History of Back Pain

What Are Low Back Pain and Sciatica?

The Spine
The spine is a column of small bones, or vertebrae, that supports the
entire upper body. The column is grouped into three sections: the cervical
vertebrae are the five spinal bones that support the neck; the thoracic
vertebrae are the twelve spinal bones that connect to the rib cage; and
the lumbar vertebrae are the five lowest and largest bones of the spinal
column. Most of the body's weight and stress falls on the lumbar
vertebrae. Below the lumbar region is the sacrum, a shield-shaped bony
structure that connects with the pelvis at the sacroiliac joints. At the
end of the sacrum are two to four tiny partially fused vertebrae known as
the coccus or "tail bone".
Vertebrae in the spinal column are separated from each other by small
cushions of cartilage known as intervertebral discs. Inside each disc is a
jelly-like substance called the nucleus pulposus, which is surrounded by a
fibrous structure. The disc is 80% water, which makes it very elastic. It
has no blood supply of its own, however, but relies on nearby blood
vessels to keep it nourished.
Each vertebra in the spine has a number of bony projections, known as
processes. The spinal and transverse processes attach to the muscles in
the back and act like little levers, allowing the spine to twist or bend.
The articular processes form the joints between the vertebrae themselves,
meeting together and interlocking at the facet joints.
Each vertebra and its processes surround and protect an arch-shaped
central opening. These arches, aligned to run down the spine, form the
spinal canal, which encloses the spinal cord * the central trunk of nerves
that connects the brain with the rest of the body. Each nerve root passes
from the spinal column to other parts of the body through small openings
bounded on one side by the disc and the other by the facets. When the
spinal cord reaches the lumbar region, it splits into four bundled strands
of nerve roots called the cauda equina (meaning horsetail in Latin).

Low Back Pain
Low back pain is usually defined as either acute or chronic. Physicians
diagnose low back pain as acute if it lasts less than a month and is not
caused by serious medical conditions. Most cases clear up in a few days
without medical attention, although recurrence after a first attack is
common. If the pain persists beyond six months, it is considered chronic
low back pain; this constitutes only 1% to 5% of all low back pain cases.
Back pain may be triggered by various problems that occur along the ridge
of bone and disc. Injuries and small fractures can occur. Muscle spasms
can cause pain. Pressure on a weakened disc may cause it to rupture so the
nucleus pulposus protrudes out from the spinal column, a condition known
as a herniated disc. The facets can become misaligned or deteriorate. The
spinal canal itself can become narrowed, a disorder called spinal
stenosis. If any of these conditions occur, the nerve roots passing
between the discs and facets may be stretched or pinched, causing pain *
usually the pain known as sciatica.

Sciatica
The nerve most likely to cause trouble is the sciatic nerve; at some time,
up to 40% of people experience pain caused by compression of this nerve,
which branches from the nerve roots that descend off the spinal cord in
the lumbar and sacral areas. Each of the two branches of the sciatic nerve
is about as wide as a thumb and threads through the pelvis and deep into
the buttocks, then down the hip and along the back of the thigh to the
foot. Sciatica usually occurs on one side when a sciatic nerve has been
stretched or pinched, usually by a herniated disc, although spinal
stenosis or other vertebral abnormalities can also cause this pain. The
sensation of sciatica can vary widely * from a mild tingling to pain
severe enough to cause immobility. Some people experience sharp pain in
one part of the leg or hip and numbness in other parts. The pain increases
after prolonged standing or sitting and is aggravated by sneezing,
coughing, or laughing. If spinal stenosis is causing sciatica, patients
may also experience it after bending backwards or walking more than 50 to
100 yards.

What Causes Low Back Pain or Sciatica?
The causes of 85% of back pain cases are unknown. Most often, pain begins
with an injury, after lifting a heavy object, or after making an abrupt
movement. A number of conditions may make people more susceptible to low
back pain.

Disc Abnormalities
A herniated disc, sometimes * but incorrectly * called a slipped disc, is
the most common cause of severe sciatica. A disc in the lumbar area
becomes herniated when it ruptures or when the gelatin within the disc
protrudes outward. If the material breaks off or extends far enough out to
press against the nerve root, sciatic pain can occur. Studies are finding,
however, that bulging and protruding discs show up on the scans of up to
60% of people who have no back pain at all. Experts now generally believe
that bulging, or even protruding, discs may be normal and do not
necessarily indicate serious back problems. One expert suggested that
discs might even swell in response to stress and then contract again.
However, disc material that extrudes (that is, it balloons into the area
outside the vertebrae or breaks off from the disc) most likely is a cause
of pain. Sciatic pain is also sometimes present when there is no bulging
or extruding of the discs. Some cases of chronic low back pain may be
caused by inward growth of nerve fibers into intervertebral discs. Some
evidence also exists that nerves in the outer ring of the disc may be the
source of pain.

Spinal Stenosis
Spinal stenosis, the narrowing of the spinal canal, is usually caused by
bone overgrowth, which occurs mostly in the elderly who have degenerative
osteoarthritis, but it can sometimes be caused by other problems,
including infection and birth defects. Pain from spinal stenosis can occur
in both legs.

Spondylolisthesis
Spondylolisthesis, another cause of sciatica, is a condition in which one
vertebra has slipped forward over the other.

Osteoporosis
Osteoporosis is a disease of the skeleton in which the amount of calcium
present in the bones slowly decreases to the point where the bones become
fragile and prone to fracture. Spinal fractures can occur simply as a
result of pressure that compresses the vertebrae together. If the
vertebrae collapse suddenly, pain is often severe. A recent study
indicated that very tiny fractures in the vertebrae may be an undetected
cause of back pain in many older women.

Osteoarthritis
Osteoarthritis occurs in joints where cartilage is damaged and then
destroyed; in reaction to this destruction, the bones associated with the
joints develop abnormalities. (Rheumatoid arthritis, which is an arthritic
condition caused by inflammation in the joints, can damage joints
throughout the body, but rarely effects the lower back.) When
osteoarthritis affects the spine, it may damage the cartilage in the
discs, the moving joints of the spine, or both. The nerves may become
pinched, causing pain and, in advanced cases, numbness and muscle
weakness. The patient may also experience muscle spasms and diminished
mobility.

Ankylosing Spondylitis
Ankylosing spondylitis is a chronic inflammation of the spine that may
gradually result in a fusion of the spine causing the patient to stoop
over. It can be quite mild, however, and it rarely affects a person's
ability to work. Symptoms include a slow development of back discomfort,
with pain lasting for more than three months. The back is usually stiff in
the morning; pain improves with exercise. It occurs mostly in young
Caucasians in their mid-twenties. The disease is more common in men, but
about 30% of the cases are in women. About 20% of people with inflammatory
bowel disease and about 20% of people with psoriasis develop a form of
ankylosing spondylitis. Researchers believe that it is probably
hereditary.

Genetic Factors
Hereditary problems that can affect the back at any age are enteropathic
arthropathy and reactive arthropathy.
Miscellaneous Causes
Sciatica can also be caused by other problems, including inflammation,
abscesses, blood clots, and tumors. Some experts believe that one cause of
sciatica is the piriformis syndrome * entrapment of the sciatic nerve deep
in the buttock by the piriformis muscle.
Sometimes back pain can be caused by problems in other organs, usually
near the spine, which is then called referred pain. These conditions can
include ulcers, kidney disease, and blocked arteries. Chronic uterine or
pelvic infections can cause low back pain in women.
Arthritic back pain may also be caused by infections that include Lyme
disease, septic arthritis, bacterial endocarditis, Reiter's syndrome,
mycobacterial and fungal arthritis, and viral arthritis.
Atherosclerosis (commonly called hardening of the arteries) may
occasionally cause chronic low back pain, because the condition reduces
the supply of blood. When it blocks arteries in the legs it may cause pain
that resembles sciatica caused by spinal stenosis. Fibromyalgia is also a
cause of back pain.
Causes of Back Pain in Children and Adolescents
Juvenile chronic arthropathy is an inherited form of arthritis that can
cause pain in the sacrum and hip joints of children and young people; it
used to be grouped under juvenile rheumatoid arthritis but is now defined
as a separate problem. In young athletes, back pain is most likely to be
caused by stress fractures in the spine (spondylolytis) or because of an
inborn exaggerated inward curve in the lumbar area (hyperlordosis).
(Scoliosis, an abnormal curvature of the spine in children, does not
usually cause back pain.)
What Are the Risk Factors for Low Back Pain?
Back pain is the fifth most common reason for visiting a physician. In
1994, 10.2 million adults reported back pain and the incidence appears to
be increasing. Just getting older is a major risk factor for back
problems.

Sedentary Life Style
People who do not exercise regularly face an increased risk for low back
pain, especially during times when they embark on stressful unaccustomed
activity, such as shoveling, digging, or moving heavy items. Although no
definitive studies have been done to prove the relationship between lack
of exercise and low back pain, sedentary living is probably the primary
non-medical culprit contributing to this condition. Experts offer as
theoretical evidence for this connection the many proven damaging effects
of sedentary life on other parts of the body. Obesity, associated with
lack of exercise, puts more weight on the spine and may increase pressure
on the vertebrae and discs. Lack of exercise results in muscle
inflexibility, which restricts the body's ability to move, rotate, and
bend. Weak stomach muscles increase the strain on the back and can cause
an abnormal tilt of the pelvis, and weak back muscles increase the load on
the spine and the risk for disc compression.

Improper Exercise
Athletes are also prone to back injuries. Improper exercise instruction
and inattention to mechanics can be sources of sudden trouble; a single
jerky golf swing or incorrect use of exercise equipment, especially free
weights, nautilus and rowing machines, can cause serious back injuries.
Over time, intense high-impact exercise may increase the risk for
degenerative disc disease.

High-Risk Occupations
Jobs that involve lifting and forceful movements, bending and twisting
into awkward positions, and whole-body vibration (usually caused by
long-distance truck driving) place workers at risk for low back pain. The
longer a person is on the job, the higher the risk. In one study, 16 out
of 100 warehouse workers reported back injuries in one year, and in two
major food service organizations 30% of all injuries involved the back. A
major study of work-related injuries reported that, in 1994, there were
nearly 330,000 cases of back injury due to overexertion in handling
objects.

Other Risk Factors
Smokers are at higher risk for back problems, perhaps because smoking
decreases blood circulation, but the association may also be due to an
unhealthy lifestyle in general. Pregnant women are prone to back pain due
to a shifting of abdominal organs, the forward redistribution of body
weight, and the loosening of ligaments in the pelvic area as the body
prepares for delivery. Tall people are at higher risk than short people.

How Serious Is Low Back Pain or Sciatica?

Indications for Seeing a Physician
Certain warning signs should alert a patient to see a physician
immediately for low back pain. Cauda equina syndrome can cause permanent
incontinence if not promptly treated with surgery. Symptoms of the
syndrome include dull back pain, weakness or numbness in buttocks, genital
area, or thigh and an inability to control urination or defecation. Pain
accompanied by fever can indicate an infection. Pain that lasts for a
month, unexplained fever or weight loss, and a history of cancer may
indicate a tumor. Other conditions warranting rapid attention are very
severe pain * particularly if it awakens the person at night or is
increased by lying down * and any neck or back pain in children.
Long-Term Outlook
Recurrence is common after a first episode of back pain. In one survey,
over a one-year period following treatment only 21% of patients had no
back pain; over four years, less than half were symptom-free. Researchers
attempted to identify factors most likely to predict an elevated risk for
recurrent pain and only found one * depression * that was a significant
factor in the majority of those who had not recovered.

Effects on Work
One study found that although severe back pain comprised only 10% of
workers compensation cases it accounted for 86% of compensation costs.
Studies have found that when people stay home because of back injury,
about 65% are back within a week, 86% are back by one month, and, by three
months, 91% return to work. Another study found that if someone is on
disability for a year or longer, there is only a 25% chance that the
patient will return. The severity of back pain and its impact on work does
not always depend on the degree of physical injury. In many cases,
prolonged absenteeism from work because of back pain may be due to
psychological and social factors. For example, in one study 50% of truck
drivers reported low back pain, but only 24% lost time at work; bus
drivers had a significantly higher absentee rate because of back pain than
truck drivers, in spite of less stress on their backs. Every one of the
truck drivers said they liked their work and 92% of them even liked their
bosses while bus drivers reported much lower job satisfaction. Similarly,
another study found that pilots (who generally reported "loving" their
jobs) reported far fewer back problems than their flight crews.

How Is Low Back Pain or Sciatica Diagnosed?
Medical History
Because back pain can have so many different causes, it is very important
to first rule out any other medical conditions. A complete medical and
family history should be taken that includes heart problems, cancer,
arthritis, and any other serious conditions. The patient should report
previous episodes of back pain as well as any history of injuries or
accidents involving the neck, back, or hips. The physician will generally
ask about frequency, duration, and the nature of the pain, e.g., whether
it is dull, piercing, throbbing, or burning. The patient should describe
its onset and whether the pain was triggered by an event, such as lifting
a heavy object. The physician will need to know what worsens the pain (for
example, coughing, exercise, straining during bowel movements, walking)
and what relieves the pain (lying down, exercise). Other important
symptoms may include morning stiffness, problems with urination or
defecation, and weakness or numbness in the legs.

Physical Examination
Patients are asked to sit, stand, and walk in different ways *
flat-footed, on the toes, and on their heels. They will be requested to
bend forward, backward, and sideways, to twist, and to lift their leg
straight up while lying down (which tests the tension of the sciatic
nerve). The physician will also move the patient's legs in different
positions and bend and straighten the knees. To test nerve function and
reflexes, physicians will tap the knees and ankles with a rubber hammer.
The circumference of the calves and thighs may be measured to look for
muscle deterioration. The physician may touch parts of the body lightly
with a pin, cotton swab, or feather to test for numbness and nerve
sensitivity.

Imaging Techniques
Imaging techniques that include x-rays, magnetic resonance imaging (MRI)
scans, ultrasound, and computerized tomography (CT) scans have fallen out
of favor for routine use. People with low back pain should have x-rays or
scans done only under certain circumstances, such as pain that lasts more
than a month, very severe pain, numbness, muscle weakness, accidents that
might involve the vertebrae, a history of cancer or smoking, or the
presence of fever. If these conditions exist, usually an x-ray is used
first, and then, if results are inconclusive, either a CT or MRI scan.
(Ultrasound is not useful.)

Myelogram
A myelogram is an x-ray of the spine which requires a spinal injection and
the need to lie still for several hours to avoid a very painful headache.
It has largely been replaced by CT and MRI scans.

Discography
A discography uses an x-ray of the disc and employs injections into discs
suspected of being the source of pain and discs nearby. It can be more
painful than a myelogram and is generally used for patients who are
undergoing back surgery to identify the location of the injured disc. Some
experts believe that discography is not at all useful in identifying the
source of pain, because it requires expert execution and analysis for any
degree of accuracy. Others argue that it is the only procedure that can
reveal the shape of the disc and identify nerve structures in the disc,
which may play a role in some cases of sciatica.

CT and MRI Scans
MRI and CT scans are not painful, but they are very expensive and are
often not accurate in identifying disc abnormalities. Many experts believe
that their routine use for back pain has led to an increase in the number
of back operations, some of which have been unnecessary and even
dangerous. Studies indicate that at least 40% of all adults have bulging
or protruding vertebrae discs, even if they have no back pain at all, so
that abnormalities in people who do have back pain may simply be a
coincidence rather than an indication for treatment. Spinal abnormalities
identified by MRIs also are not accurate in predicting long-term problems.
And, on the other hand, studies reported that 6% to 23% of patients who
show damaged discs during surgery have normal MRIs. One study reported
that only a three-dimensional CT scan * not a normal CT scan * was able to
show bone injuries in over half of a group of people with back pain. These
refinements and others, such as MRI modifications to detect weak signals
from soft tissue, may soon make diagnosis more accurate. An MRI is useful
for detecting nonspinal causes of back pain, including infection and
cancer.

Other Tests
Blood and urine samples may be used to test for infections, arthritis, or
other conditions. Injecting a drug that blocks pain into the nerves in the
back helps locate the level in the spine where problems occur. A procedure
called a facet block is also useful in locating areas of specific damage.
Provocative discometry is a test that uses an injection of saline solution
into the suspected disc to reproduce the pain, which is then followed by
injection of an anesthetic to dull the pain.
What Are Nonsurgical Treatments of Low Back Pain or Sciatica?
Back pain attributed to medical conditions, such as arthritis,
osteoporosis, or pregnancy, either resolves when the condition does or is
treated as part of the overall therapeutic plan. Treatment for back pain
is available from a variety of health care practitioners; a recent study
of patients treated by primary care practitioners, chiropractors, and
orthopedic surgeons reports similar recovery rates. When low back pain is
not caused by a medical condition, about 90% of people recover within a
month without any treatment at all. In spite of this encouraging
statistic, back pain is the third most common reason for surgery and costs
the country up to $50 million each year in medical and disability
benefits. Such a discrepancy triggered a major government investigation
into why such a minor problem ends up so often in the operating room. This
resulted in some new guidelines set by the Agency for Health Care Policy
and Research recommending very moderate treatment options for most cases
of low back pain. It should be noted that for certain patients with
sciatica and spinal stenosis, surgery may be the most effective approach.

Immediate Treatment of Acute Low Back Pain
At the onset of acute low back pain, the patient should take an
over-the-counter pain reliever and lie down in a comfortable position.
Lying on the side or back with knees bent supported by a pillow relieves
the stress on the back. Many people find that alternating ice packs and
heating pads at about twenty-minute intervals is helpful in relieving the
pain. Ice packs should be applied first. Supportive back belts, braces, or
corsets may help some people temporarily, but they can reduce muscle tone
over time and should be used only briefly.

Home Care
Rest
Most experts recommend staying in bed no longer than a couple of days. One
study reported, however, that people who avoided bed rest altogether and
simply tried to resume normal activities, without strain or stretching
exercises, recovered more quickly than those who were in bed for even as
short a period as two days. People who stay in bed a week or longer do
even worse. Long-term bed rest results in loss of muscle tone and bone
strength, increases susceptibility to blood clots, and causes depression
and lethargy. Traction probably has no benefit and may be harmful.
Getting adequate amounts of sleep, however, is very important and many
physicians feel that healthy sleep patterns play a vital role in recovery
from back pain. It is often difficult to get a good night's sleep when
suffering from back pain, particularly because the pain can intensify at
night. Lying curled up in a fetal position with the pillow between the
knees or lying on the back with pillow under the knees may help. To help
promote sleep, avoid caffeine in the afternoon and evening, take a warm
bath before bedtime, and practice relaxation techniques. It may be
necessary to take medication to help manage nighttime pain or treat
sleeplessness.

Resuming Normal Activity Levels and Exercise
At the other extreme, exercising to treat acute back pain may be equally
unhelpful. In one study, recovery from acute back pain was slower for
patients who exercised to improve flexibility than for those who gradually
resumed normal activity, simply letting pain be the guide for how much
movement they achieved. In general, normal activity should be resumed in a
gradual fashion as soon as the patient feels ready, reserving therapeutic
exercises until after the acute pain has resolved. An incremental aerobic
exercise program is less stressful than stretching or exercises
strengthening the trunk muscles. Experts suggest that walking, stationary
biking, swimming, and even light jogging may begin within two weeks of
symptoms, but patients should never force themselves to exercise if, by
doing so, pain increases. People usually recover from a strained back or a
mildly herniated disc in a few days. It may take as long as six weeks,
however, to fully recover from back pain, particularly if it is due to
sciatica. At that time, if the pain has not been relieved, additional
measures may be needed.
Exercise appears to be important in treating chronic low back pain. In one
study, for example, patients with back pain lasting for an average of 18
months were assigned 8 one-hour exercise sessions over four weeks. They
showed greater improvement in nearly every area, including reduced pain
and increased capacity, compared to patients who did not exercise. (For
more on exercise, see How Is Low Back Pain or Sciatica Prevented?, in this
report.)

Medication
NSAIDs and Acetaminophen
The most common pain-relievers are the nonsteroidal anti-inflammatory
drugs (NSAIDs). These drugs block prostaglandins, the substances that
dilate blood vessels and cause inflammation and pain. There are dozens of
NSAIDs. Some of the most common are aspirin, ibuprofen, naproxen, and
ketoprofen, but many others are now available (see below). Taking NSAIDs
with food can reduce stomach discomfort, although it may slow down the
pain-relieving effect. All NSAIDs are capable of damaging the mucous layer
and causing ulcers and gastrointestinal (GI) bleeding when taken for long
periods. The elderly are at special risk for ulcers; younger nonsmoking
adults are at lower risk. Bleeding and ulcers can occur at any time, with
or without symptoms. The risk for bleeding is constant as long as a
patient is on these drugs and may even persist for about a year after
taking them. No NSAIDs should be used for long-term pain relief except
under a physician's direction. Ibuprofen has a lower risk than naproxen
and ketoprofen for GI bleeding. Aspirin has a risk similar to that of
ibuprofen. Buffered aspirin (aspirin coated with an antacid) is not
protective against ulcers. Other side effects include dizziness, ringing
in the ear, headache, skin rash, and possibly depression. Kidney damage
has been reported in people taking NSAIDs, which resolves when the drugs
are withdrawn. (Aspirin has little or no risk for this side effect.)
People with high blood pressure, severe circulation disorders, kidney or
liver problems, and those taking diuretics or oral hypoglycemics must be
closely monitored if they need to take long-term NSAIDs. Because NSAIDs
reduce the clotting of the blood, anyone undergoing surgery should stop
taking the medication a week before the operation. Taking NSAIDs after
fusion procedures may reduce the chances for success; more research is
needed on this potential problem.

COX-2 Inhibitors
New, aspirin-like drugs, including celecoxib (Celebra) and another
(Vioxx), are being developed to target a specific prostaglandin-producing
enzyme called cyclooxygenase 2 (COX 2) without affecting COX 1, another
enzyme that generates stomach-protective prostaglandins and which other
NSAIDs block. Such drugs may allow high doses without the accompanying
gastrointestinal side effects.

Acetaminophen (Tylenol, Anacin-3, Panadal, Phenaphen, Valadol, and other
brands) is the most common alternative to NSAIDs, although many patients
report less pain relief with acetaminophen than with an NSAID. It is not
an anti-inflammatory agent. Acetaminophen can be used alone or in
combination with NSAIDs with some success. Liver and kidney damage are
potential serious side effects of acetaminophen. Alcohol use increases the
risk for liver damage. Experts recommend taking no more than 8
extra-strength tablets each day.

Corticosteroids
A one-time injection of a corticosteroid into the area around the spinal
column is sometimes administered to short-cut sciatic pain until the body
heals itself. Corticosteroids are useful only for temporarily reducing
inflammation. They are not a cure, and they offer no long-term benefits.
Oral steroids are not recommended.

Opioids
Unless the pain is very severe, experts advise against routinely
prescribing pain killers containing opioids, such as morphine and codeine,
meperidine (Demerol), or oxycodone-release (Oxycontin), which they believe
do more harm than good. Injections of local anesthetics are occasionally
used and can be helpful for temporary relief of severe pain. A skin patch
containing an opioid called transdermal tentanyl (Duragesic) may relieve
chronic back pain more effectively than oral opioids. Side effects for all
opioids include drowsiness, impaired judgment, nausea, and constipation.
Addiction is a major risk and physicians should monitor patients
periodically for the possibility of withdrawing from the medications.

Muscle Relaxants
Physicians may prescribe muscle relaxants such as cyclobenzaprine
(Flexeril), diazepam (Valium), carisoprodol (Soma), or methocarbamol
(Robaxin). Some experts believe, however, that NSAIDs are just as
effective. In addition, relaxing muscle spasm may sometimes be harmful,
because the tensed back muscles may be serving a purpose by protecting the
damaged disc or vertebrae.
Spinal Manipulation and Chiropractic
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Transcutaneous Electric Nerve Stimulation
Transcutaneous electric nerve stimulation (TENS) uses low-level electrical
pulses to suppress back pain and can be particularly helpful for patients
with spinal stenosis. (It is not helpful for relief of sciatica.) The
standard approach is to give 80 to 100 pulses per second for 45 minutes
three times a day; patients are barely aware of the sensation. Some
studies have not found this treatment to be any more beneficial than
conservative therapy, although one study reported that patients, whose
pain was not relieved by surgery, experienced relief when they were given
long-term stimulation (about 13 years). It appears to be more beneficial
for men than women.

Cognitive-Behavioral Therapy
One study reported that a course of cognitive-behavioral therapy helped
reduce chronic back pain and enhanced the patients' ability to deal with
it. The primary goal of cognitive therapy in such cases is to change the
distorted perceptions that patients have of themselves and their approach
to pain. Using specific tasks and self-observation, patients gradually
shift their fixed ideas that they are helpless against the pain that
dominates their lives to the perception that pain is only one negative
and, to a degree, a manageable experience among many positive ones. In the
study, therapists also taught relaxation techniques and methods to improve
posture. The sessions were two and a half hours each week for 12 weeks.
More research is needed.

Alternative Treatments
Acupuncture, which involves inserting small pins or exerting pressure on
certain points in the body, has relieved pain in some people. One
well-conducted study found significant benefits from acupuncture for
chronic low back pain, although another reported few benefits for
sciatica. Stress management and biofeedback techniques may also be
helpful, although studies have not yet confirmed any benefits.
What Are Surgical Procedures for Low Back Pain or Sciatica?
The most common reasons for surgery for low back pain are sciatica and
spinal stenosis. Surgical treatments for low back pain rose from 190,000
in 1983 to 335,000 in 1994. It is important to note, however, that very
few rigorous studies have been conducted on back operations, and not all
of those procedures were necessary. One study reported that 71% of people
who had surgery for sciatica experienced pain relief compared to 43% who
did not have surgery. For those with spinal stenosis, 55% of surgical
patients reported pain relief compared with 28% who chose not to have
surgery. The best spinal stenosis candidates are those with a condition
known as block spinal stenosis. Surgery does not always improve outcome
for low back pain and in some cases can make it worse.
Evidence of a herniated disc and nerve compression is not an automatic
indication for surgery; surgery is advised only for selected patients with
sciatica and spinal stenosis. Pain should be present for at least four
weeks and be so debilitating that it interferes with normal functioning.
Emergency surgery may be needed for sciatic pain if it is accompanied by
incontinence, which indicates that the bundle of nerves at the end of the
spinal cord known as the cauda equina are being pinched. In such cases, an
operation should be performed as soon as possible to avoid permanent
damage. Other indications include a progressive weakening in the legs and
evidence of some physical abnormality of the spine, such as a bone spur or
spinal stenosis due to bone growth. A patient should be sure that the
surgeon has had significant experience with any procedure to be performed.

Discectomy
Discectomy is the surgical removal of the diseased disc, thereby relieving
pressure on the disc. In spite of the fact that the procedure has been
done for 40 years, few studies have been conducted to determine its real
effectiveness. Scar tissue may develop after discectomy, which, in some
cases, can cause continued pain. A variation called percutaneous
discectomy (PAD) uses endoscopy (the use of a catheter * thin tube * that
employs tiny cameras and surgical instruments.) The tube has a device at
the tip that cuts away some of the nucleus pulposus and a vacuum that then
sucks this gelatinous matter out. Using PAD, however, surgeons cannot
observe the nerve root itself, so they cannot tell if the fragments
removed are the source of the trouble, nor can they locate and remove any
matter that has gone beyond the disc and entered the spinal canal. PAD,
then, is not usually warranted for herniated discs, a primary cause of
sciatica. Some experts argue that the procedure is rarely useful and
patients often need repeat operations. A variation called percutaneous
automated discectomy uses a motorized probe that cuts off bits of disc
material, but it does not appear to offer additional benefits. Other
endoscopic procedures are also under investigation. Lasers have been
investigated for use with discectomy, but results to date are
unimpressive.

Laminectomy or Laminotomy
Operations that shave off part of a vertebra (laminotomy) or remove all of
it (laminectomy) may be used in spinal stenosis or spondylolisthesis to
decompress the nerve or they may be used to remove benign tumors on the
spine. One study reported that the operation in children and young adults
can increase the risk for spinal deformity. Laminectomy requires general
anesthesia and a two or three day hospital stay. Recuperation takes up to
six weeks. Although it often brings immediate relief from pain, there are
small risks to the operation and it is not always successful. Some
recurrence of back pain and sciatica occurs in half to two-thirds of
postoperative patients.

Spinal Fusion
In cases where abnormal positioning or vertebrae movement puts pressure on
the nerves, such as spinal stenosis or spondylolisthesis, surgeons may
fuse vertebrae together. (It is not clear, however, whether fusion is any
more effective for stenosis or spondylolisthesis than procedures for
reducing disk pressure.) Fusion employs a bone graft or some other device
to join the vertebrae together. One medical device called the BAK
Interbody Fusion System uses a tiny hollow metal cage, which is implanted
into the disc space. Bone is removed from the patient and packed inside
the cage; over time the bone grows through the holes and around the
device, fusing the vertebrae. In one study, the device was successful in
72% of patients, who experienced decreased pain without any loss of muscle
strength or function.
Postoperative Period: Complications and Outlook
Complications of spinal surgery can include nerve and muscle damage,
infection, scarring, and the need for reoperation. One study reported that
administering an injected NSAID after a fusion procedures may reduce the
chances for successful bone healing and union; until more research has
been conducted, patients should use alternative painkillers after this
procedure. Patients now often remain in bed only three or four days after
disc surgery; studies indicate that such patients have the same or even
fewer complications than those who stay in bed for weeks. It may take four
to six weeks for full recovery. Gentle exercise may be recommended.

Other Techniques
Chemonucleolysis
Chemonucleolysis (CNL) is not performed much in the U.S. although it is
common overseas. It is usually warranted only for sciatica caused by a
herniated disc that is not relieved by other standard treatments. One
study indicated it might help some patients with sciatica caused by
low-grade (but not severe) spondylolisthesis. The physician injects the
herniated disc with chymopapain, an enzyme made from the papaya. It takes
only two to three minutes. Chymopapain, a common ingredient in meat
tenderizers, softens the nucleus pulposus (the disc's gelatinous filling)
thus reducing the bulge and relieving the pressure on the sciatic nerve.
Some experts argue that the procedure has little value, but in 17 out of
20 studies, CNL was found ultimately to be as beneficial as laminectomy,
although it may take days or even months for complete pain relief.
Well-conducted studies, however, still favor discectomy over
chemonucleolysis. Risks include severe allergic reactions to chymopapain,
which occur in less than 1% of people, and nerve damage if the enzyme
leaks out of the disc (a chance of about .05%).

Electro-Thermal Surgery (IDET)
An experimental procedure known as electro-thermal surgery employs a probe
that uses electricity to heat and shrink the injured disc tissue.

Surgery for Piriformis Syndrome
Piriformis syndrome * entrapment of the sciatic nerve deep in the buttock
by the piriformis muscle * is a controversial cause of sciatica, and some
experts do not believe that it plays any role. In one small study,
however, surgery to cut the piriformis muscle and thereby free the sciatic
nerve resulted in significant improvement for four out of five patients,
in whom the condition was suspected from MRI results.

How Is Low Back Pain or Sciatica Prevented?

Rules for Standing, Sitting, and Sleeping
Good Posture
Maintaining good posture is very important. This means keeping the ears,
shoulders, and hips in a straight line with the head up and stomach pulled
in.

Standing
It is best not to stand for long periods of time. If it is necessary, walk
as much as possible and wear shoes without heels, preferably with
cushioned soles. Using a low stool, alternate resting each foot on it.

Sitting
Sitting puts the most pressure on the back. Chairs should either have
straight backs or low-back support. If possible, chairs should swivel to
avoid twisting at the waist, have arm rests, and adjustable backs. While
sitting, the knees should be a little higher than the hip, so a low stool
or hassock is useful to put the feet on. A small pillow or rolled towel
behind the lower back helps relieve pressure while either sitting or
driving.

Riding in a Car
Riding and particularly driving for long periods in a vehicle increases
stress. Move the seat as far forward as possible to avoid bending forward.
The seat should be reclined not more than 30* and, if possible, the seat
bottom tilted slightly up in front. For long rides, one should stop and
walk around about every hour and avoid lifting or carrying objects
immediately after the ride.

Sleeping
Be sure to have a firm mattress. If the mattress is too soft, a 1/4-inch
plywood board can be put between the mattress and box spring. On the other
hand, some people have experienced morning backache from a mattress that
is too hard. The back is the best guide.

Exercise as Prevention
Although exercise is important for recovery from back pain, there are no
studies proving that exercise prevents back pain in the first place. In
fact, incorrect or long-term high-impact exercise is a cause of back pain.
Many experts believe, however, that by strengthening the muscles in the
trunk, the spine is better protected against injury. Physical activity is
important, in any case, for health, and some experts also think that
exercise helps pump fluid into dehydrated discs, helping to heal them.
Low-impact aerobic exercises, such as swimming, bicycling, and walking,
can strengthen muscles in the abdomen and back without over-straining the
back. They may even help postmenopausal women maintain bone density in the
lower spine. People vulnerable to back pain should avoid activities that
put undue stress on the lower back or require sudden movements, such as
football, rowing, ballet, and weight lifting. Jogging is usually not
recommended, at least not until the pain is gone and muscles are stronger.
Exercises called lumbar extension strength training are proving to be
effective. Generally, these exercises attempt to strengthen the abdomen,
improve lower back mobility, strength, and endurance, and enhance
flexibility in the hip and hamstring muscles and tendons at the back of
the thigh. (For examples of some good exercises for the back, see Table
below). It is important to note that all exercises for the lower back
should be performed with caution. If any discomfort is experienced, stop
and check with a physician. Exercises that put the lower back under
pressure should be avoided until the back muscles are well toned. Such
exercises include leg lifts done in a prone (face-down) position, straight
leg sit-ups, and leg curls using exercise equipment.

Protection in the Work Place
A number of companies are developing programs to protect against such
injuries. Unfortunately, studies indicate that company educational
programs do little to reduce the incidence of back pain. Back support
belts also do not appear to be very useful. In one study, with the
exception of those who already had acute low back pain, those who wore
support belts reported more back pain than the workers who didn't wear
them. In any case, nearly half of the workers who were assigned the belts
failed to wear them. Employers and workers, however, should make every
effort to create a safe working environment. Office workers should have
chairs, desks, and equipment that support the back or help maintain good
posture. Anyone who engages in heavy lifting should take precautions when
lifting and bending (see Table below).

Sit-upsSit-ups or crunches strengthen the abdominal muscles. Keep
the knees bent and the lower back flat on the floor while raising
the shoulders up three to six inches. Do this slowly with the arms
either across the chest or behind the head and exhale on the way up
and inhale on the way down.

Pelvic TiltThe pelvic tilt alleviates tight or fatigued lower back
muscles. Lie on the back with the knees bent and feet flat on the
floor. Tighten the buttocks and abdomen so that they tip up
slightly. Press the lower back to the floor, hold for one second and
then relax; gradually increase this exercise to holding for five
seconds, but be sure to breathe evenly. Then, extend the legs a
little more so that the feet are further away from the body and try
it again.

Stretching Lower-Back MusclesLie on the back and lift both knees to
the chest. Keeping arms at the sides, slowly roll the knees over to
one side until totally relaxed. Hold this position for five to ten
seconds (while breathing evenly) and then repeat on the other side.

Safe Lifting and Bending Techniques- If an object is too heavy or
awkward, get help.
- Spread your feet apart to give a wide base of support.
- Stand as close as possible to the object being lifted.
- Bend at the knees; tighten stomach muscles and tuck buttocks in so
that the pelvis is rolled under and the small of the back is flexed
slightly. Do not arch the back. (Even when not lifting an object,
always try to use this posture when stooping down).
- Hold objects close to the body to reduce the load on the back.
- Lift using the leg muscles, not those in the back.
- Stand up without bending forward from the waist.
- Never twist from the waist while bending or lifting any heavy
object. If you need to move an object to one side, point your toes
in that direction and pivot toward it.
- If an object can be moved without lifting, pull it, don't push.

Work-related back pain is among the most common occupational disorders in
the United States, according to the National Institute for Occupational
Safety and Health in Cincinnati, Ohio. Delay in return to work remains an
expensive component in the overall cost of back pain for workers'
compensation claims, as well, the institute notes. And back pain is
responsible for more loss of work time and increased medical expenses
related to treatment than any other ailment, says Robert Shields, M.D., an
osteopathic physician practicing general medicine in Plano, Texas.
"This is one of the most common problems I see in my medical practice," he
says. "Low back pain strikes 8 out of 10 adults at some point in their
lives."

Understanding Back Pain
Back pain comes in two forms, acute and chronic, and is most often felt in
the lower back. Acute pain comes on suddenly and intensely, usually from
doing something you shouldn't be doing or from doing it in the wrong way.
The pain usually lasts a short while. Chronic pain is recurring; any
little movement can set it in motion and, for whatever reason, it lingers
on and on for what can seem like an eternity.
Although back pain is usually preventable (See "Back to Exercise" below),
experts claim that 4 out of 5 Americans will experience it at some time in
their lives, given that the lower back supports most of the body's weight.
The stability of the lower back depends on the integrity of the vertebral
bodies and the intervertebral disks.
To understand the many ways you can do injury to your back, consider that
each of us has between 24 and 25 bones in and around our backs, including
the neck and chest areas, which are held together by ligaments and
muscles. Throw in some major nerves, a few disks (which act as shock
absorbers), and joints that guide the direction of movement of the spine,
and stack them all up, explains Shields. "Expect to twist and bend them in
a multitude of directions, and try to imagine what might go wrong."
Shields says you can sprain the ligaments, strain the muscles, rupture the
disks, and irritate the joints. While logic would point to injuries from
sports or traumatic accidents as the cause of the pain, sometimes the
simplest of movements will have painful results. In addition, arthritis,
congenital disorders, poor posture, obesity, and psychological problems
due to stress can be the source of back pain. Complicating the issue
further is the fact that back pain can also directly result from internal
problems such as kidney stones, kidney infections, blood clots, or bone
loss.
Even with modern technology, however, the exact reason or cause of back
pain can be found in very few people, according to the Clinical Practice
Guideline for "Understanding Acute Low Back Problems", published in 1994
by the Department of Health and Human Services' Agency for Health Care
Policy and Research. X-ray examinations explain only a small proportion of
the nonspecific complaints doctors receive.

Pain Management Options
Mettetal's troubles began 14 years ago when he nearly collapsed from
excruciating pain searing down his leg. His initial diagnosis was a
ruptured disk. Since then, even with four major surgeries to repair the
problems, his pain has only worsened. Out of desperation, he has tried
medications, physical therapies, and pain clinics * all in an attempt to
restore some semblance of a functional life.
The Journal of the American Medical Association concluded in a 1996
surgical back pain study that more than $50 billion is spent on the
diagnosis and treatment of back pain in the United States. Since the
causes are so varied, what works for one person might fail with another.
For most people, drugs work well to control pain and discomfort. But any
medication can have side effects. Back pain experts say that
over-the-counter, nonsteroidal anti-inflammatory drugs (NSAIDs) *
including acetaminophen (Tylenol), naproxen (Aleve), and ibuprofen
(Nuprin, Motrin IB and Advil) * can be of value in reducing the pain. More
severe pain may require prescription medications such as oxycodone-release
(Oxycontin), acetaminophen with codeine (Tylenol with Codeine), and
meperidine (Demerol).
Peter Rheinstein, M.D., director of the medicine staff in FDA's Office of
Health Affairs, says the many effective NSAIDs available on the market
today means there is less need for narcotics. However, he cautions that
all NSAIDs cause gastrointestinal bleeding, and advises that patients
suffering from other medical conditions need to consult with their doctors
about other treatment options for managing their back pain.
"If you have an ulcer, for example, or are taking a blood thinner,"
Rheinstein says, "you are at an increased risk for gastrointestinal
bleeding and should have your doctor prescribe medication that won't
aggravate the ulcer or cause any kind of drug interaction."
Exercise and Physical Therapy
Bed rest was once thought to be an effective treatment for back pain, but
recently its therapeutic benefit has been questioned. In a study published
in the 1996 issue of Spine, Finnish researchers experimented to find out
whether exercises to mobilize the back worked better than bed rest.
Subjects in the mobility test, who were encouraged to continue normal
activities and have no daytime rest, appeared to have better back
flexibility by the seventh day than their immobile counterparts, who
remained in bed for the duration of the experiment.
"Most people think that a week of bed rest will take away the pain," says
David Lehrman, M.D., chief of orthopedic surgery at St. Francis Hospital
and founder of the Lehrman Back Center in Miami. "But that's not so. For
every week of bed rest, it takes two weeks to rehabilitate."
Vert Mooney, M.D., professor of orthopedic surgery at the University of
California, San Diego School of Medicine, says that bed rest for low back
pain should be limited to one day and exercise should begin immediately.
He explains that exercises which increase flexibility and tone and
strengthen muscles can get back pain sufferers up and around by hydrating
disks that become painful from loss of fluid. "Exercise can actually pump
fluid back into the disk," Mooney says, "and it is important to keep the
patient moving so that the disk remains fully hydrated."
However, FDA's Rheinstein says, "For some people, bed rest is just the
most comfortable position for the first couple of days."

Chiropractic Spinal Manipulation:
Largest non drug healing profession in the world. Definition of
Chiropractic

Surgical Procedures
Doctors recommend back surgery much less often now than in the past, and
only for certain conditions that do not improve after other treatments
have been tried. FDA has approved or cleared medical devices such as the
Intervertebral Body Fusion device, Anterior Spinal Implant, and Posterior
Spinal Implant to treat degenerative disk disease and stabilize and fuse
the spine.
Implantable spinal cord stimulation devices are another aid in the
management of chronic pain of the trunk and limbs. These devices
electrically stimulate the spinal cord by discharging a one-time or
continuous stream of electrical pulses. The implanted portion of the
device consists of a pulse generator (which contains an internal power
source similar to that used in a cardiac pacemaker) and lead extensions
that are connected to electrodes placed in the spinal canal. The
nonimplanted components of the system include the programming device and
screening pulse generator, which are controlled by the physician or
patient.

Acupuncture
Acupuncture is a centuries-old Chinese healing technique that employs
needles placed at specified points on the body. FDA classified acupuncture
needles in 1996 as medical devices for "general use" by trained
professionals.
The needles are required to have proper labeling, and good manufacturing
practices must be followed. Manufacturers must include on the label the
statement "for single use only" and provide information about device
material sterility and compatibility with the body. The needles must also
bear a prescription label restricting use to qualified practitioners as
determined by individual states.
Harold Pellerite, assistant to the director of compliance in FDA's Center
for Devices and Radiological Health says, "I think today's society is more
receptive to alternative medicine. This just points to the need for our
agency to be able to have some degree of control over what the American
public is exposed to."
Complicating the evaluation of effectiveness of treatment is the fact that
most back problems clear spontaneously. How can you tell if the problem
was relieved by a particular treatment or if it would have gone away in
the same period without treatment? "You really can't," says Shields.
Out of all these options, only two things have given Mettetal any measure
of relief * the Spinal Cord Stimulation System and acupuncture. But, as
Shields points out, "One of the most important things to keep in mind is
that pain is caused by a variety of underlying problems, and it is naive
to think that one modality will help improve all back pain."

Back to Exercise

Trying to move an immovable object is the number one cause of back
problems in the United States. It encourages you to push, pull, twist,
bend, lift, and strain the wrong way. Even an unexpected awkward turn can
be the onset of low back pain, and people who are in poor physical
condition or perform work that requires long periods of sitting or
standing are at greater risk for back problems. These people also recover
more slowly. And the more time you spend in front of the TV or computer,
the more you must do to prevent back pain, say experts. Emotional stress
or long periods of inactivity may make back symptoms seem worse, but good
posture and body mechanics will ultimately reduce the stress on your back.
To reduce the incidence of self-inflicted back problems:
Be careful. Learn to lift and lean properly. Avoid positions that cause
sudden, quick or jerky movements.
Exercise. Strengthening the muscles of the back and abdomen helps to
minimize the frequency, and possibly the severity, of future incidents.
Lose weight. If you are more than 10 percent over your ideal body
weight, you can reduce further incidents by losing weight through
dietary restriction of calories and aerobic exercise, as prescribed by
your personal physician.
* C.L.
Carol Lewis is a writer in FDA's Office of Consumer Affairs.
Lower-Back Exercises
A. Lie flat on your back. Hug your knees to your chest and at the same
time, bring your chin to your chest. Repeat twice, holding for 15 seconds
each.
B. Begin on your hands and knees. Simultaneously raise and straighten your
right arm and left leg until they are parallel to the ground. Hold for 2
seconds and come back slowly to a starting position. Repeat with left arm
and right leg, alternating 10 times.
C. Lie facedown, arms extended overhead, palms on floor. Simultaneously
raise your right arm and left leg as high as comfortably possible. Hold
for 10 seconds and slowly return to start. Repeat with left arm and right
leg, alternating 10 times. Gradually build up to 20 times.
D. Lie facedown, arms at your side and place heels under couch. Slowly
raise chest off the floor as high as you comfortably can. Hold for 2
seconds and return to start. Gradually increase to 20 times.
Strong lower-back muscles and abdominals work together in maintaining a
pain-free and healthy back. These exercises will help strengthen the
muscles of the lower back, but it is important that you begin your
exercises slowly and increase levels gradually. Always begin any exercise
program with stretching. Talk to your doctor before attempting any
exercises, especially if you are already experiencing back pain.

The Epidemiology of Neck Pain
Donald R. Gore, MD, Medical College of Wisconsin, Milwaukee, Wis.
Abstract Neck pain is a common problem in our society and, at any given
time, affects about 10% of the general population. The sources of pain are
caused by conditions that compress, destroy, or irritate pain-sensitive
structures such as the annulus fibrosus, posterior longitudinal ligament,
and the capsule of the zygapophyseal joints. Involvement of the cervical
nerve roots usually results in pain and neurologic findings in the
distribution of the nerve. Referred pain from visceral disease may cause
neck pain and may also be confused with primary shoulder disease and
peripheral nerve entrapments. Common conditions thought to cause neck pain
are degenerative disc disease, with or without disc herniation, and
degenerative arthritis of the zygapophyseal joints. Aside from patients
with disc herniations demonstrated on imaging studies and pain in a
specific nerve root distribution, the relationship with degenerative
changes is not always clear. This is because degenerative conditions are
common with aging and many times are incidental findings in asymptomatic
people. Specific conditions that have been studied but also are not well
understood are post-traumatic neck pain syndrome, commonly known as
whiplash injuries, and pain following repetitive activities in an
occupational setting. Although causes of neck pain are not well
understood, outcome studies have shown that it frequently is not a
self-limiting condition and can be a long-term problem. [© 1998 Medscape,
Inc.]
Introduction Epidemiology is the branch of medical science that studies
the causes, incidence, prevalence, and control of a disease in a defined
population. Although there are numerous epidemiologic studies of low-back
pain, relatively few investigations of neck pain have been conducted.
There are several reasons for this, the most important being that neck
pain is not as common as low-back pain and, when present, is not as
disabling; therefore, it doesn't have the same economic impact on society
as does low-back pain. Neck pain is a symptom of a disease process.
Knowing the etiology of neck pain aids in understanding its epidemiology.
Sources of Neck Pain
The human neck is a complex structure that contains the extension of a
number of vital visceral structures, including the trachea, esophagus, and
the carotid and vertebral arteries, and a musculoskeletal system that
provides for support and motion of the head. The cervical spine itself is
a series of seven separate bone elements, all with intricate articulations
and an elaborate system of ligaments and associated muscles. The first and
second cervical vertebrae are different in size and shape from each other
and the remaining five vertebrae. However, all of the segments have true
synovial joints. The anterior articulations of the vertebrae below C2
occur via intervertebral discs. Both the anterior and posterior joints are
surrounded by a fibrous capsule and supported by ligaments and muscles.
These joints both allow and limit neck motion. The capsule, ligament, and
muscles all contain an abundance of free nerve endings which are capable
of transmitting pain impulses. Irritation or damage to these structures
causes primary neck pain.
The cervical vertebrae also protect and allow passage of the spinal cord
and cervical nerve roots. Pathologic processes such as compression,
especially of the nerve roots, are a frequent source of neck pain and
referred pain from the neck. Cervical nerves are both sensory and motor so
that damage, in addition to pain, may cause numbness, tingling, muscle
weakness, and reflex deficits in a specific location. Signs and symptoms
along the distribution of a cervical nerve root are called cervical
radiculopathy.
The cervical nerve roots C5, C6, and C7 are the most commonly involved and
result in characteristic signs and symptoms in the upper extremities.
Because the distal-most innervation of C4 is to the top of the shoulder,
compression of the C4 nerve root does not produce symptoms below the level
of the shoulder, and usually there is no demonstrable muscle weakness or
any reflex abnormalities. Damage or irritation of C1, C2, and C3 does not
result in reflex or motor deficits but can result in pain in the back of
the neck extending along the back of the head. Pain from neck sources
other than cervical nerve roots does not result in sensory, motor, or
reflex deficits and the pain patterns are not as well defined. Pain
reproduction studies have investigated patients with neck pain but without
evidence of specific nerve root involvement. Discography and zygapophyseal
joint injections[1] were used, indicating that there are a variety of
etiologies for neck pain. Other possible sources of neck pain, whose
importance has not been established, are the cervical sympathetic nerves
and the innervation present in the anterior surface of the dura.

Causes of Neck Pain
Pain originating in and confined to the neck may arise from infections,
tumors, and degenerative changes of the zygapophyseal joints and
intervertebral discs. Cervical radicular pain is pain in the distribution
of a cervical nerve root. This can be caused by any process that
compresses or irritates the nerve, the most common being herniated
intervertebral discs (Figure 1a,b) and osteophytes which narrow the
neuroforamen (Figure 2a,b,c). Disc protrusion and osteophytes can also
narrow the spinal canal, causing pressure on the cervical cord and
resulting in a myelopathy (Figure 3).
Referred neck pain is generated by disease in an anatomic structure other
than the neck. Examples of this are visceral diseases such as angina,
apical lung tumors, and subdiaphragmatic irritation as in a
subdiaphragmatic abscess. The most common conditions that may be confused
with neck problems are intrinsic shoulder diseases such as impingement,
rotator cuff tears, and adhesive capsulitis. Peripheral nerve entrapment
occurring in thoracic outlet syndrome, ulnar cubital tunnel syndrome, and
carpal tunnel syndrome can simulate cervical nerve root compression.
Systemic diseases such as rheumatoid arthritis, spondyloarthropathies,
fibromyalgia, and herpes zoster may also cause neck pain. However, in
these conditions it is unusual for the only symptom to be in the neck.
Incidence and Prevalence of Neck Pain
Neck pain has most frequently been studied in five different populations
Incidence is the number of new cases of a disease which occur during a
specified period of time, whereas prevalence is the number of cases
present at any one time. Most reports in the medical literature are crude
prevalence studies. Since neck pain has many causes, and a number of
factors such as age, sex, occupation, and cigarette smoking effect its
occurrence,[2] it is difficult to compare the results obtained from
research done on differing study populations. In addition, most reports
are based on questionnaires, so the cause of the pain cannot be validated;
also, neck, shoulder, and upper-extremity pain are frequently considered
together.

General Population Even with the limitations mentioned above, some
information -- mostly from Scandinavian countries -- is available. Neck
pain occurs half as often as low-back pain[3] and is slightly more common
in women. In Norway, Bovim and colleagues,[4] in a random sample of 10,000
persons ages 18-67 years, found a prevalence of 13.8%. In a similar study
in Finland, Makela and associates[2] discovered neck pain in 9.5% of males
and 13.5% of females. The United States' National Center for Health
Statistics reported 7.0% of men and 9.4% of women had neck pain in the
period between 1976-1980.[3] In addition to neck pain being more common in
women, Makela[2] also found that older patients, those involved in both
mentally and physically stressful jobs, and current smokers were more
likely to have neck pain.

Auto Accident
Post-Traumatic Pain
The most common post-traumatic neck pain syndrome is a whiplash injury and
follows an automobile accident. The term was first used by Crowe[5] in
1928 in an unpublished report, then in an article by Davis[6] in 1945, and
later by Gay and Abbott[7] in 1953. The original descriptions were of a
mechanism of injury rather than a disease process. Although many now
object to its use, the term "whiplash" is routinely used by laymen,
lawyers, and medical professionals in reference to a patient with neck
pain after an automobile accident in which a more specific diagnosis
cannot be made.
The most frequent scenario is a patient whose vehicle is struck from
behind causing a hyperextension motion of the neck. The combination of
seat belts and properly adjusted head restraints reduces the likelihood of
neck injuries.[8]
Recently Grauer and colleagues[9] have shown with cadaver studies that in
a simulated whiplash injury the neck forms an S-shaped curve with initial
hyperextension of the lower cervical spine and upper-level flexion,
followed by extension of the entire cervical spine. It would be expected
that if physiologic limits of motion are exceeded, than injury would
occur. This physiologic limit of motion was reached in the lower cervical
spine in their studies.
Hyperextension injuries of the neck can damage a number of structures,
including the anterior muscles and ligaments, the disc, and zygapophyseal
joints. These injuries have been demonstrated on cadavers and experimental
animals and found in human autopsy studies of victims of motor vehicle
accidents.[10]
Recently Jonsson and coworkers[11] reported on 50 consecutive patients
with whiplash-type cervical spine distortions in automobile accidents. At
6 weeks, 24 had persistent neck pain and underwent MRI imaging. Of these,
8 were found to have large cervical disc protrusions and had surgery. Two
patients had posterior fusions for instability based on lateral flexion
and extension films. This report is in contrast to our own experience and
that of others' where, despite careful evaluation of whiplash patients,
conclusive objective pathology is rarely found.
Borchgrevink and associates[12] studied 201 patients with neck pain
following automobile accidents. The patients were randomly divided into
two treatment groups. In one group, immobilization by means of a cervical
collar and sick leave from work was provided. In the other, no
immobilization was used, no sick leave was given, and the patients were
instructed to act as usual. At 6 months, the "act-as-usual" group showed
more overall progress, as measured by subjective symptoms ratings. The
researchers found, however, that 10% of this group still had severe
symptoms at 6 months, which emphasizes that neck pain following an
automobile accident in many patients is not a self-limited condition.
The symptom complex most frequently seen is neck pain that may not be
present immediately after the accident but begins in most patients within
24 hours.[13] Other frequent complaints are headache, dizziness,
paresthesia, and cognitive somatic and psychological sequelae.
This unrelated constellation of symptoms without objective evidence of
structural injury has led to speculation that the condition is an
emotional rather than a physical problem. Since the neck pain patient's
vehicle has been struck from behind, causation and therefore liability
usually rest with the other driver. Our current tort system favors
documentation which encourages frequent physician visits, exaggeration of
complaints, expensive testing, and extensive symptomatic treatment, most
of which have no proven value in altering the natural history of the
patient's symptoms.

Occupational Neck Pain
Occupational neck pain can be divided into two categories -- those
patients who have had specific injuries and those in whom the onset of
neck pain seems to be related to normal work activity.
Specific injuries that may occur in the workplace include motor vehicle
accidents, falling from a height, and being struck on the head. In these
instances, causation is not hard to determine; neck pain that begins
during normal work activities, however, is more difficult to assess.
Employees in occupations which require repetitive use of the upper
extremities such as machine operators, carpenters, and office workers are
more likely to have neck complaints.[14] If work activity is truly the
cause the of the patient's complaints then a strong relationship with the
activity and the onset and persistence of the symptoms should be evident.
For instance, it must be established that the symptoms began after
performing the activity and the complaints improve or completely subside
if that activity is eliminated. Usually the distinction between work
causation and other factors is not clear because preexisting disease and
activities that are not involved with work cloud the picture. In addition,
there is no conclusive evidence in the medical literature that overuse
results in structural damage. There is, however, a segment of the
population with permanent symptoms after a period of overactivity at a
specific task. In these situations, evaluation and treatment proceeds as
with any other group of patients but causation usually cannot be
established.

Herniated Intervertebral Cervical Discs
In contrast to studies of patients with neck pain as a syndrome, a
herniated cervical disc is a specific diagnosis. The only published study
that provides an incidence rate was done by Kondo and colleagues.[15] They
analyzed residents of Rochester, Minn, from 1950 to 1974 and found an
annual herniated disc incidence of 5.5/100,000 people. The most frequent
level involved was C5-6, followed by C4-5 and C6-7. In reviews of
surgically-treated patients, these are also the most frequent levels
involved.
Kelsey and associates[16] reported on 88 people with cervical disc
protrusions living in New Haven and Hartford, Conn. Forty were surgically
treated after the diagnosis of herniated cervical disc was made. Based on
their clinical appearance, 20 were listed as probable and 28 as possible
disc protrusions. Fifty-two patients were men and 36 were women, and most
patients were in their 40s and 50s. The researchers compared cervical disc
protrusion patients with age- and sex-matched controls. A strong
association was found between protrusion and recurrent lifting of heavy
objects on the job, cigarette smoking, and frequent diving from a board.
Driving vibrating equipment and time spent in motor vehicles were weakly
associated. Frequent twisting of the neck on the job and sitting on the
job were not associated with the clinical diagnosis of herniated disc.
The association of lifting heavy objects and driving vibrating equipment
with prolapsed disc is not surprising, but the relationship with smoking
is not as easily explained. Cigarette smoking has been implicated in
impeding bone metabolism and in interfering with fracture repair, in
nonunions in fractures, in arthrodesing procedures, and in increasing the
rate of postoperative wound infections.[17] A number of studies have
identified smoking as a risk factor for low-back pain, and although
several explanations have been proposed, the mechanism has not been
elucidated.

Degenerative Changes
Degenerative changes of the intervertebral discs cause disc-space
narrowing, osteophyte formation, and sclerosis of the vertebral body end
plates (Figure 4). These changes are easily seen on lateral roentgenograms
but are the response of the vertebrae to disc degeneration and so appear
after the process is well developed. Therefore, any study based on plain
roentgenograms underestimates the prevalence of disc degeneration.
Degenerative changes in the zygapophyseal joints include joint-space
narrowing, sclerosis, and osteophyte formation; but the changes are not as
easily seen or quantified on plain roentgenograms (Figure 5). The joints
are paired and located behind the vertebral bodies, so they can only be
isolated by oblique views; and even then, one oblique view usually does
not show all the joints. For these reasons, little information is
available on the frequency of degenerative changes in these joints.
Plain lateral roentgenogram showing end-plate sclerosis, narrowing of the
intervertebral disc space, and anterior osteophyte formation.
5. (click image to zoom) Plain lateral roentgenogram showing sclerosis,
narrowing, and osteophyte formation in the C3-4 zygapophyseal joint.

Degenerative changes of the cervical spine, as seen on plain
roentgenograms and more sophisticated imaging studies, are common in both
symptomatic and asymptomatic people and are thought to be part of the
normal aging process (Figure 6). Degenerative findings are considered to
be pathologic when they produce symptoms. However, with the exception of
patients with radicular pain, localizing neurologic deficits, and nerve
root compression as seen on MRI or CT myelogram studies, the relationship
with the patient's neck pain is unclear.

Figure 6. (click image to zoom) A. Normal, plain lateral roentgenogram of
44-year-old, asymptomatic female. B. Plain lateral roentgenogram of
54-year-old female, indicating degenerative changes of zygapophyseal
joints most severe at C4-5 and intervertebral disc degenerative changes at
C6-7.

One of the most perplexing clinical challenges is to distinguish the
source of a patient's pain when degenerative changes are present. In a
review of 200 asymptomatic women, we found that by age 60 to 65, 95% and
70% of women had degenerative changes as seen on plain roentgenograms.[18]
Boden found MRI abnormalities of the cervical spine in 19% of 63
asymptomatic volunteers. Fourteen percent occurred in subjects under the
age of 40, and 28% in those over 40.[19] Zapletal and colleagues[20]
evaluated the atlanto-odontoid joint in 500 consecutive patients who
underwent computed tomography of the brain or paranasal sinuses. They
found no abnormalities before the fourth decade but thereafter the
prevalence increased steadily with age, so that by the ninth decade over
60% had degenerative changes. In a separate article, Zapletal and
associates[21] evaluated 355 occipital frontal radiographs of the
paranasal sinuses for evidence of osteoarthritis of the lateral C1-C2
joints. Degenerative changes were found ranging from 5.4% in the sixth
decade to 18.2% in the ninth. They emphasize that these degenerative
changes could be a source of upper neck pain and occipital headaches
(Figure 7).
Plain open-mouth roentgenogram showing unilateral degenerative changes at
C1-2.

Outcome
In 1982, Rothman[22] stated, "It does not appear that cervical disc
degeneration is a brief self-limited disorder but rather a chronic disease
productive of significant pain and incapacity over an extended period of
time."
As discussed in the previous sections, degenerative disease of the
cervical spine and neck pain are not synonymous. Degenerative changes are
often present in asymptomatic people, and in some people with neck pain no
structural abnormality can be demonstrated. However, in our experience,
Rothman's statement holds true for patients with neck pain with or without
degenerative changes.
In 1987, we reported on a review of 205 patients initially seen for neck
pain in an office setting.[23] Patients with previous neck surgery,
objective neurologic deficits, malignancies, or rheumatoid arthritis were
excluded. The patients were re-examined and interviewed an average of 15
years (10 to 25 years) after the onset of their neck problems. In all
patients, lateral roentgenograms were available for comparison between the
initial visit and the final evaluation.
At follow-up, 79% had a decrease in pain, and of these, 43% were
pain-free; however 32% had moderate or severe residual pain. Patients who
had been injured and initially had severe pain were most likely to have an
unsatisfactory outcome; however, no other clinical features were of value
in predicting the final result. Initially, 121 patients had injuries, of
which 76 were due to motor vehicle accidents. Sixty-eight were involved in
litigation, 58 in personal injury claims, and 10 in workman's compensation
claims. At final evaluation, all but 4 claims had been settled, and all of
these patients stated their initial pain had decreased in severity.
Interestingly, 23 patients were dissatisfied with the outcome of their
litigation. However, there was no statistical relationship between their
level of satisfaction and the amount of pain or pain relief reported at
final interview.
The roentgenographic features measured were degenerative changes at each
intervertebral disc space, sagittal diameters of the spinal canal at each
disc space, and cervical lordosis. None of the roentgenographic findings
present initially or developed in the follow-up period correlated with
pain or had any predictive value for pain relief.
Most important, this study emphasizes that neck pain is frequently not a
self-limited problem, and that many patients will have long-term symptoms
that may be moderately disabling.
Summary Neck pain is a common problem in our society and at any given time
affects about 10% of the general population. The actual cause of the
problem is frequently difficult to determine. Neck pain in as many as
one-third of patients is not self-limiting and may produce moderate
long-term disabilities.

The Epidemiology of Neck Pain


Medical Treatments for Back and Neck Pain
From:The Chronic Pain Control Workbook
By:Ellen Catalano, M.A., Kimeron Hardin, Ph.D.
Surgery
There are only two situations that usually require immediate surgical
intervention for back and neck pain: (1) if there is a mass lesion (a
tumor or other disc material) pressing upon the major nerve roots or
spinal cord, and (2) if there is spinal cord or nerve root compression
from a fracture or other major instability from injury. The following are
the most commonly performed surgeries for these conditions:
Laminectomy. The surgeon cuts through the lamina (part of the bony ring
surrounding the spinal cord or nerve roots) in order to remove the
herniated disc.
Micro laminectomy. Similar to the laminectomy above except the herniated
disc is removed by laser, thereby allowing a more precise procedure.
Discectomy. Discectomy for a herniated or ruptured disc is considered
following unsuccessful conservative treatment (bed rest, traction,
medications) that has gone on from one to four months. A partial
laminectomy provides access to the disc, which is then removed. The
success rate varies from 40 to 80 percent, based on the patient’s specific
circumstances. Repeated disc surgeries are significantly less successful,
probably due to the buildup of scar tissue around the surgical site.
Spinal fusion. Fusions are sometimes performed for spinal instability, or
in order to stabilize the spine following a discectomy. Vertebrae are
"welded together" by bone grafts, which are pieces of bone that can be
placed between the vertebrae to allow the bone to heal as a single piece.
This type of surgery is done if injury or disease has resulted in
instability of the spine, or in order to stabilize or straighten the
abnormal curves of scoliosis.
Chemonucleolysis. In 1982, the FDA approved the use of Chymopapain, which
is a substance injected into the disc space to dissolve the problem disc.
Chymopapain is derived from the papaya plant and is related to the active
substance in meat tenderizer. One advantage of this process is that it
does not require an incision and can be less traumatic to your back than
surgery.
Medication
In the acute stages of back or neck pain, when muscles are spasming and
mobility is severely hampered, some narcotic medications are extremely
useful in helping you to rest and relax. Examples of these are Darvon,
Percodan, and Vicodin. If the problem hasn’t resolved after several weeks
however, you will likely develop tolerance to these drugs (they will lose
some of their effectiveness), you may feel significant unpleasant side
effects (such as constipation), or you may find yourself becoming addicted
— all problems that outweigh the benefits. Anti-anxiety medications (or
minor tranquilizers) have also been used for people with acute pain,
mainly to decrease anxiety associated with the pain and to help them
relax. In the long run however, these drugs have been found to have many
more negative side effects such as addiction, chronic sleeplessness, and a
lowered pain threshold (increased sensitivity). Nonsteroidal
Anti-Inflammatory Drugs (NSAIDs) are frequently used for back pain when
there is an inflammatory component to the pain, but over time, these can
cause serious stomach upset if used frequently. Antidepressants are used
quite frequently to treat chronic pain of many types, including backs and
necks. Antidepressants are typically prescribed at a much lower dose for
pain management than for the actual treatment of depression. These drugs
have the advantage of being nonaddictive, and there are now many choices
in this drug class that allow for the selection of one that has the most
beneficial effect for you with the least side effects.
Nerve Blocks
Local anesthetic nerve blocks and trigger point injections are used to
interrupt the pain-spasm-pain cycle, which can prolong your pain sensation
by keeping you tense and anxious. These blocks can help relieve postural
stress and allow you to participate in gentle exercise, relaxation
techniques, and other rehabilitative treatments. One safe and effective
type of nerve block is a steroid injection into the epidural space
surrounding the spinal cord and nerves. Epidural steroid therapy is
especially helpful for sciatica, the leg pain secondary to disc disease.
Another newer type of block, less common but apparently as safe, is a
facet joint injection. Trigger point injections place a local anesthetic
at the actual site of pain in a muscle (a trigger point is a tender site
in the muscle) or at the referred pain site to block the nerve impulses
carrying the pain message. All three of these blocks can be extremely
useful for at least temporarily alleviating chronic back pain. All are
most useful when combined with exercise and other resources from a pain
management center. You should not look to nerve blocks for your only
treatment for pain, but regard them as part of a comprehensive treatment
program.

Other Physical Treatments
Your doctor may prescribe more conservative (less potential for risk)
forms of treatment for you, such as braces. These are formfitting jackets
that look like corsets and help support and immobilize the spine. Neck
braces hold the chin at a level or slightly lowered position and also
support the neck muscles and cervical area. Braces are usually used during
the healing phases immediately following an injury or surgery. If they are
used continually after this initial phase however, they may lead to muscle
atrophy and more pain, especially when the brace is not worn. This is
because the brace begins to take over the supportive work of the muscles
themselves and your body begins to depend on the brace, instead of the
underlying muscles, to hold your head or body up.
Traction is used to straighten and stretch the soft tissue around the
facet joints in order to straighten the spine. This may be helpful for
pulling the vertebrae slightly apart to allow a herniated disc in the back
or neck to heal. Again, this is helpful primarily during the initial
healing phases of an injury or surgery, not as a solution for a chronic
condition.

TENS (transcutaneous electrical nerve stimulation) devices can perform a
useful function by providing an alternate tingling sensation to the pain
that blocks the pain signal to the brain. Point stimulation, a newer form
of electrical stimulation, may work similarly to acupuncture in providing
pain relief. All forms of electrical stimulation can be placed at trigger
points or at the site of pain.
Heat can be applied in several different ways. Hot towels or heating pads
applied directly to the pain site or hot baths can increase blood flow and
soothe tensed and spasming muscles. Moist heat generally penetrates more
deeply; several microwavable hot packs are now available, allowing for
quicker application and convenience. Diathermy stimulates deep muscle heat
by means of an electric current applied lightly to the surface of the
skin. Ultrasound also elevates tissue temperature by penetrating deeply
into the muscle with high-frequency sound waves.
Popular heat-generating devices are two hands. Massage can be an excellent
way to warm and relax a tight muscle by stimulating increased blood flow
to the area. But if you or your massage therapist press too firmly on a
spasming muscle, the spasm can get worse. Try a hot bath or heating pad
first. Any time you feel a sharp pain when using massage, back off.
Cold can also be beneficial for back or neck pain, particularly if your
condition has been determined to include an inflammatory process. Many
people have found that ice seems to "numb" the painful area, providing at
least temporary relief. Gel packs are now available that can be frozen or
heated, depending on what feels the best to you. Some gel packs are
especially made not to freeze solid, but to stay at a consistency like
gelatin so that the pack can conform to your back. For some, lightly
rubbing the painful area with an ice block until numbness occurs is even
more effective than a cold pack because of the more intense stimulation.
Many people with neck or back pain can get some relief, or increase their
activity, by paying attention to posture and positioning. You may fondly
remember a parent saying "sit up straight" or "don’t slouch" and how you
would try to adjust to his or her expectations. When you have a back or
neck injury, poor posture may create excess strain (caused by gravity)
that keeps your pain at an unbearable level. Several different types of
health care professionals can teach you how to stand, sit, and walk in
ways that reduce the strain on your spine and thereby reduce pain. Many
physical and occupational therapists teach movement classes that may be
useful for you, often called "back school," to teach you proper postures
and safe ways of moving. For example, men may carry wallets in their back
pants pocket, which can cause one side of their buttocks to sit higher
than the other, creating tension and pain. Some styles of shoes can also
create awkward body postures, leading to back pain. Physical therapists
can also suggest cushions or other devices that can help you improve your
ability to do daily activities with less pain. Occupational therapists can
perform an analysis of your workstations (desk, sink, and so on) to help
you design a more ergonomically correct system (a system that works best
for you as an individual).
Sometimes back and neck pain sufferers find relief for acute or chronic
pain by using the services of a chiropractor, a highly trained health care
professional who uses spinal manipulation or adjustment to correct spinal
misalignment caused by disease and injury. A chiropractor works on each
specific vertebra, manually moving one segment at a time to bend, twist,
or stretch the vertebral joint, helping to reposition it. A newer, and
some believe safer, approach by some chiropractors involves the use of a
special tool called an activator, which "taps" the misaligned vertebra to
increase mobility and avoids the traditional manipulation techniques more
commonly used. When there is nerve root compression, as with a herniated
disc, chiropractors will determine this condition first through a series
of diagnostic tests (such as X rays, CAT scans, or straight leg raises)
before they attempt to manipulate your spine. If nerve-root compression is
present, they may elect other forms of treatment, such as traction tables
or other traction devices. A chiropractor may also refer you to a surgeon
if you have clear nerve-root compression.
As do physical therapists, osteopaths, and athletic trainers,
chiropractors employ a wide variety of treatments to alleviate pain such,
as electrical stimulation techniques, acupuncture, or massage. They will
work closely with your regular general practitioner to monitor your
medication and diet. Chiropractors are also aware of the importance of
regular exercise and will often prescribe exercises that enhance back and
neck flexibility, strength, and range of motion to supplement regular
treatment.
As with other medical treatment, research is still inconclusive regarding
the effectiveness of chiropractic treatment. Ask your doctor or friends
for a recommendation to a reputable chiropractor in your area. Carefully
discuss your back or neck problem with your doctor or chiropractor before
you begin any treatment. Manipulation can make some problems worse, such
as fracture of a vertebra resulting from the brittle bones of
osteoporosis.

TESTS FOR BACK PAIN

From: The Back Pain Sourcebook

What may be standard treatment for one back may not be standard for
another. While there are several tests for back problems, it’s wise to ask
yourself and your practitioner a few questions before embarking on a
series of diagnostic procedures. Foremost, do you absolutely require the
procedure? Are there risks involved? Is the procedure painful, and are
there side effects? Did you know that except for life-threatening
emergencies, you are the person to authorize tests, not your doctor? Many
individuals fail to inquire about a test; they simply accept that the
doctor has ordered it. Doctors are aware that they have a legal obligation
to explain potential hazards or risks, but if they aren’t forthcoming with
information, it’s up to you to ask. Many times you must sign a release
before a test is administered. Read the fine print. If you have
reservations about any test, discuss it with your doctor before
proceeding. A second opinion is always a good idea if you are have
misgivings about the type of test recommended. The following procedures
are often part of the diagnostic window to help doctors clearly understand
your back problem. Some procedures are more frequently used than others.

X Ray
The X ray still remains a standard test with most practitioners. Why do
doctors bother with X rays while there are so many more sophisticated
high-tech choices for detecting spinal disorders? Primarily, X rays are
relatively low in cost and are a prudent choice both physically and
medically. Spine X rays are commonly used to evaluate neck and back
injuries or persistent numbness. An X ray shows only bone, not soft
tissue. And as you well understand, if bone is not the significant culprit
causing problems in your spine — and the majority of the time it is not —
nothing will show up on film. This is the greatest limitation with this
type of test. On the brighter side, an X ray can rule out other
possibilities, such as tumors or referred complications. In a major
departure from traditional practice, federal health officials convened by
the Agency for Health Care Policy and Research recently released a study
suggesting that expensive tests used to diagnose low back pain may be
useless unless symptoms indicate fractures, tumors, infections, or spinal
nerve-root problems. While not everyone may agree with the findings,
unless your practitioner suspects an urgent spinal complication, he or she
will start with an X ray. The procedure takes about twenty minutes and
requires removal of all jewelry. The greatest concern with X rays is
exposure to radiation. If you’re pregnant, carefully weigh the risk
factor. If your back trouble disappears within a few weeks, you won’t need
other tests. On the other hand, if the pain intensifies and your condition
worsens, the X ray is just the beginning in your search.

CAT Scan
A computed axial tomography reveals high-quality cross-sectional images of
the spine or area in question. You lie on a table while the technician,
who remains behind a glass, uses a computer-guided X-ray tube. Although
you must sit still, the procedure is painless. You can hear the rotation
or clicking of the scanner as the machine rotates. Sometimes the
technician will help you change positions to obtain a better image. The
drawback with this type of test is that you are exposed to radiation.
Inform your doctor if you have a reaction to shellfish; sometimes a dye is
used in the scan that such people cannot tolerate. Obviously, if you are
pregnant, you may want to consider skipping this diagnostic test, or else
discuss alternatives with your doctor. The CAT scan remains a good tool
for evaluating herniated disks, spinal stenosis, or injuries to the bones.
Tumors, degenerative bone diseases, and spinal infections are visible in a
CAT scan.
Compared with the X ray, CAT scans are costly, but they are a much better
tool for evaluating more invasive problems related to the spine.

MRI
Magnetic resonance imaging, a noninvasive test conducted without
radiation, is considered a gold mine in high-quality testing. The patient
must lie quietly in a large, body-length tube while being scanned. The
procedure can run from an hour and a half to two hours. It’s painless. The
scan visualizes tissue with a magnetic field recording that uses
high-speed computers to provide very clear images of the spine and other
tissue. The MRI is effective for visualizing soft-tissue disorders, disk
disease, tumors, infections, and spinal nerve compression from stenosis
and nerve disorders. The MRI can see through bone. It uses a powerful
magnetic field and radio-frequency energy to produce images. The images
are monitored by a computer, which processes the images on a video screen
for interpretation. While your entire body lies perfectly still in the
tube, the scan examines only the area of your spine in question. It does
not scan the entire body. The room is very quiet, and you can hear the
sounds of the scanner machine. The technician produces the images with
special equipment. You have no direct contact with the equipment. There
are no known harmful effects with an MRI.
Claustrophobia may be a concern, since you are cooped up inside that tube.
The MRI cannot be conducted on women with intrauterine devices (IUDs) or
individuals with metal implants or pacemakers. The estimated cost for an
MRI is considerable: around $1,000.

EMG
An electromyogram is an invasive test administered by a specialist. The
test measures the speed of motor-nerve conduction. Fine wires or
electrodes are inserted into muscles and nerves and then electrically
stimulated. The purpose of the test is to help diagnose nerve disorders
and to differentiate between primary muscle disorders. This technique
determines which nerve is injured and if the injury occurred recently. You
will be asked not to smoke for twenty-four hours prior to the test and to
refrain from caffeine intake for several hours before. Inform your doctor
if you are taking medications.

An electromyograph machine detects and measures response. A needle is
inserted into the selected area. A sharp, brief pain ensues each time the
needle electrode is reinserted. The muscle or nerve’s electrical potential
is measured during rest and contraction and is displayed on a screen. The
procedure may be a bit uncomfortable and lasts approximately one hour.

Blocks
Blocks, an injection of corticosteroids administered into the site of pain
are useful when the amount of pain is severe. They can be used in
diagnostic treatment of chronic problems, but tend to be more effective
with such acute problems as pinched nerves.
The steroid in the block reduces inflammation, which is critical. If, for
example, a pinched nerve is not remedied, blood supply is cut off,
resulting in permanent tissue damage. The injection cuts the swelling so
that the blood supply can flow normally. A block will not change the
structure of the problem, such as a pinched nerve, but it will buy time,
allowing the body to heal. If successful — and statistically between 70
and 85 percent are — the block allows for a modicum of normality while the
body heals. If the block is not successful, the individual must repose
until the inflammation diminishes and further tests are taken.
Blocks have been widely used for the last decade. While there are
subcategories to blocks, the two types commonly used today are epidural
and facet blocks. Facet blocks are injected into the facet. Epidural
blocks are injected into epidural space. An anesthesiologist, surgeon, or
physiatrist can perform these procedures.
The procedures consist of injecting corticosteroids with a solution into
the spine. Alternately, the steroid may be taken orally. The steroid
remains in your body for approximately six weeks. Some individuals report
very little pain, others insist the procedure is painful. For the person
dealing with long-term pain, there may already be a nerve sensitivity in
the area, thus creating an uncomfortable experience. If the individual
responds well to the injection, relief comes within seventy-two hours. If
not, a second or third injection from a different approach may be more
successful. Sometimes there is no response. Some physicians administer
blocks in a series of three injections. But since the solution remains in
your body for six weeks, this may not be necessary. The only rationale for
a second block is if the first one doesn’t work. So consider this if a
second or third injection is offered.
Blocks are sometimes performed to pinpoint pain or to glean information
about the area in question. Although a local anesthetic is given, the
individual must remain awake to communicate his or her response to the
needle. The needle must be moved, and, because anything in this region is
hypersensitive, this can hurt.
In general, blocks are not a risky procedure. As in any invasive
procedure, protecting the nerves is always the main concern. Blocks may or
may not be done with X rays or a fluoroscope machine. They are always
performed in a clinic or hospital. Costs run between $250 and $800,
depending on where the block is performed, and who is administering it.

Myelogram
This invasive procedure examines the fluid-filled sac that lies around the
nerves and spinal cord in your spinal canal. The myelogram at one time was
used in locating and identifying such problems as a herniated
intervertebral disk, tumors, or injuries to the nerve roots branching off
the spinal cord. Today, an MRI scan is performed either in place of or
prior to a myelogram, since the myelogram is an invasive procedure and
carries a slight risk of adverse reaction. An MRI may be a more prudent
procedure, although in some cases a myelogram and CAT scan give the most
information.
Instruction to avoid food but to take plenty of liquids is given prior to
the test. You may be given a sedative or injection to relax. You lie
facedown, and the site of the procedure is anesthetized with a local
anesthetic. A longer needle then protrudes into the spinal canal and a
small amount of fluid is taken from the spine and sent to the lab for
analysis. The position of the needle is monitored by a fluoroscope, which
is connected to a screen. A contrasting X-ray dye is injected into
fluid-filled space that surrounds the spinal cord. You are tilted under a
fluoroscope so that the dye can be observed. X rays follow. The body
absorbs the water-based dye.
You must sit up or lie with your head elevated for six to eight hours
after the procedure. Although you’ll leave the hospital or clinic the same
day, plan to rest a few days after this procedure. Some complain that this
is a painful experience, while others report a headache afterward, or some
discomfort as the needle goes in. Side effects include nausea, headaches,
vomiting, and post-procedure infection at the injection site. Myelograms
may be followed by a CAT scan while the dye is still present to pinpoint
the exact location and degree of herniation.

Discogram
A discogram is a surgical staging test to try and identify which disk or
disks are problematic or abnormal. It is frequently painful, and spine
surgeons or anesthesiologists and radiologists perform it. There is a risk
of disk infection in one in five hundred procedures.

Bone Scan
A bone scan is a procedure in which an injection of radioactive material
travels through the bloodstream to attach itself to the bone. This
material moves to areas that are either actively breaking down bone or are
making new bone. It shows up in large amounts in areas of abnormal bone
and detects the early signs of bone cancer, infection, or fractures. The
bone scan helps evaluate unexplained bone pain or abnormalities found on
regular X rays. The test is done in the department of nuclear medicine,
and although it does not require an overnight stay, it is lengthy. After
the radioactive substance is injected into your veins, you must wait
approximately three hours for the material to distribute throughout your
body. Drinking a massive amount of water is required to clear the body of
radioactive material not involved with the bone tissue. The actual scan
takes about one hour, as you lie on your back and the camera moves slowly
back and forth above your body. Infants, pregnant women, and breastfeeding
mothers are not good candidates for this procedure. A bone scan is
expensive and is not done routinely.
You may never have cause for more than an X ray or an MRI. If, however,
tumors or certain infections invade your body, several of these tests may
be helpful.

Drugs
From:The Back Pain Sourcebook

The first thing many of us do when in pain is reach for a drug. This is
understandable; after all, we have been conditioned as a society to search
for the quickest form of relief. But while relief might be just a pill
away, be cautiously aware that back pain is not cured by taking drugs.
Drugs give only temporary relief. Be careful when taking narcotics for
your back problems. They are not a solution.
If you have any questions about the drug you have purchased over the
counter or that your doctor has prescribed, by all means, consult your
physician or pharmacist. Yes, your local pharmacist is a wonderful source
of information when it comes to the pills you swallow. Ask for a brief
consultation about the drug:
What are the side effects?
Should the drug be taken with food or on an empty stomach?
What does your pharmacist suggest if you have a reaction?
How potent is the drug compared with another similar drug?
Are there foods that should not be taken with a specific drug?
When should you dispose of the drug?
Can you have an adverse reaction if combined with other medicine?
Does your pharmacist have an opinion about the drug you are purchasing?
If the differences between anti-inflammatories (or nonnarcotic
analgesics), painkillers, and muscle relaxants confuse you, perhaps your
pharmacist can offer more information on the subject or give you a
pamphlet.
Drugs for treatment of backaches generally fall into three categories:
anti-inflammatories (or nonnarcotic analgesics), painkillers, and muscle
relaxants. New drugs are continually being discovered, and some of the new
generation of medicines are not habit forming.
Anti-Inflammatories or Nonnarcotic Analgesics
Nonnarcotic analgesics fall into two categories. The first, an
acetominophen class of drug such as Tylenol, comprise mild analgesics that
work for reducing fever. They are not anti-inflammatories. In other words,
they are unable to soothe irritated tissue in conditions such as
arthritis, because they have no anti-inflammatory agents. They are,
however, effective for mild pain.
In the second category are the nonsteroidal anti-inflammatory drugs
commonly referred to as NSAID. Aspirin is the best known of these. We tend
to take an aspirin for all sorts of common ailments, including fever, but
aspirin has very effective anti-inflammatory properties. Ibuprofen, Advil,
Nuprin, and Motrin are a few of the brand names sold over the counter.
The theory is that NSAID work to reduce the tissue concentrations of
chemicals involved in the production of inflammation and pain. They are
effective for mild to moderate pain, but can irritate the stomach lining,
cause nausea, and in rare cases cause kidney damage. They can also stir up
trouble with gastritis and ulcers.

Painkillers
Narcotics are powerful painkillers and may be prescribed for pain relief.
Science has searched for pain relief for many centuries. Opium is one of
the oldest painkillers known to humankind. In the 1800s morphine, named
after Morpheus, the Greek god of dreams, was first purified from opium. It
decreased opium’s nasty side effects and increased its painkilling
properties. In the beginning, morphine was used as an anesthesia prior to
operations. Patients needed to be anesthetized with rather large doses,
which led to other problems. (As you know, both opium and morphine are
highly addictive.)
Man still continues the quest for the perfect drug, yet some ancient
truths still apply: Painkillers may mask the pain and give temporary
relief, but they do not alleviate the problem. If you take painkillers for
any amount of time, possible abuse of the drug and addiction need to be
monitored, preferably by yourself, and if not, by your doctor.
As the user’s tolerance to a narcotic increases, the doses need to be
increased to obtain the same effect. Drugs that fall into this category
include codeine, morphine, Darvon, and Demerol.
Your doctor may prescribe acetaminophen (Tylenol) for pain. Tylenol is a
moderate painkiller that may, if taken in large quantities, upset your
stomach, but it is not addictive.
Side effects of narcotics include addiction, sedation, and loss of sex
drive if taken long term.
Muscle Relaxants
Many physicians avoid muscle relaxants. Muscle relaxants work on much the
same principle as painkillers. Sometimes the two are prescribed
simultaneously. Parafon, Flexeril, and Valium are commonly prescribed
muscle relaxants. Muscle relaxants do exactly what they say: They relax
you. The extended use of these powerful relaxants can produce depression,
and one of the side effects is drowsiness. Muscle relaxants are addictive
if abused.
Drugs for Depression
Depression understandably may be wedded to long-term pain and is often
associated with sleeping difficulties. Serotonin, a chemical produced in
the brain, is also associated with depression, chronic pain, and sleep
disturbances. Certain antidepressants are used to help serotonin levels in
the brain return to normal. Antidepressants take a few weeks to begin
working. They don’t activate overnight.
Newer antidepressants on the market, like Tricyclse, are not habit
forming. Side effects may include weight gain, grogginess, dry mouth, and
in some cases, constipation.
Referencing Drugs
How many times have you taken a drug like tetracycline, gone and soaked up
a few rays, and come home with spots all over your body? A reaction to the
drug? Not really. Tetracycline is photosensitive and does not mix well
with sunshine. Nevertheless, this frightening side effect is often not
noted by the hurried physician or busy pharmacist. Of course, the small
print on the prescription advises you not to go in the sun. But did you
read it?
So what’s the point? When taking drugs for pain, know their potency, side
effects, and what they mix and don’t mix with. Frankly, your doctor
probably doesn’t have the time, or may not even know everything there is
to know about the drug. But there are drug references to help you, and
you’ll find them in libraries as well as pharmacies. The following are
excellent guides to help you understand the drug or drugs you are taking.

 

SURGERY
Traditional Types of Surgery
From:The Back Pain Sourcebook

Spine surgery is rapidly changing. The following surgical techniques have
been around for some time. If these are your options, familiarize yourself
with them before going under the knife.
Laminectomy
The laminectomy, considered by some the standard of back surgery, has been
performed for some thirty years. A laminectomy is a removal of the
posterial portion of the ring of bone that surrounds the nervous tissue in
the spinal canal. Laminectomies are performed to relieve compression of
the spinal cord, caused by a bone displaced due to an injury or resulting
from disk degeneration. Performed under general anesthesia, the underlying
problem should, theoretically, be corrected. But this doesn’t always
happen. As with Irve, the laminectomy did not relieve pain, and the
problem was not corrected. Sometimes the surgeon does not remove enough of
the laminae but has no way of knowing this until after the patient has
recovered from surgery.

Fusion
Fusion surgery stabilizes vertebrae that are unstable due to degenerative
disks or worn-out facet joints. Fusion is the replacement or bridging
across a disk with bone. The bone is either donated or taken from the back
of the pelvis. The concept is that living bone will grow over the area in
your back and fuse together.
There are many types of fusion surgery. Some techniques involve attaching
hardware, such as screws or rods, to the back or front of the spine bones
to stabilize them. This surgery is very extensive. St. Mary’s Spine Center
in San Francisco has recently developed a percutaneous fusion technique
that has been successful in over sixty patients at this time.

Microdiscectomy
Microsurgery uses a microscope so that the incision site is only an inch
long. This is not a percutaneous procedure, it’s major surgery, although
pain is less severe than with other dramatic surgeries. Nerves to the
spinal muscles aren’t cut, ligaments to the spine aren’t cut, and tissue
damage is reduced. The surgeon’s field of vision is more restricted than
in a traditional laminectomy. The doctor must be sure of the exact
location where the disk is impinging on the nerve; otherwise, symptoms may
reappear due to missed parts of the disks. There is less operative pain
with a microdiscectomy and more rapid return to daily activity.
Foramenotomy
A foramenotomy is performed to provide a passageway for the spinal nerves
from spinal stenosis. The small openings in the vertebrae, called foramen,
allow the spinal nerves breathing space. With spinal stenosis, a narrowing
of the space within the spinal column causes the nerves to become
constricted and swell. With a foramenotomy, the bone around the foramen is
shaved, allowing for breathing space for the nerves and blood to circulate
freely.

Chymopapain or Chemonucleolysis
Chymopapain, once a controversial treatment, still appears to be in use.
With many newer, less invasive surgeries on the horizon, chymopapain has
become less popular. Chymopapain, an enzyme derived from the papaya fruit,
acts like a meat tenderizer on the nucleus of the herniated disk. It
involves partial destruction of the nucleus, as the nucleus of a herniated
disk is digested by the injection of chymopapain. The procedure ideally
shrinks the protruding area of the disk, thus lessening pressure on the
nerve root.
A number of complications plagued chymopapain in the beginning: back
spasms, neurological damage, and allergic reactions. As chymopapain’s
popularity rapidly peaked in the early ‘80s, many physicians received
rapid but inadequate training, underscoring the need for more thorough
understanding. Today, chymopapain is skillfully used as a treatment by
some doctors. It’s less expensive than other procedures and incurs less
scarring, but some people are highly allergic to the drug and cannot
tolerate it. A preliminary skin test can detect a measure of adverse
reaction, but sometimes even the skin test cannot foretell possible
problems.
When Spine Surgery Is Absolutely Indicated
If you have sudden loss of bowel, bladder, or nerve control, call your
doctor immediately or get to an emergency room. You may be suffering from
a longtime injury that has suddenly worsened, cutting the blood supply off
from the nerve and killing the nerve cells. Loss of bowel or bladder
control indicates possible extensive nerve damage. If not surgically
treated immediately, it may result in permanent nerve damage.
What is New on the Surgical Horizon
The future of spine surgery may be heading from the back to the front.
Laparoscopic procedures are proving successful in certain types of spinal
surgical procedures and some percutaneous procedures. Laparoscopic spine
surgery may soon be a better and more cost-effective option for spine
surgery.

The Back Implants
The back spinal implants, still new and not widely available, is used in
fusion surgery to stabilize motion in the spine. Bak implants, similar to
large, hollow screws with holes in them, are usually implanted in pairs
inside the spine. They are made from titanium metal. Bak implants can be
put in posteriorly or laparoscopically. They are used to stabilize the
spine.

The Controversial Pedicle Screws
Pedicle screws are used to stabilize the spine after spinal injury or to
correct severe spinal curvatures and other abnormalities. In many cases
they have replaced other methods of spine stabilization, such as wires,
rods, and hooks. The controversy surrounding the pedicle screws is that
they have not been approved by the FDA but are still widely used. Under
the law, before orthopedic screws can be marketed as pedicle screws, their
manufacturers must submit scientific data to the FDA establishing that
these devices are safe and effective. Limited studies of pedicle screws
have been ongoing for a number of years, and the FDA has approved using
the screws for the purposes of these studies. According to the Back Pain
Association of America’s April 1993 newsletter, the studies on pedicle
screws have not been completed and the manufacturers have not accumulated
enough data to show, one way or another, whether the screws are safe. Does
this mean the pedicle screws are unsafe? Some hold that there is simply is
not enough scientific data at this point to say one way or the other.
Surgeons using pedicle screws believe they are by far the most effective
hardware on the market to stabilize the spine, far more effective than the
wires once used.

Staving off Back Surgery
You’ve done everything possible, and like Judith and Hank, surgery is the
last alternative for you. Here are a few tips to help you prepare for back
surgery and to return to a healthy, productive life after the surgery:
Search for the right medical team and get a second opinion. Ascertain if
the spine surgeon has a pain clinic, a physical therapist, a
neurosurgeon, a psychologist, physiatrist, osteopath, or chiropractor on
board.
Ask your surgeon to have the surgery explained to you. Ask about the
success rate and risk. Talk about your fears, how you manage pain, and
what outcome you expect from the surgery.
Consider whether your projected outcome is realistic, how much
recuperation time is needed away from work and normal activities, and
the requirements of your recovery period.
Discuss with your practitioner what happens if you need another surgery.
A second surgery is not so uncommon.
Follow up with back exercises and changing patterns. Don’t expect the
surgeon to do any more than perform surgery. It will be up to you to
carry on with your back exercises and change lifestyle patterns that
undermined your back. Most doctors agree that changing postural habits
and exercising can drastically reduce your chances of needing surgery.

ALTERNATIVE MEDICINE
From:WebMD Electronic Library Collection
By:Vivekan Flint
Introduction
During the past decade, the American public's interest in alternative
medicine has skyrocketed. The evidence for this trend is everywhere * in
the media, in the growing number of popular books on "wellness" and
non-traditional therapies for illness, and in booming sales of supplements
and herbs.
The magnitude of this trend was highlighted in a report by David
Eisenberg, M.D., of Harvard Medical School published in a 1993 issue of
the New England Journal of Medicine. Eisenberg estimated that Americans
made approximately 425 million visits to alternative therapy providers
during 1990 and that expenditures associated with these therapies were
comparable to non-reimbursed expenses incurred for all hospitalizations.
The growth in the use of alternative medicine has been accompanied by more
subtle changes in the attitudes of both patients and physicians. Though
still widely used, the term "alternative medicine" has been gradually
falling out of favor in recent years. Many who work in the field feel that
the term reinforces the old and divisive (and inaccurate) stereotype of
desperate and naive patients foregoing promising mainstream therapies in
favor of unproven or "alternative" therapies offered by "quack"
practitioners.
This view began to change with the publication of a 1988 study by Barrie
Cassileth, Ph.D. Cassileth's survey suggested that, for the most part,
unconventional therapies in the United States are offered by licensed
physicians or other credentialed health care practitioners who believe in
the therapies they offer, who are not charging excessive fees for
treatment, and who are treating patients of above-average education and
income. Further, these patients are likely to be more deeply engaged than
the average patient in exploring their choices. Significantly, in the
large majority of cases, these patients also choose to remain under the
care of a mainstream physician. Generally, patients who completely leave
mainstream medicine do so only because doctors have said there is nothing
more they can do for them.
More and more patients are finding that alternative medicine has a great
deal to offer, especially for treating chronic conditions with which
Western Medicine has little success. The vast majority of patients,
however, do not see conventional and unconventional therapies as an
either/or proposition. Rather, they seek to make informed, personal
choices about how to integrate both. For this reason, "complementary" or
"integrative" medicine have become the favored designations for this
emerging field.
A vast array of approaches fall under the heading of complementary
medicine. Some, such as acupuncture and Ayurveda (the traditional medicine
of India), are ancient traditions used by millions of people over
thousands of years. Most cultures have also developed herbal traditions
based upon the local medicinal plants. Other approaches, such as
macrobiotics or Anthroposophy are branches of wider philosophical systems
applied to medicine. Chiropractic and homeopathy are examples of systems
that arose in the West * alongside orthodox medicine * that view disease
processes much differently than mainstream medicine. Mind-body therapies
(e.g., stress reduction techniques, biofeedback, meditation) comprise a
large class of approaches that owe a great deal to the spiritual
traditions of the East.
The most effective use of complementary therapies is often in combination
with mainstream therapies. There is evidence, for example, that Chinese
herbs can potentiate the effectiveness and lessen the side effects of some
chemotherapies and that acupuncture can greatly reduce the nausea
connected with cancer therapy. In the same way, chiropractic or
acupuncture can greatly reduce or even eliminate the need for analgesics
for chronic back pain.

Complementary Therapies Are Not Always Harmless
It is important to know that complementary therapies are not by definition
harmless. They run the gamut in terms of their potential for harm, though
many do tend to be quite benign. If you choose to use complementary
medicine, it is a good idea to consider using one or more therapies that
are considered to be intrinsically health promoting regardless of whether
one is ill or not. As Michael Lerner has pointed out in his book Choices
in Healing, these "lifestyle therapies" can give you a sense of taking
charge of your own health and often enable you to better tolerate
difficult therapeutic regimes.
The spiritual and mind-body approaches are primary among lifestyle
therapies. Prayer, meditation, psychological therapy, imagery and support
can, at the very least, bring about a transformation in the way you view
illness and your own body. These approaches can also affect the way pain
is perceived, and there is evidence they may actually affect the course of
the illness itself in some cases. Nutritional approaches (if not carried
to extremes) and physical approaches, like massage, exercise and yoga, are
also generally health promoting.
At the other end of the spectrum are some of the unconventional
pharmacological, herbal and vitamin supplementation approaches where
overdoses and other toxicities are possible, as well as interactions with
prescription drugs. Extreme dietary approaches can also lead to unhealthy
weight loss and nutritional imbalances.
The Research Evidence for Complementary Therapies
Generally, there is little hard research evidence for the effectiveness of
complementary therapies. This does not mean that these approaches are not
useful * just that the question is still open. As these approaches are
researched, they either tend to move into the mainstream, as is currently
happening with a range of mind-body therapies and acupuncture, or they are
essentially abandoned, as has largely happened with laetrile, the popular
cancer "cure" derived from apricot pits.
But cultural and institutional considerations also play a role in deciding
what is and what is not considered "alternative." Almost by definition, a
therapy is considered "alternative" if it is not taught in medical
schools, even if there is good research evidence for efficacy as there is
for acupuncture, chiropractic and some herbal therapies. For example, the
strength of the research for the effectiveness of homeopathy for some
conditions is quite compelling, yet because there is no rational
scientific mechanism to explain its action, it is still dismissed by many
researchers. And though the research on promising herbal therapies is
readily available to American doctors, herbal remedies are rarely
prescribed by American physicians. In Europe, however, this is quite
common. In Germany, for example, the herb St. John's Wort is prescribed
much more often for mild to moderate depression than is the drug Prozac.
Choosing a Complementary Therapy
Most mainstream physicians are of little assistance when it comes to
providing guidance to patients in the area of complementary medicine. At
the same time, there is an explosion of media "hype" and commercial
ventures touting non-toxic cures for illnesses ranging from acne to
cancer. How does a consumer of health services interested in exploring
complementary therapies make sense of it all?

Obtain a Medical Diagnosis
Always begin by obtaining a medical diagnosis for your condition from a
physician. If you decide to stop using mainstream medicine, do so only
because you have weighed the benefits and side effects of the treatment
and determined that there is no longer a sufficient reason to continue.
Never abandon a promising mainstream therapy in favor of an unproven
complementary therapy.

Educate Yourself
Once you have a diagnosis and comprehensive information on mainstream
treatments for the condition, it is well worth your time to educate
yourself thoroughly about the field of complementary medicine for your
condition so that you will have a context for comparing therapies and
making decisions.
It is very common for a patient to hear about a complementary therapy that
has been helpful for someone else and to expend considerable effort to
locate that therapy for themselves. While it's useful to hear from
individuals who feel they have been helped by a given therapy, keep in
mind that people who were not helped are less likely to talk about it than
those who experienced dramatic positive results. The person you heard
about may be one out of a hundred who actually benefited from the
treatment!
Most medical conditions are self-limiting * they get better eventually
even without treatment. Other conditions, including some serious diseases
like multiple sclerosis, can wax and wane regardless of treatment. In
these cases knowing that someone improved when using an alternative remedy
tells you nothing, because it could have happened even without the remedy.
Also remember that people who use these therapies often use a number of
them at once in addition to Western medicine. Therefore, it is often
impossible to know exactly which therapy or combination of therapies
actually helped.
Check Resources
There are a number of useful resource books that may be of great help in
understanding the field of complementary medicine and in choosing specific
therapies. Some of these are listed in the "Resources" section below.
The Internet can be a valuable tool for locating information about the
range of complementary therapies available. If you have access to a
computer, look at the Internet sites that provide information about your
condition. But beware that the web is full of unreliable information.
Remember * just because it appears on the web doesn't mean it's true!
Medically oriented sites generally provide the most reliable information,
but these rarely discuss complementary therapies. If they do, they are
likely to err on the side of conservatism when it comes to complementary
medicine. If a medically oriented site says a given complementary therapy
is unproven, it means only that * it's unproven, not necessarily
ineffective.
Internet sites established by patient advocacy or support groups are often
very good sources of information about complementary therapies. Discussion
groups can give you a sense of which therapies people are finding helpful.
The same is true of support groups. Hearing from many people who have
tried a particular therapy is a good indication that you should
investigate more closely.
Be wary of web sites that have been set up by proponents of a particular
therapy, especially if a product line is being promoted. Be skeptical of
any information, on the web or in print, which describes "miraculous"
outcomes or "cures" for conditions that mainstream medicine considers
incurable, or encourages patients to leave mainstream medicine in favor of
an alternative approach.
When evaluating information on the web or in print, look for references to
research studies. It is fairly common for whole books to be based on one
small study! Look for numerous citations to different studies. It is the
nature of research that studies are often contradictory and that only a
large body of research can begin to yield definitive answers. Studies in
human subjects are much more important than studies in animals or in test
tubes (sometimes called in vitro studies).
You can also perform an on-line search for the medical literature yourself
using PubMed, a service developed by the National Library of Medicine (see
Resources for Internet address). Many hospitals in large cities also have
patient libraries that perform this kind of search for you, usually for a
fee. Staff members in these libraries can also be quite helpful in
locating information for you.
If there is little research evidence for the therapy, you might ask
yourself the following questions:
What is the context from which the therapy arose?
Is the therapy science-based? Is the scientific foundation widely
accepted?
Is the therapy part of a non-scientific system? If so, what is that
system, and does the system make sense to you as a worldview?
Did the therapy arise from one of the traditional medicines of the world
with a long history of use?
Is the therapy a "secret formula," or does the proponent welcome
independent evaluation?

Choosing a Practitioner
Once you have settled on a therapy that you would like to try, the next
step is finding a practitioner. For some therapies this may not be
necessary. You can make modest changes in your diet, for instance, or
begin a moderate exercise regimen unassisted. But if your condition is
serious, the therapy is complex or if the lifestyle change is a major one,
it's wise to seek out some assistance * at least initially.
The advice of a properly trained practioner is important in making
decisions. It's appealing to simply go to the natural foods store and pick
up some supplements or herbs. But remember these can have serious
interactions with drugs you may be taking, and the therapy may require
taking higher doses than are indicated on the bottles. Similarly, Chinese
or homeopathic remedies are available over the counter, but these
"formulas" may bear little resemblance to the prescription a practitioner
would write for you since they are highly individualized treatments. Also,
never rely on "recommendations" by employees of health food stores * their
training in the use of herbs and supplements usually comes from sales
representatives, not schools of naturopathy!
When seeking a practitioner, a personal referral is best, but it is also
wise to talk to many people with the same condition until one name comes
up two or three times. Support groups are also good places to find this
kind of information as are local branches of support organizations.
Referrals can also be obtained from another practitioner whose opinion you
trust.
If these kinds of direct referrals are not available, the state or
national credentialing organization for that discipline will often provide
referrals. "New Age" newspapers found at natural food stores and
bookstores may contain ads and listings for local practitioners, as well.
If all else fails, try the telephone book!
Once you have located a candidate, don't be shy about interviewing him or
her.
Find out what their training is and how long they've been in practice.
Ask if they are licensed and credentialed.
Determine if they have worked with many people with your condition. If
you have cancer, find out if they have worked with other people with the
same kind of cancer.
Get a sense of their attitude concerning mainstream medicine and if they
would be willing to work with your doctor.
If for some reason you decide not to work with that practitioner, ask for
a referral to another.
Before you actually begin the therapy, tell your physician. If the
physician is knowledgeable and open minded, he or she may agree to work
with you to coordinate care from different sources. Be prepared, however,
for the possibility that you will not be supported in your decision to use
complementary medicine. You may be told you are wasting your time or even
be warned of dire consequences. If this is the case, try to determine
whether or not the physician's response is based upon an accurate
understanding of the therapy you would like to undertake. If you have been
able to locate research studies on a complementary therapy you find of
interest, show these to your doctor. For some people, the support of their
physician in this area is important enough that they will decide to seek
out a doctor who will be supportive.
Increasing numbers of open minded practitioners on both sides of the
alternative-conventional medicine divide are coming to understand that the
future of medicine clearly lies in some form of integrated healthcare,
where traditional, mind-body and lifestyle approaches take a place
alongside Western allopathic medicine. But until that time arrives, it is
up to the patient to put these pieces together. The challenge can seem
daunting, but the task is not impossible and the rewards are well worth
the effort.

Resources
Internet
Internet address for PubMed:
http://www4.ncbi.nlm.nih.gov/PubMed/overview.html

ACUPUNCTURE
An Ancient Alternative Treatment
From:The Back Pain Sourcebook

In 1971, while in China, New York Times. correspondent James Reston
received acupuncture for pain relief after an emergency appendectomy.
Reston’s rave reviews brought acupuncture out of the framework of Oriental
philosophy and into the daily American press. His postoperative treatment
was hailed by the Western media. Reston’s reporting brought acupuncture
into American living rooms at the same time diplomatic doors slid open
between China and the United States.
While acupuncture has been a healing art in China for over 3,000 years,
its entrance onto foreign soil wasn’t easy. Many Western practitioners
were admittedly fascinated by the accounts of acupuncture used as an
anesthesia and analgesia. But the Chinese philosophy of body dysfunction
is very different from the accepted Western view of how the body works.
Western medicine is based on the Cartesian philosophy that the body
represents one functioning system and the mind another. Chinese medicine
assumes the body is a whole and that all parts of it are connected.
Chinese medicine postulates that health is achieved and disease prevented
by maintaining the body in a balanced state; thus mental and physical
well-being must be combined.
The principle behind the therapy of acupuncture is to balance the body’s
energy flow. The body is a delicate balance of yin and yang. Yin
represents water, quiet, substance, and night; yang represents fire,
noise, function, and day. These two opposites must be present to allow the
other to exist. Once the vital energy, or chi, is disrupted along any of
the body’s fourteen meridians or pathways that correspond to primary
organs, the acupuncturist corrects the imbalance by putting needles in
specific acupuncture points on the body.
When the flow of energy is interrupted, the body’s energy unit needs to be
tuned up, or balanced. Pain is simply a blockage of this vital energy, not
unlike a traffic jam. When your car is stuck in traffic it cannot move,
and the energy in your body works on the same principle. Once the chi is
blocked, it needs help to circulate. Acupuncture addresses underlying
causes dealing with circulation by treating local points. The cause of a
problem in your back, for example, may stem from muscle spasms, stress, or
a musculoskeletal misalignment. Because everything in the body is
connected, acupuncture treats several points. Back pain and neck pain
respond well to acupuncture, but while the relief in most cases is
immediate, it may not be long lasting. This depends on the problem.
Joy’s Story
Joy believes her back might well have been cured from the beginning with
acupuncture. She stumbled into an acupuncture clinic after trying several
other alternatives.
An active woman, Joy worked from sunup to sundown on a ranch. There were
long, arduous hours of climbing, digging and shoveling, and actively
keeping her body and mind fit. She’s fond of saying that she earned her
rest at night and never had trouble sleeping.
An unfortunate disagreement altered the working relationship Joy had with
her landlord, so she moved on. For the next year she traveled up and down
the state. Her lifestyle altered radically from active to sedentary:
sitting, driving, drinking a lot of coffee, and chain-smoking. Bad habits
coupled with lack of movement made Joy’s back feel tense and stiff.
Joy had a hard time finding work and became depressed. She felt trapped,
uptight, and tense. Money scarce, she rented a small room. Lack of
exercise and poor eating habits intensified Joy’s backaches.
Joy returned to physical work. She began cleaning houses, vacuuming and
rearranging furniture. A compulsive cleaner, Joy went home tired and
crawled into bed with a backache. She smoked and drank more coffee than
ever before.
Trying to remedy her back problems, Joy tried stretching and back
exercises. For a few months she did Pilate's, a bodywork program using
stretching and machines, but then couldn’t afford to stay with it. She
moved into a more spacious apartment, but the move created financial
stress. By now her back ached constantly.
Fortuitously, Joy picked up the book Between Heaven and Earth, by Harriet
Beinfield and Efrem Korngold, on acupuncture. It made more sense to her
than anything she’d read in a long time.
She decided to give acupuncture a try and without an appointment walked
into an acupuncture clinic. Joy credits the acupuncture practitioner with
saving her back.
"He put me on a table and put needles in me from my neck to my heels. I
fell asleep and dreamed. During the twenty-minute session, the
practitioner wandered in and adjusted the needles. I felt completely
comfortable, and when I got off the table I was pain free for the first
time in months."
Joy continued her acupuncture for nearly three months, combined with
Chinese herbs. She credits both the herbs and acupuncture with healing her
back and aligning her body. Joy no longer smokes, and she’s working toward
the day when she will no longer desire caffeine. Back problems, as Joy
well understands, are lifestyle issues, and acupuncture treats the whole
person, not just the back.
Because back pain stems from a variety of things, most acupuncturists
encourage you to check with your doctor to rule out acute problems.
Treatment
The sooner the back problem is treated, the faster the condition heals.
Acupuncture works best as part of a series of treatments. In China, a
series of ten is traditional. Depending on your acupuncturist and
particular problem, you might have two or three treatments a week to begin
with, tapering off to once a week. It all depends on your condition and
how your back responds.
Acupuncture is administered by inserting very fine sterile needles into
the body at specific reactive points. You should feel a slight aching
sensation after the needle is inserted. This "reaching the chi" plays a
role in rebalancing the energies of the body.
If you have ever been treated by an acupuncturist, you may be familiar
with a kind of medicinal odor that floats through the office. The odor is
not unpleasant and comes from herbs. Herbs are often used in combination
with acupuncture treatment. Some acupuncturists send you home with an
odd-looking concoction to brew up and drink several times a day. The
concoction is typically bitter, and for many, it is difficult to swallow.
Herb capsules tend to be a more popular form.
How do herbs affect low back pain? According to acupuncturist and Chinese
herbologist Larry Forsberg at the Chinese Medicine Works in San Francisco,
herbs are used a great deal in low back pain, because in Chinese medicine
other organs, such as the kidneys, are implicated in low back problems.
The herbs strengthen the implicated organ. Acupuncture works from the
outside in; herbs work from the inside out. Herbs simply build energy,
while acupuncture moves energy.
An acupuncture treatment usually lasts from twenty to forty minutes.
Needles are placed in the proper points and stimulated. Sometimes the
needles are attached to a little box that stimulates the points and
enhances the treatment. It is not painful. Sometimes moxa, a
strong-smelling herblike substance, is used to heat the painful area. The
heat is not applied directly on your back; rather, the acupuncturist moves
it above the area being treated.
While the prospect of having needles stuck in various meridian points may
sound daunting to some, the treatment is actually relaxing. Many people go
to sleep or fall into a kind of meditative repose.
Acupuncture is most commonly used for sciatica, menstrual irregularities
manifesting in low back pain, muscle spasms, and whiplash.
Risk, Cost, and Certification
Acupuncture is not risky, but it can be costly. If your insurance covers
acupuncture treatment, you’re in luck. If you have to pay for it, it can
be expensive. Again, depending on the acupuncturist, the range is
approximately $40 to $60 a treatment. I’ve had treatments for $35, but
that was when treatment was recommended two or three times a week. You may
want to ask how many treatments your acupuncturist thinks you will need
and what the estimated cost will be.
How do you find an acupuncturist? If you are unfamiliar with acupuncture,
you may feel more comfortable talking to someone you know who has had
acupuncture for back-related pain.
Acupuncturists do not have to be licensed doctors, so you may want to
check certification. Certified acupuncturist (C.A.) and licensed
acupuncturist (L.Ac.) are nonmedical titles granted by some state
licensing boards. Requirements vary from state to state. A diploma of
acupuncture (Dipl. Ac.) indicates certification by a national association
of acupuncturists. There are over fifty acupuncture schools in this
country that certify.
Copyright © 1995 by the RGA Publishing Group, Inc. From The Back Pain
Sourcebook, by arrangement with Lowell House.
 

ALTERNATE THERAPIES
From: The Back Pain Sourcebook

Often back pain sufferers turn to bodywork in their search for an
alternative practitioner for their particular problem. Sometimes they
combine bodywork with traditional modalities of treatment. Bodywork has
come into its own over the last two decades, and techniques vary among the
different schools.
The following chapter discusses the most popular types of bodywork and
ancient practices that you may encounter in your search. Rest assured,
well-meaning friends who have experienced satisfactory relief from one
school will swear that it is the solution to your own back problem as
well. It may be, and then again it may not be. Thank them for their
gracious concern, gather a few more testimonials, and make your own
decision. The differences and similarities among bodywork techniques are
subtle; all aim to realign or retrain the body to function naturally. The
insightful founders of these healing methods — Feldenkrais, Alexander, and
Rolf — each understood that the emotional and nervous system can be
organized or rearranged to heal the physical musculature. They believe
that the individual has the ability to engage in new learning, no matter
how ingrained bad habits are. Sensory re-education is at the heart of
several types of bodywork; in other words, you feel it.
This chapter is not meant to promote a particular school of work. It
simply offers information on some of the alternatives in dealing with
back, posture, and structural problems. Bodywork does not cure a "slipped
disk" or "spinal stenosis," but it does help in understanding what may
have contributed to spinal problems. Then it goes to work altering
ingrained patterns of movement and emotions related to your particular
problem. Some of the bodywork and practices discussed have been around for
centuries, others for decades. Always seek a practitioner who is licensed,
not a student or someone in training.
How expensive is bodywork? That depends what you compare it with. If you
compare several bodywork sessions with surgery, the cost is ridiculously
low. If you compare it with a session with your chiropractor, the cost is
similar or slightly higher. Bodywork traditionally requires more than one
session, and ongoing work can be expensive if your insurance does not
cover it. Nevertheless, for the individual who benefits from it, or who
obtains relief from back or neck pain through a few sessions on a table or
mat, the cost is minimal, considering the outcome.
If you are skeptical about bodywork or think it’s all hocus-pocus, talk to
individuals who have benefited from this approach before you make a final
decision.

Rolfing
Dr. Ida Rolf, a pioneer in bodywork, was a former organic chemist. She
perfected the technique of structural integration called Rolfing.
According to Dr. Rolf, the traditional idea of standing up straight,
shoulders back, stomach in and head high actually misaligns the spine and
deforms the skeleton.
Rolf’s theory postulates that when the body’s structure is corrected,
basic chemical changes take place within it that improve overall health.
Rolfing works in 10-session segments. Rolfer and teacher Neal Powers says
that’s what it takes to take the strain out of the body and put it back in
order. The first 7 sessions work to make the body strain free, and the
last 3 sessions methodically realign the body along its natural vertical
axis. Rolfing straightens the body by correcting the relationship between
major body segments (the head, shoulders, thorax, pelvis, and legs) toward
vertical alignment. In the last decade, Rolfing techniques have evolved
from intense probing to something more akin to sculpting.
Rolfing works with longitudinal alignment of the fibrous tissue,
lengthening the body. A Rolfer feels the bundles of irritated tissue and
with intense, digging-in pressure, splits the bundles. Similarly,
orthopedic massage realigns fibrous tissue, but instead of digging in,
orthopedic massage rolls the tissue and allows the bundled tissue to layer
apart like an onion.
Rolfers perform deep manipulation of the connective tissue called
collagen. The collagen changes from the hands-on energy applied and
becomes more pliable.
In a sequence of hands-on manipulation, Rolfers move the tissue back
toward symmetry and balance that the body demands. Sufficient force
stretches and moves the tissue. Pain may be momentarily intense. Rolfing
is not as subtle as other types of bodywork. Sometimes people being Rolfed
recall a traumatic episode associated with the body and often emotion is
released after or during a Rolfing session. Prices vary from $75 to $120 a
session, with $100 the median for an hour-and-a-half session.

Mensendieck
Mensendieck is a hundred-year-old paramedical system of correct body
mechanics, correct muscle function, and correct posture based on sound
fundamental research developed by Dr. Bess Mensendieck. It has widespread
popularity in Europe, specifically Denmark, Sweden, Norway, and the
Netherlands. Its comprehensive approach and practice is credited in Europe
for the low statistics in back surgery.
Dr. Mensendieck was born in 1861 to American parents in New York City. Her
father, a civil engineer, traveled extensively with his family. Dr.
Mensendieck was gifted both artistically and musically, and made a
successful concert debut in Paris before studying sculpture. It was the
often awkward bodies of her sculpture models that made her aware of the
human form. With a keen eye she began observing children, men, and women.
She attended medical lectures on the muscles and finally quit sculpting to
attend the University of Zurich to obtain her medical degree. She came to
see the musculoskeletal system as a remarkable machine with a marvelous
capacity for adapting itself to perform perfectly the most complex
movements. She lectured around the continent, explaining her schemes for
correcting the common abuses of the body. Dr. Mensendieck set up schools
around Europe and in the 1930s opened her first school in the United
States.
The Mensendieck system works on the premise that if movements are executed
in a beneficial and correct manner, it contributes to a habitually
well-functioning body. Mensendieck emphasizes posture and not permitting
the skeleton to hang into its frame but to move taller and with natural
grace. It is a unique and comprehensive approach, utilizing exercise
rehabilitation to address occupational stresses, sports-related injuries,
postoperative recovery, as well as chronic back and joint pains produced
by bad posture and musculoskeletal diseases. Mensendieck requires no
equipment. A session starts by examining one’s posture in a mirror. It
demands motivation and perseverance to unlearn faulty postural habits,
such as slumping in front of the TV, that put pressure on the sciatic
nerve.

Alexander Technique
The Alexander technique is a rethinking of how we perform all of our
everyday activities, specifically the activities that we take for granted.
The educationally based technique is subtle and was founded a century ago
by a young Australian actor. Alexander found himself plagued with
hoarseness and ultimately laryngitis onstage. Rest restored his voice, but
stress weakened it. Alexander reasoned that he must be doing something to
cause this. Plotting a course of a discovery, over a three-year period
Alexander studied himself while reciting lines. He spent hours in front of
a three-way mirror, and found that while speaking he tightened his neck,
which caused his head to be pulled back and down into his spine. The
result was pressure and strain along the entire back.
Alexander refers to sessions as lessons and to the patient as the student.
Eyes are always open, you are fully clothed, and it’s up to the student to
pay attention. Alexander believed that in order to produce awareness, the
head and neck must be lifted off the spine instead of collapsing into the
spine. With this achieved, the neck is freed and the spine lengthens,
allowing a completely different manner of movement. The technique
essentially looks at posture and how one moves the body in everyday life.
Alexander teachers do not follow formal lesson plans. Half of a lesson may
be on a table, with the other half taking place while the student goes
about a daily activity — playing flute, washing dishes, or whatever
produces the pain.
The technique re-educates people to use their own body in a more efficient
way. It is so subtle that one doesn’t work to align the mind and body, but
must talk to the body and have it listen. Through verbal instruction,
demonstration, and light touch, the Alexander technique creates space in
the torso. Lessons, tailored to the individual’s needs, comprise a minimum
of thirty sessions and run between $30 and $55 each. There is no risk to
this gentle technique. You’ll find variations of it incorporated into back
schools across the country.

Trager
Peter de Zordo began practicing Trager fourteen years ago. A practitioner
at the Trager Institute in Mill Valley, California, he says that Trager is
a sensory experience. Trager effects change through passive body movement.
It considers body restrictions and patterns of movement. Like several
other types of bodywork, Trager is not a confrontive technique.
Milton Trager refers to his bodywork as psychophysical integration and
mentastics. Mentastics refers to the mind. In Trager, the mind is
everything.
Trager was training to be a boxer when he discovered his exceptional
ability to work with his hands while rubbing down his trainer. Trager quit
boxing to take care of his hands and began the long pursuit that
eventually took him to medical school. What distinguishes Tragering from
other bodywork is the focus and intent of the practitioner’s
manipulations.
Trager’s focus and intent are not specifically directed toward local
conditions in the body tissue, muscles, joints, or skin, like Rolfing, but
toward reaching the unconscious mind. It has taken Trager over fifty years
to expand and develop his technique.
Trager mentastics is a system of effortless movements to enhance the
body’s sense of lightness, freedom, and flexibility. Rhythmic massage and
stretching movements encourage the body to let go. Through a series of
movements — swinging, stretching, pressing, and rocking the entire torso —
the body moves into a restful, meditative state. Once the body relaxes,
the moves appear effortless. Plan on about an hour to an hour and a half
for each session. Trager carries no risk and is gentle. Costs range from
$50 to $75 a session, depending on the practitioner.

Feldenkrais
Moshe Feldenkrais, a mind-body holistic health practitioner, was an
engineer who worked on the French atomic-research program. A judo master
and soccer player, he was forced by an injury to apply his engineering
mind to the mechanics of the body and brain. This resulted, in the 1940s,
in the Feldenkrais technique. There are literally thousands of exercises
in this technique, and the mind and imagination play a key role.
Feldenkrais drew on the works of other pioneers. He recognized that a
great deal of pain results from patterns of movement that involve
unnecessary muscle tension. Insightfully, he felt people could "learn to
learn" to move in a free and graceful way. Feldenkrais held that most
people lose the grace, freedom, and joy in movements that they had as
infants and small children. He understood that the relationship of
movement with thinking, feeling, and sensing can effect changes in
behavior, and he coined this "functional integration."
A Feldenkrais session communicates to the brain precise movements that
change habitual patterns and provides new information to the neuromuscular
system by gentle touch, movement variation, and verbal guidance. A
practitioner gently lifts, halts, and supports the head, arms, legs, back,
and chest as you are guided through slow, easy movements. Touch is light,
not deep.
Prior to his death, Feldenkrais worked with individuals affected by
multiple sclerosis and cerebral palsy, claiming that his method could
improve the health and well-being of anyone having trouble with movement.
In some circles he was considered a holistic guru. For Feldenkrais, touch
evoked cure.
There is no risk involved with this method. Feldenkrais can be taught in a
group setting or individually. Group classes start at around $8, and
individual classes may start at $35 and go up from there.

Aston-Patterning
Judith Aston came to Ida Rolf for treatment after an automobile accident.
Originally trained as a dancer, she was told she should give up her
career. She went on to study Rolfing, but felt that similar results could
be achieved with less force. Aston-Patterning postulates that no one has a
symmetrical body, that the body is not linear but has curves. Working in a
gym on symmetrical Nautilus equipment, for example, works against the
body’s natural symmetry. So instead of projecting symmetry as the ultimate
goal, Aston-Patterning encourages body parts to cooperate with one another
through a system of education through movement. Aston-Patterning focuses
on three integrated movement systems. An evaluation determines the
restrictions limiting movement options; treatment aims at facilitating
change throughout the body so that movement is freed up; and the
individual performs exercises that loosen patterns of tension. The pace
and sequence of Aston-Patterning sessions depends on the individual’s
need. Aston-Pattering practitioners work with a variety of back and neck
problems particularly in individuals who, like Judith, were told they
couldn’t perform a certain activity again due to injury. The sessions
include both massage and movement work, so the client has immediate
feedback about how to release tension in the body. Price ranges from $75
to $85 a session.

Hellerwork
Hellerwork is based on the work of Joseph Heller, who also originally
trained in Rolfing. He expanded this work to include movement
re-education. Hellerwork uses the same deep-tissue manipulations as
Rolfing, but also includes verbal interactions that focus on the
individual’s personality traits and attitudes toward life. Hellerwork
emphasizes structural balance and movement education. It also incorporates
deep-tissue massage, facial restrictions, postural alignment, and body
awareness. Its goal is to realign the body and release chronic tension and
stress.

Pilates Method
A herniated disk that did not respond to traditional healing modalities
resulted in Mathew’s exploration of alternative possibilities. He had some
success with a healing center, where he was taught to relax his upper
body, to breathe, and to practice visualization. And he felt better, but
not cured. He contemplated laser surgery, but when the surgeon recommended
a more traditional approach, Mathew changed his mind. A pain therapist
helped him manage his pain, and then recommended Pilates.
After a few months with his Pilates trainer, religiously taking classes
three times a week, Mathew’s posture and body mechanics altered radically.
He walked differently, and he says his body is more open. More important,
today, as he continues to practice Pilates, he feels alive and has few
days of back pain.
Introduced in 1923 in New York by Joseph Pilates, the Pilates method is a
resistance control exercise that has long been the best-kept secret of
dancers, singers, and movie stars. Pilates works with muscle resistance in
the way muscles are designed to function, not against their natural
mechanics. The Pilates method utilizes mental and physical training to
teach people how to work from the inside out. Because the method looks at
the body as a whole unit, it also ends up improving posture, breathing,
and releases tension.
Pilates method is different from other bodywork in that it uses
specifically designed apparatus, which create variable resistance through
a set of springs. The apparatus has no relationship to machines in a gym,
though the exercises strengthen supporting muscles in the body. Each
exercise is designed to stretch and strengthen all the muscles and the
joints to release tension.
This holistic method allows each individual to work at his own pace. While
each piece of apparatus permits over a dozen different types of exercise
movements, several work specifically to strengthen the spine and abdominal
muscles. An individual works independently with an instructor, and each
program is designed for each person’s appropriate physical level. Pilates
has become very popular in the last few years. Risk are minimal, with
ignorance of how to use the equipment the only potential problem. Pilates
can be done in a group or in semiprivate or private classes. Depending on
where classes are taken, prices may vary. Typically, a private session can
range from $30 to $55, while a twelve-week session of lessons can run
between $300 and $500.

Tai Chi
Many years ago, I watched an elderly Chinese man perform a cross between a
graceful dance and a martial art. Fascinated with the slow, meditative
movement, I approached the unassuming gentleman, who told me he was
practicing tai chi. I learned that he was an ancient master and taught a
class on Saturday morning in the park. I joined the class and later
studied privately with him. Although I admired the beauty of the
movements, I couldn’t seem to concentrate and found my mind soaring above
the trees. I quit, and through the years, as tai chi’s popularity grew, I
noticed individuals practicing tai chi on the beach or in parks, and hoped
that at another time I might be a more attentive student. Twenty years
later, in another time and place, tai chi reappeared in my life.
Authoring a book is stressful. Sitting at a computer screen or in the
library challenges one’s back, eyesight, and head. Halfway through this
book, I realized I badly needed to balance my stress and confinement at
the computer. I returned to the graceful martial art of my youth and began
tai chi class one night a week. I marveled at how relaxed I felt after the
first few sessions.
One of the oldest martial arts, tai chi is also considered the mother of
the martial arts. Tai chi was designed to make manifest the I Ching, or
Book of Changes. No one knows who wrote the I Ching, but the ancient book
declares that everything in nature houses a yin and yang, two energies
that are found everywhere in the universe. Originally, the book was used
as a meditation tool and to predict the future, but the philosophy was
later developed into movement, or tai chi. Tai chi charges that everything
in nature shows the balance of two energies. Tai chi uses the names of
animals to describe the movements and their relationship to the universe.
A movement like the Crane reflects the yin, or retreating and less
substantial energy, while Carry the Tiger to the Mountain reflects the
yang, or strong, forceful, forward energy.
Both nature and the self, like a life force, consist of both energies. Tai
chi holds that bringing these two energies in to harmony benefits one’s
health both mentally and physically.
Tai chi originated centuries ago in China to improve endurance,
flexibility, and balance. The tai chi practitioner understands that human
beings are constantly changing and always working through inner conflict.
Change is a given in life; tai chi helps you find a balance in that
change. It does so by reducing stress, preserving youth, and enhancing
good health. Tai chi is an internal martial art, internal because it is
based on working inside one’s system, the mind and body. With the mind,
tai chi controls our thoughts: inside the body, it works to control our
energy, or chi. Tai chi is a top-down method. It connects the mind at the
top to the body at the bottom. It works simultaneously on the mind, body,
and chi.
To practice tai chi, you must become aware of your body and how you move.
You cannot practice tai chi without first becoming conscious of your
physical presence. Because most of us use our body incorrectly, tai chi
works with warm-up exercises to acquaint us with how the body should
function in movement. Hip rotation and waist and arm rotations warm the
body. Tai chi rotates all the joints in the body. Chinese medicine
believes that if the energy is static or blocked in the joints, aging
ensues. When the joints open, one feels better, and the aging process is
slowed. Tai chi is a gentle martial art that must be practiced to benefit
from.
This graceful discipline is as reflective as it is vigorous. The effect is
one of relaxation and pleasure. I think of tai chi as the universe in
harmony. As we constantly change and shift, we must learn to balance life,
and tai chi is the guardian of that balance. It is also a good exercise
for the back in that it requires a therapeutic routine in which the mind
and body must move together to maintain that fragile balancing we all
strive for. There is little risk involved with tai chi. Cost varies, but
classes range from $8 to $10, perhaps higher in some cities. Group
sessions may be cheaper, as private may be more expensive. Tai chi can be
practiced anywhere, inside or outside.

Meridian-based Therapies
Traditional Chinese medicine is a unified healing system that has evolved
over the past 3,000 years. It covers acupuncture, herbal therapy, massage,
exercise, and diet. In traditional Chinese medicine, prevention and
treatment of disease is stressed by strengthening the body’s own
self-regulation, thus restoring the body’s balance within.
Chinese medicine postulates that the life energy — chi, or ki — flows
along invisible body pathways called meridians. The chi is the life force
that circulates through the body, and its balance is considered to be the
essence of health. When the chi becomes blocked at specific pressure
points, illness occurs. The following are a few approaches, based on
acupressure/finger pressure, to unclog the energy paths by manipulating
the pressure points, thus balancing the body.

Acupressure
Acupressure, an ancient therapy for tension and pain relief, uses the same
points as acupuncture. The distinction between acupressure and acupuncture
is that needles are used in acupuncture, and a gentle but firm pressure of
the hands is the basis for acupressure. Acupressure is the older of the
two techniques. Acupressurists postulate that the power and sensitivity of
the human hand is most effective in relieving tension related to ailments.
In order to relax muscular tension and balance the vital forces of the
body, acupressure uses a system of points. Acupressure sessions focus not
only on relieving discomfort but on responding to these tensions and
toxicities in the body before they develop into an illness. The practice
of acupressure has developed primarily through a combination of instinct
and hands-on experience. A session runs between $20 and $30 and incurs no
risk.

Shiatsu
This method of finger pressure has been used widely in Japan for over a
thousand years. During the Tokugawa period in Japan, the shogunate
organized a school of massage for the blind in order to give them a
profession. From that time until the Second World War, anma, or Japanese
massage, was practiced primarily by the blind. These blind professionals
were known as anma-san. They walked through the streets blowing
high-pitched bamboo whistles to alert their clients that they were
available to come into their homes to give a shiatsu treatment.
Today the shiatsu practitioner, often a small individual, uses his or her
palms, thumbs, feet, and sometimes knees to apply a rhythmic pressure to
the body. By using finger pressure on the acupuncture points, shiatsu
stimulates the chi to flow through the bones, nerves, arteries, and skin.
Moderate pressure applied all over the body stimulates the flow of energy.
While there may be moments of intense pressure, shiatsu promotes a feeling
of well-being and relaxation. The environment is relaxing and peaceful.
Shiatsu can help your backache by stimulating your life-blood energy to
flow.
While shiatsu applied correctly has little risk, some folks don’t care for
the intense pressure. There can be moments where the pressure borders on
pain, but once released, the pain gives way to relief. Ask your
practitioner to adjust the finger pressure if it is too intense. Shiatsu
may not be as relaxing as a Swedish massage, which uses stroking
movements, but the result is one of rejuvenation and balance. An hour
shiatsu session costs between $50 and $60, and it ends with a cupped
pounding on the back to wake up the energy. Truly, you feel reborn after a
shiatsu massage.

Reflexology
Reflexology is a Western pressure point therapy that focuses on the feet.
It asserts that our feet truly connect us with the earth. Our feet are our
foundation, yet we remain unaware of them. Reflexology holds that points
on the bottom of the feet are linked to specific organs. By massaging
these areas, health is promoted to corresponding organs. Reflexologists
believe that toxic deposits collect in the feet and that reflexology
breaks them up and facilitates other parts of the body.
Since alternative bodywork has been refined to an art over many years, you
may find components of these techniques in back schools around the
country. If your physician directs you toward a conservative approach for
treatment, back school will certainly be included. The following chapter
doesn’t cover the whole curriculum when it comes to back schools in this
country, but it does give a perspective on how back education helps you.
Copyright © 1995 by the RGA Publishing Group, Inc. From The Back Pain
Sourcebook, by arrangement with Lowell House.

Self-Care
This section covers a variety of things you can do for yourself to
increase your health, speed your recovery, ease pain, or aid
rehabilitation. Included are materials on lifestyle and behavior changes,
diet, exercise, body-mind approaches, and similar self-care measures. We
selected these materials because they are accepted by both traditional and
alternative medical establishments and have proven helpful to many people.
These approaches can be adopted or modified to whatever extent you feel
comfortable.
From Our Self-Care Advisor

Backaches
From: Self-Care
A collection of "do's and don'ts" and self-care options for preventing
and treating low back pain. Also provides suggestions for when to see
your healthcare provider when you back is hurting.
Exercise and Fitness

Back-Smart Moves
From: Health Pages
Good advice about exercises you can do to prevent a repeat back attack.
Prevention

Positioning Yourself When You Have Backache
From: Backache: What Exercises Work
This helpful article tells you how to go about everyday activities with
the best posture for your back. It covers everything from making the bed
to washing dishes, child care, and gardening.

Web Links & Support Resources
After reading the previous sections of your report, we encourage you to
take this knowledge and use it as a springboard to enter the research and
support networks out there focused on your health concern. The following
resources may include suggested reading, newsletters and support groups,
research and advocacy organizations, agencies, and government bureaus.
Organizations and Internet Sites

Web Links and Support Resources:
Back Pain
From: WebMD Electronic Library Collection
An annotated list of organizations and websites to go to for more help
and information.




Copyright © 1995 by the RGA Publishing Group, Inc. From The Back Pain
Sourcebook, by arrangement with Lowell House.

Further Reading
Branch, C. L. 1994. Low Back Pain. Kansas City: American Academy of Family
Physicians.
Imrie, D. 1984. Goodbye Back Ache. New York: Fawcet Book Group.
Kerkaldy-Willis, W., and C. Burton, eds. 1992. Managing Low Back Pain. 3rd
ed. New York: Churchill Livingstone.
McKenzie, R. 1993. Treat Your Own Back. 6th ed. Waikanae, New Zealand:
Spinal Publications.
McKenzie, R. 1993. Treat Your Own Neck. 2nd ed. Waikanae, New Zealand:
Spinal Publications.
Macnab, I. 1994. Neck Ache and Shoulder Pain. Baltimore: Williams &
Wilkins.
Oliver, J. 1994. Back-Care: An Illustrated Guide. Boston:
Butterworth-Heineman.
Wei, N. 1995. Low Back Pain: What You Need to Know and What You Can Do
About It. Frederick, MD.: N. Wei.
Wilson, A. 1994. Are You Sitting Comfortably?: A Self-Help Guide for
Sufferers of Back Pain, Neck Strain, Headaches, RSI, and Other Associated
Health Problems. London: Optima.
Online Information Can Be Found At:
http://weber.u.washington.edu/~crc/IASP.html
http://neurosurgery.mgh.harvard.edu/ncpainoa.htm
http://www.relaxtheback.com/
http://pc1.mednwh.unimelb.edu.au/pubs.htm

Recent Literature
Administration of methylprednisolone for 24 or 48 hours or tirilazad
mesylate for 48 hours in the treatment of acute spinal cord injury.
Results of the third national acute spinal cord injury randomized
controlled trial. Journal of the American Medical Association, 5/28/97
Epidural corticosteroid injections for sciatica due to herniated nucleus
pulposus. The New England Journal of Medicine, 6/5/97
Getting to the root of back pain. Johns Hopkins Medical Letter, March 1997
Laser discectomy performs poorly in randomized trial. The Back Letter,
July 1998
Lumbar supports and education for the prevention of low back pain in
industry: A randomized controlled trial. JAMA, 6/10/98
My aching back: A guide to acute low back pain. Harvard Men's Health
Watch. August 1997
New Cochrane collaboration meta-analysis on surgical treatments. The Back
Letter, July 1998
New systematic review of intervention strategies for back pain in
industry. Back Letter, February 1998, Vol 13, No. 2
Should you wear a back belt? Consumer Reports on Health, March 1997
Spinal Surgery for Severe Back Pain. HealthNews. 10/8/97

Well-Connected Board of Editors
Harvey Simon, M.D., Editor-in-Chief
Massachusetts Institute of Technology; Physician, Massachusetts General
Hospital
Masha J. Etkin, M.D., Gynecology
Harvard Medical School; Physician, Massachusetts General Hospital
John E. Godine, M.D., Ph.D., Metabolism
Harvard Medical School; Associate Physician, Massachusetts General
Hospital
Daniel Heller, M.D., Pediatrics
Harvard Medical School; Associate Pediatrician, Massachusetts General
Hospital; Active Staff, Children's Hospital
Irene Kuter, M.D., D. Phil., Oncology
Harvard Medical School; Assistant Physician, Massachusetts General
Hospital
Paul C. Shellito, M.D., Surgery
Harvard Medical School; Associate Visiting Surgeon, Massachusetts General
Hospital
Theodore A. Stern, M.D., Psychiatry
Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation
Service, Massachusetts General Hospital
Carol Peckham, Editorial Director
Cynthia Chevins, Publisher


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