tales of Henry’s obesity and the miseries he suffered during flare-ups of gout – exquisitely painful episodes of arthritis that come from the buildup of uric acid crystals in joints.  Gout was known as “the king’s disease,” because it afflicted wealthy people who could afford the meats and sea foods that trigger uric acid crystal formation.   The guides also point out the “confectionary,” a corner room near the kitchen wing, and describe the sugar-rotted royal teeth produced by the then scarce sweetener.  The guides do not link Henry’s gout to the royal sweets, but perhaps they should.  Sugar is composed of equal parts glucose and fructose, and scientists are now beginning to link increased fructose intake not only to obesity and type II diabetes, but also to increased uric acid in the blood – a risk factor for gout.

What is uric acid

Some uric acid in the blood is normal, because every cell in the body makes uric acid out of purines, chemical compounds that come from the regular breakdown of DNA and RNA as cells recycle themselves.   Purines also come from many foods, but are particularly concentrated in red meat, organ meats like liver, many fish and shellfish, and yeasty beverages like beer and red wine.  Uric acid in the blood is not bad – it serves as a powerful antioxidant.  However, in some genetically susceptible people, uric acid levels become too high because they make too much, or  because their kidneys don’t excrete enough into the urine.

When uric acid crystallizes

Abnormally high uric acid levels in the blood, a condition called hyperuricemia, can be present for 10-20 years without any symptoms.  But just as minerals crystallize out of water in caves and form stalagmites and stalactites, uric acid can crystallize out of fluids in the body, forming microscopic deposits in tissues, especially kidneys, joints, tendon sheaths and skin.  The painful part comes with the inflammation that ensues when the body attempts to eliminate the crystals. The classic case of gout, also known as podagra, begins suddenly with exquisitely painful, bright red swelling in the joint space between the foot and the big toe. Symptoms last from days to weeks.

The swelling comes from inflammatory fluid in the joint space. Diagnosis of gout depends on withdrawing some of this fluid through a needle and examining it under a microscope, where the uric acid crystals show up as pointy spicules which bend light waves in an identifiable way. Fluid withdrawal can also relieve some of the pain, but the mainstays of treatment during acute attacks are anti-inflammatory drugs such as Indocin, ice and or heat, and plenty of water.  Prevention of attacks depends on efforts to lower uric acid levels, by diet, weight loss and use of medications that block uric acid production or increase its elimination in the urine.

Fructose is a building block for uric acid

For centuries, dietary advice about gout has revolved around foods high in protein.  But as numbers of gout cases climbed steadily over the last forty years and average uric acid levels in people without gout also increased, a correlation with increased sugar consumption began to emerge.  Scientists are now studying the relationship of sugar intake to uric acid and gout and also attempting to tie uric acid to hypertension, obesity and heart disease.

Sugar consumption was once rare to non-existent.  Table sugar, a mixture of the two simple sugars sucrose and fructose, came only from sugar cane, which originally grew only tropical regions.  Sugar’s spread around the world followed trade routes, and accelerated markedly after the discovery of the beet as a sugar source in the 18th C.  But the most dramatic rise in sugar consumption followed the invention of high fructose corn syrup (HFCS) in the 1970s. From work done so far, it appears that sugar’s fructose is a bigger culprit than its glucose in aggravating the metabolic syndrome (obesity, high blood pressure, heart disease and diabetes). And the metabolism of fructose actually produces uric acid.  

When the glucose/fructose mix of sugar enters the body, glucose is transported directly into cells for use, but fructose requires processing.  This requires energy, provided by ATP (adenosine triphosphate), and ATP breakdown produces uric acid. Eating fructose regularly also makes fructose easier to metabolize because it “induces,” or makes the body produce specific enzymes required to break it down.   For someone prone to overproducing uric acid, or someone whose kidneys excrete it inefficiently, a diet chronically high in fructose may not only provide the building blocks for uric acid, but also speed its production.

Cutting fructose may help – and will do no harm

Cutting purine-rich foods down in a diet helps many susceptible people remain gout free. There is no data yet on the effectiveness of limiting fructose intake on gout or hyperuricemia, but such a diet can do no harm. Limiting fructose sources to whole fruits would dramatically lower total fructose intake for most people. Fructose is the major sugar in fruits, but it is combined with fiber and vital nutrients and present in much lesser quantities than in sugar-sweetened beverages, soft drinks, baked goods and many processed foods. Even ketchup contains HFCS.

When dietary modification is not enough to keep people gout free, drugs that block uric acid production or increase its elimination help. Ideally, uric acid levels should be in the range of 3-6 mg/dl. Diet is important not only for those who have suffered acute gout attacks, but also for those who have high uric acid levels without any symptoms. Hyperuricemia warrants a good look at the amount of dietary fructose.

Henry VIII’s confectionary was a clue to the relationship of girth to gout.  As  uric acid research progresses,  blood tests for uric acid will probably become routine,  because high levels  often precede  the development of high blood pressure and Type II diabetes, even in people not susceptible to gout.

 

 Other Gout Facts

Many diuretics in common use raise uric acid levels and can trigger gout, especially the thiazide group.

Gout attacks commonly follow trauma or surgery because tissue breakdown produces purines.

Cancer treatments may also raise uric acid levels as tumor cells break down.

Uric acid levels increase in women after menopause and women rarely suffer from gout before then.

Uric acid levels in men rise at the time of puberty.

Pain in the Neck: More than a Metaphor

The cervical spine is a slender stack of fragile bones that balances the 15-17 lb. skull atop the body. Each bone has a round thick body and an arch of thinner bone projecting from its backside. The knobs of bone you feel in your own spine are just the tips of each bony arch, called the spinous processes. A wide array of ligaments, tendons and muscles hold the vertebrae together, and thirty-seven separate joints allow the head to move through a wide range of finely calibrated movements.  Arthritic changes accumulate in most necks over the years, particularly in the lower regions where most movement takes place.   In scans of people over 50, almost all will show some degree of wear and tear change in the lower vertebrae.

Aging changes in bones neck bones and ligaments

Wear and tear takes form of thickening of bony edges of the vertebrae and degeneration of the discs between them.  These changes may put pressure on the nerves that exit from the spinal cord through bony canals between the stacked vertebrae, and occasionally on the spinal cord itself, which travels through a canal formed by the centers of the stacked arches.  The ligaments that line this canal also thicken with age and create ridges inside the canal that press on the spinal cord. Degenerative changes contribute to episodic neck pain, and sometimes to more severe symptoms that require medical attention.

Why the neck hurts

The neck is second only to the low back pain as a common source of pain. Most neck pain is benign and episodic, coming from muscles, tendons, ligaments and joints. Painful episodes usually occur after some unaccustomed activity, such as painting a ceiling or suddenly twisting or bending the neck, or after sustaining a neck position for an unusual amount of time – for example, over a long drive.  Even an unaccustomed head position occasioned by wearing new bifocals can trigger a bout of stiff neck.

Other symptoms

Neck pain requires medical attention when it persists or is associated with neurological symptoms in the arms or legs.  Sensory symptoms like numbness or tingling in fingers and arms are quite common when underlying degenerative changes are present in the neck. While they may indicate pressure on nerve roots, sensory symptoms also occur when neck pain is simply a reflection of tight muscles and ligaments. The same nerve fibers that carry pain sensations also carry sensory messages and pain seems to have a kind of spillover effect into other sensory pathways.  That same spillover effect also can also cause a wide variety of sensory and pain symptoms in the head.  Headaches, pain in the back of the head, and even eye pain can be attributed to some neck problems.

Red flag symtoms: weakness and bladder control problems

Neurological symptoms indicating trouble in the motor nerves or in the spinal cord, in the setting of neck pain and degenerative changes, often indicate a more serious degree of trouble. Weakness in arm or hand muscles may mean that motor nerve roots are being squeezed as they exit the spinal column.  Weakness, fatigue and stiffness in the legs, and new trouble with bladder control are symptoms of pressure on the spinal cord. Sensory problems usually recover when the painful cause is successfully treated, but motor nerves and the spinal cord are more fragile and less reliably improve even after surgical decompression.  When motor problems are part of the picture, medical attention should be sought sooner rather than later.

Diagnosis

Careful history and physical examination are crucial to the proper diagnosis.  Diagnosis of a painful, stiff neck begins with taking a history. Most people do this before they ever see a doctor. What did I do yesterday? Did I sleep sitting up on a plane? In a strange bed? What movement makes this worse? What makes it better? Do I have any other funny symptoms? Most people also do the right thing by avoiding maneuvers that cause pain, applying either heat or ice, and even trying a soft cervical collar, which does not really immobilize the neck, but gives the head a temporary place to rest. Most often the neck improves and no medical attention is required.

Medical attention, when sought, should begin with a very detailed history, not only of the current episode, but of past problems, and other medical problems which might cause or complicate neck problems.  Important facts include history of trauma, rheumatoid arthritis, cancer, vascular disease, infections and past radiation treatment. Evaluation then moves to a physical examination, not only of the neck, but a general physical exam and a neurological exam. Imaging studies, electrical evaluation of nerves and muscles, and blood work follow under some circumstances. These include symptoms persisting more than 6 weeks, severe symptoms involving a single joint, presence of fever and weight loss, suspected fracture or dislocation, associated neurological symptoms or findings, and failure of simple treatments over a course of 4-6 weeks.

Treatment

Conservative measures are effective for treating common types of neck pain, especially if carried out conscientiously. Massage, hot or cold applications, topical pain relieving and muscle relaxing creams and intermittent use of aspirin or non-steroidal anti-inflammatory agents are all helpful but they are play a  only a supporting role. The major goal is to correct posture, not only of the neck, but of the whole spine, by strengthening and stretching of the muscles that support the spine and those that suspend and move the shoulders.   An effective exercise program, under supervision of a qualified physical therapist, involves the entire spine, as well as legs and arms.  In addition, supporting the neck’s normal curve in sleep with a good cervical pillow is crucial.

When conservative measures fail, more invasive means of treatment such as injections of anti-inflammatory and analgesic drugs are often added. Surgical treatment of neck pain problems is reserved for situations in which a nerve root or the spinal cord must be decompressed, or ones in which pain is so severe and unremitting that fusing the bones to decrease movement of the neck is considered the only option. In comparison to the number of people with neck pain at some point in their lives, surgically treated neck complaints are actually few and far between.  Considering how much the neck moves, how much wear and tear it sustains and how little protection it has, this is a remarkable measure of its resilience.

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