The Economy Class Squeeze

Once again, it’s boom season for holiday air travel, as hordes take to the skies--mostly in coach class--to visit family and friends.

But with the boom comes a downside: an increased risk of flying-related ailments, brought on or aggravated by cramped quarters. On the list of potential problems is so-called economy-class syndrome, which is an increased risk of blood clots in the legs after cramped seating, such as on a long-haul flight in coach class. Flights in close quarters can also lead to back pain, swollen ankles, leg cramps and psychological distress.

Economy-class syndrome is not common, according to Dr. Stanley Mohler, director of aerospace medicine at Wright State University in Dayton, Ohio, who reviewed the literature and published a report in the journal “Aviation, Space, and Environmental Medicine.” But travelers should be aware of it because it is a potentially fatal yet preventable hazard of air travel. At higher risk for economy-class syndrome are obese people and tall people, along with anyone who has suffered the condition previously, smokers and those on oral contraceptives. Risk is believed to increase with age.

Travelers might not notice the symptoms--chest pain, coughing, or both--until two or three days after disembarking from a long flight.

When they head to a hospital emergency room, Mohler said, “the ER doctor often thinks they have had a heart attack. Quite often [the condition] is not tied to the flight [by the examining doctor].” What has often happened, Mohler said, is that the clots that formed in the legs during the long period of inactivity aloft may have traveled to the lungs, causing the pain and coughing.

Prevention techniques are simple.

“Two days before a flight, take an aspirin [a day] if you can tolerate it,” he said. As a result of the medication, although blood will still pool in the legs when they are inactive, it hopefully will not form clots, he explained.

Avoid wearing tight panty girdles or below-the-knee stockings, Mohler also advised.

Before the flight, take some time to massage the feet, and tighten the muscles in the calves and thighs to improve circulation. Continue the massage and muscle tightening once on board. “The in-place exercise probably is the most important preventive,” he said.

To make it easier, Northwest Airlines, for instance, shows “Airobics,” a brief video demonstrating in-seat stretches and also dispenses other travel advice to combat economy-class syndrome, fatigue and other potential side effects of long-haul flights. Passengers traveling on other carriers can ask their physicians to suggest a similar regimen.

Mohler also recommends getting up and walking around when possible, although he concedes that is not always feasible, with fully booked flights and food carts blocking aisles.

What would greatly help, Mohler said, is more leg room, although he doesn’t predict that will happen any time soon in coach class. The ideal space between seats, called “pitch” by the airlines, is about 40 inches, Mohler said. A pitch of 32 inches in coach class is about average, according to spokespersons from US Airways and Northwest Airlines.

Another side effect of flying in cramped quarters is back pain. Most vulnerable are the very tall--6 feet and over--and the petite--5 feet, 3 inches or under, said Dr. Robert Swezey, a UCLA clinical professor of medicine and back specialist who founded the Swezey Institute in Santa Monica.

Tall passengers often find their knees rubbing the seat in front of them. Their confinement becomes worse if the passenger in front of them reclines the seat.

“Try for a bulkhead seat if you can,” Swezey recommends. Shorter passengers often find that their feet don’t touch the floor, which can mean added strain on the back and upper legs.

Back support is crucial. “Grab a blanket and pillow early on,” Swezey advised. “Roll or place the pillow or blanket in the small of your back so you have a comfortable support.” Those not quick enough to snag a pillow or blanket might use a sweater or coat.

Before settling down to sleep or rest, “divert the air flow nozzle away from your neck,” Swezey recommended. Doing so lowers the risk of waking up stiff and sore. To avoid discomfort, shorter passengers should roll up a magazine and use it as an arm extender to turn off the light or divert the air, Swezey said.

In the airport before boarding, try to do slow, easy stretches. Travelers with a history of back problems who have been given an exercise regimen should follow it. Taking along cold packs or a heavy plastic bag that can be filled with ice if back pain strikes aloft is another wise measure, Swezey said.

Travelers who arrive at their destination in pain should ask for help from the flight attendant, Swezey recommended, and even request a wheelchair if the pain makes walking difficult. Once in the terminal, consider seeking help at the in-house first-aid or medical clinic.

Usually less serious, but just as annoying, are swollen ankles and leg cramps that can strike. Besides walking around when possible, try in-seat exercises, recommends Dr. Michael Levi, a Santa Monica podiatrist on staff at St. John’s Health Center, Santa Monica.

With shoes off, make a circular motion with the feet to the count of 10, Levi suggested. Rest and repeat. Try for three sets every 30 minutes or so. If possible, stand up in the aisle on tiptoes every hour or so, with shoes on, and raise and lower the heels of the feet 10 times. Rest and repeat three times.

Bend over, knees soft (not contracted), slowly touching hands to ankles until a slight stretch is felt in the calves, Levi suggested. Stretch slowly to the count of 10. Repeat three times. Do this every hour, if possible.

Immediately before the flight, Levi added, “go for a brisk walk for 10 or 15 minutes and end with stretching.”

Close quarters and rude seatmates can take their toll, too, creating a reaction that Santa Monica psychiatrist Mark Goulston describes as “airborne road rage.” But it can be even worse than the earthbound version, he said, partly because the offending parties are sitting much closer, often invading one’s space.

The more aggravated nearby passengers are, the more the feeling might spread. “Anxiety, agitation and stress are contagious,” Goulston said.

What to do? “Hope for the best, but plan for the worst,” Goulston said. “Bring a snack to soothe hunger or a beverage. Plan how you want to spend your time during the flight. Take a novel. Take your laptop.”

Visualize the worst possible flight scenario before taking off, Goulston suggested. “Anticipate that someone three times the size of an economy-size seat will be sitting next to you. Visualize every seat taken. The person sitting next to you has terrible breath and body odor. . . . “

Of course, the chances of all that coming to pass are small. And that’s the point, Goulston said.

“Anything less [than what was envisioned] and you’re going to feel like you’re in first class.”

The Healthy Traveler appears the second and fourth week of every month.