Consumer Reports On Health, May 2000

Back pain: Does anything work? (Unnecessary, ineffective, even harmful 
treatments abound. Here's what may be worth trying - and what to avoid.)


In a recent survey of some 47,000 Consumer Reports readers, back pain 
was the most common physical complaint - and almost at the top of our 
"misery index," a rating of how painful various conditions are. 

Fortunately, bouts of back pain usually get better on their own. 
Unfortunately, they often get better slowly, and there's no proven way 
to substantially speed healing, beyond simple self-help steps. That 
creates temptations for practitioners and pitfalls for patients. In one 
recent study, for example, where doctors talked candidly in focus 
groups, they acknowledged that they sometimes order X-rays or MRI 
(magnetic-resonance imaging) tests of questionable value, mainly to 
reassure back-pain patients that they were trying to do something. 
Meanwhile, the lack of effective medical treatments drives many patients
 to look elsewhere. In the Consumer Reports survey, 54 percent of
readers  who had experienced back pain said they'd tried chiropractic 
manipulation, deep massage, acupuncture, or some other alternative 
therapy. 

Chiropractors and possibly physical and massage therapists may be able 
to treat acute back pain - an isolated incident lasting less than a 
month or so - slightly better than medical doctors can. But the costs, 
at least for chiropractors and physical therapists, are much higher than
 for conventional therapy - in part because of the protracted treatments
 those practitioners often recommend and the X-rays chiropractors often 
order. 

The stakes increase when back pain becomes chronic, lasting longer than 
a month or so. Many people with such pain undergo surgery, which can 
help in many cases. But that help is often limited. And the operation is
 sometimes performed prematurely, when other options might have worked, 
or needlessly, when surgery can't help at all. 

Here are the facts that can help you treat yourself, decide whether and 
when to see a doctor or other practitioner, and protect yourself against
 superfluous or ineffective tests and treatments. 

TOO MUCH TESTING 

Back pain usually stems from a strain, or minor tear, of the muscles and
 ligaments that support the lower back. Sometimes a specific incident - 
for example, bending or twisting in an awkward manner or lifting a heavy
 object - causes the injury. More often, the strains seem to just
happen,  perhaps due to bad posture or even emotional stress. Apart from
strains,  the most common causes of low-back pain are arthritis of the
spinal  joints; spinal stenosis, or bony overgrowths that narrow the
spinal  canal; and a bulging or herniated disk, where one of the spinal 
cushioning pads protrudes beyond the vertebrae. 

Different causes of back pain often produce similar symptoms. To try 
pinpointing the cause, many practitioners order X-rays or MRI tests. But
 in most cases of acute back pain, those tests are needless and possibly
 harmful. 

First, imaging tests seldom do identify what's causing the pain. Muscle 
strains are seldom detected by an MRI and never detected by X-rays. Back
 X-rays can suggest spinal arthritis or stenosis, and an MRI can confirm
 them. But those problems are actually harmless in the vast majority of 
cases; in fact, they're almost as common in people who don't have back 
pain as in those who do. Similarly, an MRI reveals a protruding disk in 
up to 70 percent of asymptomatic people; that's because the protrusion 
causes pain only in the few cases where it actually presses on a spinal 
nerve. 

Even if the cause of acute back pain could be identified, that 
information usually would not influence the proper choice of treatment. 
Regardless of the cause, doctors generally advise the same steps - 
mainly painkillers, icing and heat, and gentle exercise - for acute back
 pain. 

Avoiding needless tests is important. For one thing, back X-rays expose 
you to 20 times more radiation than chest X-rays or mammograms. And 
needless X-rays or MRIs may lead to needless treatment, such as surgery 
to correct a harmless "abnormality." 

Chiropractors often use X-rays to spot "subluxations," supposed spinal 
misalignments that they say influence back pain and many other aspects 
of health. And they often use those results to recommend repeat visits 
after the pain has subsided, to correct the subluxations. But there's 
little if any scientific evidence on whether further treatment after 
recovery from the pain can actually help prevent recurrence - or provide
 any other health benefit. Of course, needless tests also create
needless  costs: typically about $300 for X-rays and $2,000 for an MRI,
although  both are usually covered by insurance. 

In general, you should undergo an X-ray or MRI for acute back pain only 
if you have one or more of the following signs of a potentially serious 
problem: 

- A recent accident, or a history or high risk of osteoporosis. 
(Possible problem: spinal fracture.) 

- Unexplained weight loss, a history of cancer, or incontinence. 
(Possible problem: spinal cancer.) 

- Fever, night sweats, or a recent bacterial infection. (Possible 
problem: spinal infection.) 

- Severe or progressive leg weakness, or pain radiating from the back to
 the lower leg. (Possible problem: a badly protruding disk, or a tumor.)


- Age 70 or over. (That makes cancer, osteoporotic fractures, and 
infection more likely). 

TREATMENT: LIMITED OPTIONS 

The standard treatment for an acute bout of back pain is so 
straightforward that you can usually do it on your own. Take an 
over-the-counter, nonsteroidal anti-inflammatory drug (NSAID) such as 
aspirin or ibuprofen (Advil, Nuprin) to relieve pain and reduce 
inflammation. (If that doesn't help, ask your doctor about prescribing a
 stronger drug. Corticosteroid injections might be worth considering for
 very severe, immobilizing pain, although no clinical trial has tested 
whether they actually work.) Apply a cold pack to reduce pain and 
swelling during the first day or two, then a heating pad, set on low. 
(Deep-heating creams may ease pain temporarily - but never use them with
 a heating pad.) 

Don't rest in bed for more than a day or two, since inactivity tends to 
worsen the problem. Once the worst is over, stretching plus gentle 
aerobic activities like walking, swimming, or bicycling can help. 
Exercises to strengthen the abdomen or back don't seem to speed 
recovery, but they may help prevent recurrence. (See "Exercises to beat 
low-back pain" and "For more information," below, for details on 
exercises for the back.) 

With nothing more than simple self-help steps, some 60 percent of people
 with acute back pain get better within a week, 90 percent within a 
month. (Even the pain of a protruding disk usually resolves on its own 
within six weeks, as the protrusion shrinks.) But many people want 
faster relief than those self-help steps afford. Or they want to avoid 
NSAIDs, which can cause gastrointestinal side effects. The treatments 
that physicians used to offer - traction, corsets, and transcutaneous 
electrical nerve stimulation, (TENS), or application of a mild 
electrical current to the skin over the painful area - have all been 
discredited, leaving doctors with no established options for acute back 
pain other than strong medication and the usual conservative steps. 
(Preliminary research does suggest that a version of TENS called 
percutaneous electrical nerve stimulation (PENS), which delivers the 
electricity through acupuncture needles, may offer some relief.) 

The evidence that acupuncture or relaxation therapy eases back pain is 
generally weak. There's even less support for other alternatives, like 
magnets and supplements such as glucosamine and chondroitin. 

WHAT ABOUT HANDS-ON CARE? 

Not surprisingly, frustrated patients often turn to practitioners who 
can provide direct manual treatment. That usually means chiropractors, 
physical therapists, or massage therapists. 

Chiropractors aim to restore range of motion and ease pain primarily by 
manipulating, or realigning, the spine, often by applying short, 
powerful thrusts. (Some osteopathic physicians - who derive from the 
same tradition as chiropractors but now receive a complete medical 
education - also manipulate the spine.) Massage therapists often treat 
back pain with one of four aggressive methods: deep-tissue massage, 
myofascial release, or rolfing, all designed to stretch the muscles and 
connective tissue by applying steady, even slightly painful pressure; 
and neuromuscular massage, where strong pressure is applied to painful 
knots in the muscles. Physical therapists may combine massage and 
perhaps manipulation with advice on exercise, posture, and body 
mechanics. 

People clearly like such hands-on care. In the Consumer Reports survey, 
the percentages of readers who said that specific treatments made them 
feel much better were 49 percent for chiropractic treatment, 43 percent 
for deep-tissue massage, and 35 percent for physical therapy, compared 
with 25 percent for prescription drugs. 

Many studies of manipulation and the few studies of physical therapy or 
massage have suggested that such treatments may ease acute back pain. 
However, the best studies of chiropractic or physical therapy have 
generally found only slight improvements in pain, mobility, or recovery 
speed. (No rigorous study of massage for back pain has been published.) 

In the largest of the well-designed studies, published recently in The 
New England Journal of Medicine, researchers randomly assigned some 320 
people either to visit a chiropractor or physical therapist or to 
receive a booklet containing the standard advice. Those treated with 
manipulation or physical therapy showed only marginally less pain and 
restricted motion than those who merely received the advice. 

Moreover, the rate of recurrent back pain over the next two years was 
the same in both groups, a finding confirmed by other research. For 
example, a recent two-year study from the University of North Carolina, 
involving more than 900 people with acute back pain, found that slightly
 over half of the patients experienced a relapse, whether they initially
 saw a chiropractor or a medical doctor. 

In addition, the study in The New England Journal of Medicine found that
 chiropractic care and physical therapy each typically cost about three 
times as much as standard therapy, mainly because those treatments 
require more visits to a practitioner. With chiropractors, some of that 
higher cost comes from the X-rays. A recent survey conducted by the 
American Chiropractic Association found that 69 percent of its members 
routinely use X-rays before treating back pain; in contrast, only about 
20 percent of primary-care doctors follow that practice. 

Jerome F. McAndrew, former president of the American Chiropractic 
Association, says the X-rays serve mainly to rule out any condition, 
such as a tumor or fracture, that might make manipulation dangerous. But
 complications of spinal manipulation are extremely rare, so it's
unclear  whether complications or the X-rays themselves pose the bigger
threat. 

SURGERY FOR CHRONIC BACK PAIN? 

If the pain doesn't clear up in a month or so, the pain may be becoming 
chronic, and X-rays and possibly MRIs are now necessary, mainly to rule 
out a tumor or other underlying disease. If there's no such disease, 
most people with chronic back pain should try exercise first. In fact, a
 targeted exercise regimen could save many people from undergoing 
surgery. 

In one recent study, Minnesota researchers recruited 60 
chronic-back-pain patients who'd been told to have surgery to treat 
either a protruding disk or spinal stenosis. Instead, the researchers 
asked them to undergo a ten-week back-strengthening program. Sixteen 
months later, 35 of the 46 patients who completed the program were still
 getting along without surgery. (To develop an exercise program for 
yourself, see "Exercises to beat low-back pain" and "For more 
information" - or see a physical therapist.) 

If exercise doesn't help, spinal manipulation or massage therapy might 
be worth considering - despite the fact that the evidence that they work
 is weaker for chronic back pain than for acute pain. 

There are several reasons to try the nonsurgical options first. For one 
thing, while back surgery relieves chronic pain caused by herniation or 
stenosis in 85 to 90 percent of appropriate cases, that benefit is 
sometimes temporary. By the end of one four-year clinical study 
involving some 126 people with painful herniation, those who simply 
waited were experiencing no more pain, on average, than those who 
underwent surgery - partly because the pain sometimes recurred after the
 operation and partly because it sometimes eased in those who avoided 
surgery. And there's even less known about the long-term efficacy of 
surgery for spinal stenosis than there is for disk surgery. 

Even when nonsurgical treatments fail, surgery should be done only when 
the problem seen on MRI clearly conforms to the patient's symptoms. For 
a protruding disk, the confirming symptom is clear-cut sciatica - pain, 
usually with numbness and tingling, that radiates from the lower back, 
through one buttock, to below the knee. For stenosis, the key symptoms 
are back pain plus thigh pain and weakness, usually in both legs, that's
 worse when you walk, particularly downhill. 

Disk surgery usually entails a one-day stay in the hospital, six weeks 
of recovery, and some risks, including a very small chance of death, 
mainly from the general anesthesia. (Laparoscopic diskectomy, in which 
the surgeon works through several small incisions, may speed recovery 
slightly. But it still requires general anesthesia, its effectiveness 
beyond one year is unknown, and it can't be used for severe or 
hard-to-reach protrusion. Studies have found another alternative, laser 
disk surgery, to be less effective than the standard operation.) Surgery
 for stenosis generally involves a longer stay, lengthier recovery, and 
greater risks than the disk operation, since stenosis surgery is usually
 more extensive and the patients are older and frailer. 

SUMMING UP 

The following guidelines can help you get the optimal treatment for your
 back. For acute pain: 

- You can generally treat yourself, with nonprescription painkillers, 
icing, heat, and, as soon as possible, gentle exercise. Doctors can do 
very little to speed that process, and you'll almost always get better 
on your own in one to four weeks. 

- Avoid X-rays and MRIs unless you have clear signs of a potentially 
serious problem (listed above) other than a protruding disk or spinal 
stenosis. 

- You could consider seeing a chiropractor, an osteopath, a physical 
therapist, or a massage therapist. But see a physician first to rule out
 potentially serious problems and possibly to provide a referral. 
Moreover, be aware that the benefits of hands-on treatment are generally
 small, that chiropractors are more likely than other practitioners to 
order X-rays, and that such therapies can be expensive and are only 
sometimes covered by insurance. 

For chronic pain, lasting more than a month: 

- Be sure to undergo imaging tests. 

- In general, consider surgery only if strengthening and stretching 
exercises (and possibly manual therapy) have failed, imaging tests 
reveal a protruding disk or stenosis, and the symptoms described in this
 report show that the problem seen on the tests is clearly causing the 
pain. But bear in mind that the benefits of surgery may not last. 

FOR MORE INFORMATION 

- "The Back Pain Helpbook," by James E. Moore, Ph.D., and others. 
Exercises for back pain plus general information on the condition. 
Perseus Books, 1999. $15. To order, call 800-386-5656. 

EXERCISES TO BEAT LOW-BACK PAIN 

In the 19th and early 20th centuries, low-back pain was commonly treated
 with exercise. Now researchers are reviving that neglected approach. 
Studies in the past several years suggest that strengthening exercises 
may help ease chronic back pain and prevent painful episodes as well. 
Other research suggests that stretching exercises and aerobic activities
 that don't jar the back - such as walking, swimming, and biking - may 
also help relieve acute or chronic back pain and prevent recurrence, 
too. The guidelines listed here can help most people who have back pain.
 However, see a physical therapist if you want more detailed advice, if 
exercising on your own doesn't help, or if you have symptoms of spinal 
stenosis. 

Begin stretching and low-impact aerobic exercises as soon as the pain 
permits. (But stop if it becomes markedly worse during or after the 
exercise.) Gradually work up to at least 30 minutes a day of gentle 
aerobics. Doing the two stretches described below once or twice a day is
 enough to start with, but you should add others to your routine,
ideally  until you're stretching for at least 10 to 15 minutes a day -
though  even the minimum will probably help prevent recurrence. You
could also  gradually increase the duration or intensity of your
low-impact aerobic  workouts. 

Strengthening exercises during the first month or so don't seem to speed
 recovery, and they may cause discomfort. But if the pain lasts longer, 
it's worth trying to work through the discomfort, provided the pain 
doesn't worsen. 

Fortunately, it doesn't take much exercise to substantially strengthen 
the back. For the average person, all that's required is one set a week 
of the floor extensions described here; doing them twice a week can 
maximize the gains. Once the pain subsides somewhat, adding the modified
 sit-ups to your weekly routine can add further support by strengthening
 the abdominal muscles. Performing 8 to 12 repetitions of those
exercises  if you're under age 50 or so is the best way to build
strength and  endurance. If you're older than that or it's too
uncomfortable, do 10 to  15 repetitions of a somewhat easier version of
the exercise. To keep  building strength once you've hit 12 or 15 reps,
increase the difficulty  as described below. 

- Strengthening: Floor extensions. Lie face down on the floor with your 
hands folded under your chin. Using your low-back muscles only, raise 
your chest and shoulders about 10 degrees off the floor, then lower 
them. If you can't do that, push down on the floor with your hands to 
help raise yourself. As you get stronger, gradually build up until you 
can hold your body about 30 degrees off the floor. To increase the 
difficulty further, wear a weighted backpack. 

- Strengthening: Partial sit-ups. Lie on your back, with knees bent and 
palms face down at your sides. Slowly lift your shoulders and upper back
 off the floor. Hold for a count of three, and slowly drop them back 
down. To increase the difficulty, perform the maneuver more slowly, hold
 a light weight on your chest, place your hands loosely behind your
head,  or do the sit-ups on an incline, with your feet higher than your
head. 

- Stretching: Leg pull. Lie on your back, with one knee bent and the 
other leg flat on the floor. Keeping the small of your back pressed 
against the floor, flex both feet toward your head and grip the bent leg
 just behind the knee; gently pull it toward your chest until you feel 
the stretch in your buttocks and lower back. Hold for 10 seconds, then 
repeat with the other leg. When you can do that easily and without pain,
 repeat with both legs, rolling your shoulders forward, tucking your
chin  to your chest, and lifting your upper body a few inches off the
floor. 

- Stretching: Hip rolls. Lie on your back with your knees bent, feet 
flat on the floor, arms straight out to each side, and head turned to 
the left. Now bring your knees toward your chest and, keeping them bent 
at a 90-degree angle, slowly let them fall to the right until your right
 leg rests on the floor. Relax and hold that position for 10 seconds. 
Then bring your legs back toward your chest and repeat the maneuver in 
the opposite direction.

16 responses total.

A few years ago, I had a minor back problem. It was chronic as I had 
this pain constantly for a few months. It was a very minor pain though 
and didnt impair my functioning at all. I am pretty sure it was related 
to my posture as it started right after I started working at a computer 
all day. I went to a massage therapist for short sessions (20 mins) once 
a week for about 2 months. It really helped. The pain went away after 
only 3 weeks! Then I got a new chair at work and the pain hasnt come 
back. 

Anyhow, even if the massage hadnt helped my back pain, it still would 
have been worth the money as it was very enjoyable in its own right. 
Hey, it feels good. :) 

Percodan, but don't bother asking your health provider for narcotics.

My back was really sore for a few days midweek (I have spondololisthesis) 
so I went and played some racquetball and it's been fine ever since.

Er, oops.  The correct spelling is: spondylolisthesis.

The condition was precipitated by damage to the cartilege which 
previously held my 5th lumbar in place.

(?)

(how did playing racquetball help, if I may ask?)

Sometimes if you work the muscles of your back (depending on what is going
on with your back) you can help alleviate pain and help with fixing the
problem.  Most of the time, if I have a back ache, it means I need to
excercise more... then I do yoga.

That is essentially it.  I got some exercise, and the back pain went 
away.

I've found that laying on my stomache, and lifting each arm for about 20 reps,
and then switching to each leg.  It really helps. especially after I get done
with my situps...loosens the muscls up.

Well, I'm on some fun narcotics, but I'm trying to not take them too much.
Ruins the fun, eh?

I have a herniated disk, to the left side, in L5/S1 (the region of the lower
back just above your pelvis)  It was impacting the nerve bundle so that it
was causing raidiating pain that progressed into numb/sleeply feeling from
the left side of my leg and foot to the entire thing, hamstring pain, and
charliehorses that little would help.  Short of drugging me out that is.  

I have an appt with my doc tomorrow to see if I should go to neurosurgery
since I am still having neuro problems, including I have no reflex in my left
ankle.  I might not need surgery Pprays prays} but it wiould be nice to have
the consult anyway.  I have a person coming out and she's a visiting nurse,
and she's cool.  so now I'm to do a couple of times a day "extendor
excersizes
  --lying on the bed, on my tummy, and pull on the edge of the bed relaxing
back muscles to strech the spine.
  --lying on bed, on tummy, pull up on elbows as far as possible without pain,
and then hold to strech out spine
  --lie on back, with resistance band, and pull arms to sides from in front,
so that muscles in back and stomach contract to pull down to help straighten
back.

However, even doing these, I'm still confined to bedrest and drugs, and I hurt
like hell.  it's better, but it's been 6 frickin weeks.

how do you 'grex'?

From the resident proofreader:  cartilage, stomach, radiating, extender,
exercises are the correct spellings.  Not sure about frickin.

Apparently I've gotten lax.  It seems Keesan's trying to elbow in on my
territory.  

I think "frickin" is about as correct as it's going to get, though.  An
apostrophe might help, but I doubt it.

re10  HAW!!!

RE: 10, I grex when I'm lucid at odd hours to talk to my deaf friend since
we can't talk on the phone, I calk to her on ICQ while I do my cf-ing, and
then back to bed.  but I'm supposed to sit in a chair for a while now, with
a pillow behind my back sitting up straight, so I can grex for a little while.

Thanks keesan.  normally I can spell, but I'm kinda out of it.  And while I'm
out of it...frickin seemed a little bit more umm...<thinks of the word> polite
;)

Botox could help back pain

May 22, 2001 Posted: 2:47 PM EDT (1847 GMT)

(CNN) -- A drug derived from a type of bacteria that causes food 
poisoning may provide relief for those who suffer chronic low back-
pain, according to a new study.

Researchers at the Walter Reed Army Medical Center found that people 
who received injections of botulinum toxin A, or Botox, experienced a 
reduction in back pain for as long as three to four months. 

But they noted that "this conclusion should be considered cautiously, 
due to the small number of patients studied" -- just 15 men and 16 
women. Details of the study appear in Tuesday's issue of Neurology, the 
scientific journal of the American Academy of Neurology. 

According to the study, nearly 90 percent of adults experience back 
pain during some time in their lives, and chronic low back pain costs 
the American economy about $50 billion each year. 

Michael Ramina, one of the study participants, began experiencing back 
pain after a parachuting accident 20 years ago. 

"Something as simple as putting a grocery bag in a car, my legs would 
just stop working," Ramina said. "I'd find myself on the parking lot… 
just numb." 

All the people who took part in the research had experienced lower back 
pain for an average of six years, and all of them were taking various 
medications to relieve the pain, inflammation and muscle spasms 
associated with their condition. They stayed on the medication 
throughout the experiment. Fifteen patients received botulinum toxin A, 
or Botox, injections, and 16 received a placebo of saline solution. 
After three weeks, 11 of the 15 Botox patients said their pain 
diminished by at least half. Four of the 16 who received saline said 
their pain had been reduced by at least 50 percent. 

After two months, nine of the 15 Botox recipients said their pain had 
been reduced by more than 50 percent. Only two patients on the saline 
solution reported a similar reduction. 

The Botox treatment appeared to be safe. While two patients on saline 
said their pain got worse, none of Botox patients reported a worsening 
of pain or any negative side effects, although flu-like symptoms can 
occur. 

The relief wasn't permanent, however; Botox patients needed another 
injection after three to four months. Lead study author Dr. Bahman 
Jabbari said more studies are needed to determine if the relief 
continues after repeated injections. 

"That has been the case for patients who receive botulinum toxin 
injections for other disorders, such as the muscle disorders dystonia 
and spasticity," he said, "so hopefully, that will be true for people 
with low back pain as well." 

Botox is typically used to treat muscle spasms and migraines, and to 
reduce the appearance of facial wrinkles. 

Ramina said he felt better within a week of getting his Botox 
injection. 

"Has it fixed it completely? No. I know it everyday. But do I have 
episodes where my legs just stop working because of the shooting pains? 
No. That's stopped." 

Doctors said there are several reasons patients might have experienced 
less pain after receiving the injections. The drug may have reduced 
patients' muscle spasms or reduced sensory input to the spinal cord. 

CNN Medical Correspondent Rea Blakey contributed to this report. 

flexibility excercises, muscle strengthening and proper posture
in all activities (expecially those that last more than an hour)
*will* keep any deterioration from getting worse ,.... if you catch
it in time. 
  
that does presume, by the way, minimal actual *damage* to the
assorted parts.

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