of Back Pain
What Are Low Back Pain and Sciatica?
The spine is a column of small bones, or vertebrae, that supports
entire upper body. The column is grouped into three sections: the
vertebrae are the five spinal bones that support the neck; the thoracic
vertebrae are the twelve spinal bones that connect to the rib cage;
the lumbar vertebrae are the five lowest and largest bones of the
column. Most of the body's weight and stress falls on the lumbar
vertebrae. Below the lumbar region is the sacrum, a shield-shaped
structure that connects with the pelvis at the sacroiliac joints.
end of the sacrum are two to four tiny partially fused vertebrae
the coccus or "tail bone".
Vertebrae in the spinal column are separated from each other by
cushions of cartilage known as intervertebral discs. Inside each
disc is a
jelly-like substance called the nucleus pulposus, which is surrounded
fibrous structure. The disc is 80% water, which makes it very elastic.
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
processes. The spinal and transverse processes attach to the muscles
the back and act like little levers, allowing the spine to twist
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
spinal canal, which encloses the spinal cord * the central trunk
that connects the brain with the rest of the body. Each nerve root
from the spinal column to other parts of the body through small
bounded on one side by the disc and the other by the facets. When
spinal cord reaches the lumbar region, it splits into four bundled
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
caused by serious medical conditions. Most cases clear up in a few
without medical attention, although recurrence after a first attack
common. If the pain persists beyond six months, it is considered
low back pain; this constitutes only 1% to 5% of all low back pain
Back pain may be triggered by various problems that occur along
of bone and disc. Injuries and small fractures can occur. Muscle
can cause pain. Pressure on a weakened disc may cause it to rupture
nucleus pulposus protrudes out from the spinal column, a condition
as a herniated disc. The facets can become misaligned or deteriorate.
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
usually the pain known as sciatica.
The nerve most likely to cause trouble is the sciatic nerve; at
up to 40% of people experience pain caused by compression of this
which branches from the nerve roots that descend off the spinal
the lumbar and sacral areas. Each of the two branches of the sciatic
is about as wide as a thumb and threads through the pelvis and deep
the buttocks, then down the hip and along the back of the thigh
foot. Sciatica usually occurs on one side when a sciatic nerve has
stretched or pinched, usually by a herniated disc, although spinal
stenosis or other vertebral abnormalities can also cause this pain.
sensation of sciatica can vary widely * from a mild tingling to
severe enough to cause immobility. Some people experience sharp
one part of the leg or hip and numbness in other parts. The pain
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
What Causes Low Back Pain or Sciatica?
The causes of 85% of back pain cases are unknown. Most often, pain
with an injury, after lifting a heavy object, or after making an
movement. A number of conditions may make people more susceptible
A herniated disc, sometimes * but incorrectly * called a slipped
the most common cause of severe sciatica. A disc in the lumbar area
becomes herniated when it ruptures or when the gelatin within the
protrudes outward. If the material breaks off or extends far enough
press against the nerve root, sciatic pain can occur. Studies are
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
that bulging, or even protruding, discs may be normal and do not
necessarily indicate serious back problems. One expert suggested
discs might even swell in response to stress and then contract again.
However, disc material that extrudes (that is, it balloons into
outside the vertebrae or breaks off from the disc) most likely is
of pain. Sciatic pain is also sometimes present when there is no
or extruding of the discs. Some cases of chronic low back pain may
caused by inward growth of nerve fibers into intervertebral discs.
evidence also exists that nerves in the outer ring of the disc may
source of pain.
Spinal stenosis, the narrowing of the spinal canal, is usually caused
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
in both legs.
Spondylolisthesis, another cause of sciatica, is a condition in
vertebra has slipped forward over the other.
Osteoporosis is a disease of the skeleton in which the amount of
present in the bones slowly decreases to the point where the bones
fragile and prone to fracture. Spinal fractures can occur simply
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 occurs in joints where cartilage is damaged and then
destroyed; in reaction to this destruction, the bones associated
joints develop abnormalities. (Rheumatoid arthritis, which is an
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
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
Ankylosing spondylitis is a chronic inflammation of the spine that
gradually result in a fusion of the spine causing the patient to
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
the morning; pain improves with exercise. It occurs mostly in young
Caucasians in their mid-twenties. The disease is more common in
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
ankylosing spondylitis. Researchers believe that it is probably
Hereditary problems that can affect the back at any age are enteropathic
arthropathy and reactive arthropathy.
Sciatica can also be caused by other problems, including inflammation,
abscesses, blood clots, and tumors. Some experts believe that one
sciatica is the piriformis syndrome * entrapment of the sciatic
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
include ulcers, kidney disease, and blocked arteries. Chronic uterine
pelvic infections can cause low back pain in women.
Arthritic back pain may also be caused by infections that include
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
the supply of blood. When it blocks arteries in the legs it may
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
cause pain in the sacrum and hip joints of children and young people;
used to be grouped under juvenile rheumatoid arthritis but is now
as a separate problem. In young athletes, back pain is most likely
caused by stress fractures in the spine (spondylolytis) or because
inborn exaggerated inward curve in the lumbar area (hyperlordosis).
(Scoliosis, an abnormal curvature of the spine in children, does
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.
1994, 10.2 million adults reported back pain and the incidence appears
be increasing. Just getting older is a major risk factor for back
Sedentary Life Style
People who do not exercise regularly face an increased risk for
pain, especially during times when they embark on stressful unaccustomed
activity, such as shoveling, digging, or moving heavy items. Although
definitive studies have been done to prove the relationship between
of exercise and low back pain, sedentary living is probably the
non-medical culprit contributing to this condition. Experts offer
theoretical evidence for this connection the many proven damaging
of sedentary life on other parts of the body. Obesity, associated
lack of exercise, puts more weight on the spine and may increase
on the vertebrae and discs. Lack of exercise results in muscle
inflexibility, which restricts the body's ability to move, rotate,
bend. Weak stomach muscles increase the strain on the back and can
an abnormal tilt of the pelvis, and weak back muscles increase the
the spine and the risk for disc compression.
Athletes are also prone to back injuries. Improper exercise instruction
and inattention to mechanics can be sources of sudden trouble; a
jerky golf swing or incorrect use of exercise equipment, especially
weights, nautilus and rowing machines, can cause serious back injuries.
Over time, intense high-impact exercise may increase the risk for
degenerative disc disease.
Jobs that involve lifting and forceful movements, bending and twisting
into awkward positions, and whole-body vibration (usually caused
long-distance truck driving) place workers at risk for low back
longer a person is on the job, the higher the risk. In one study,
of 100 warehouse workers reported back injuries in one year, and
major food service organizations 30% of all injuries involved the
major study of work-related injuries reported that, in 1994, there
nearly 330,000 cases of back injury due to overexertion in handling
Other Risk Factors
Smokers are at higher risk for back problems, perhaps because smoking
decreases blood circulation, but the association may also be due
unhealthy lifestyle in general. Pregnant women are prone to back
to a shifting of abdominal organs, the forward redistribution of
weight, and the loosening of ligaments in the pelvic area as the
prepares for delivery. Tall people are at higher risk than short
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,
area, or thigh and an inability to control urination or defecation.
accompanied by fever can indicate an infection. Pain that lasts
month, unexplained fever or weight loss, and a history of cancer
indicate a tumor. Other conditions warranting rapid attention are
severe pain * particularly if it awakens the person at night or
increased by lying down * and any neck or back pain in children.
Recurrence is common after a first episode of back pain. In one
over a one-year period following treatment only 21% of patients
back pain; over four years, less than half were symptom-free. Researchers
attempted to identify factors most likely to predict an elevated
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%
workers compensation cases it accounted for 86% of compensation
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,
months, 91% return to work. Another study found that if someone
disability for a year or longer, there is only a 25% chance that
patient will return. The severity of back pain and its impact on
not always depend on the degree of physical injury. In many cases,
prolonged absenteeism from work because of back pain may be due
psychological and social factors. For example, in one study 50%
drivers reported low back pain, but only 24% lost time at work;
drivers had a significantly higher absentee rate because of back
truck drivers, in spite of less stress on their backs. Every one
truck drivers said they liked their work and 92% of them even liked
bosses while bus drivers reported much lower job satisfaction. Similarly,
another study found that pilots (who generally reported "loving"
jobs) reported far fewer back problems than their flight crews.
How Is Low Back Pain or Sciatica Diagnosed?
Because back pain can have so many different causes, it is very
to first rule out any other medical conditions. A complete medical
family history should be taken that includes heart problems, cancer,
arthritis, and any other serious conditions. The patient should
previous episodes of back pain as well as any history of injuries
accidents involving the neck, back, or hips. The physician will
ask about frequency, duration, and the nature of the pain, e.g.,
it is dull, piercing, throbbing, or burning. The patient should
its onset and whether the pain was triggered by an event, such as
a heavy object. The physician will need to know what worsens the
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
defecation, and weakness or numbness in the legs.
Patients are asked to sit, stand, and walk in different ways *
flat-footed, on the toes, and on their heels. They will be requested
bend forward, backward, and sideways, to twist, and to lift their
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
reflexes, physicians will tap the knees and ankles with a rubber
The circumference of the calves and thighs may be measured to look
muscle deterioration. The physician may touch parts of the body
with a pin, cotton swab, or feather to test for numbness and nerve
Imaging techniques that include x-rays, magnetic resonance imaging
scans, ultrasound, and computerized tomography (CT) scans have fallen
of favor for routine use. People with low back pain should have
scans done only under certain circumstances, such as pain that lasts
than a month, very severe pain, numbness, muscle weakness, accidents
might involve the vertebrae, a history of cancer or smoking, or
presence of fever. If these conditions exist, usually an x-ray is
first, and then, if results are inconclusive, either a CT or MRI
(Ultrasound is not useful.)
A myelogram is an x-ray of the spine which requires a spinal injection
the need to lie still for several hours to avoid a very painful
It has largely been replaced by CT and MRI scans.
A discography uses an x-ray of the disc and employs injections into
suspected of being the source of pain and discs nearby. It can be
painful than a myelogram and is generally used for patients who
undergoing back surgery to identify the location of the injured
experts believe that discography is not at all useful in identifying
source of pain, because it requires expert execution and analysis
degree of accuracy. Others argue that it is the only procedure that
reveal the shape of the disc and identify nerve structures in the
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
often not accurate in identifying disc abnormalities. Many experts
that their routine use for back pain has led to an increase in the
of back operations, some of which have been unnecessary and even
dangerous. Studies indicate that at least 40% of all adults have
or protruding vertebrae discs, even if they have no back pain at
that abnormalities in people who do have back pain may simply be
coincidence rather than an indication for treatment. Spinal abnormalities
identified by MRIs also are not accurate in predicting long-term
And, on the other hand, studies reported that 6% to 23% of patients
show damaged discs during surgery have normal MRIs. One study reported
that only a three-dimensional CT scan * not a normal CT scan * was
show bone injuries in over half of a group of people with back pain.
refinements and others, such as MRI modifications to detect weak
from soft tissue, may soon make diagnosis more accurate. An MRI
for detecting nonspinal causes of back pain, including infection
Blood and urine samples may be used to test for infections, arthritis,
other conditions. Injecting a drug that blocks pain into the nerves
back helps locate the level in the spine where problems occur. A
called a facet block is also useful in locating areas of specific
Provocative discometry is a test that uses an injection of saline
into the suspected disc to reproduce the pain, which is then followed
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
treated as part of the overall therapeutic plan. Treatment for back
is available from a variety of health care practitioners; a recent
of patients treated by primary care practitioners, chiropractors,
orthopedic surgeons reports similar recovery rates. When low back
not caused by a medical condition, about 90% of people recover within
month without any treatment at all. In spite of this encouraging
statistic, back pain is the third most common reason for surgery
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
resulted in some new guidelines set by the Agency for Health Care
and Research recommending very moderate treatment options for most
of low back pain. It should be noted that for certain patients with
sciatica and spinal stenosis, surgery may be the most effective
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
the stress on the back. Many people find that alternating ice packs
heating pads at about twenty-minute intervals is helpful in relieving
pain. Ice packs should be applied first. Supportive back belts,
corsets may help some people temporarily, but they can reduce muscle
over time and should be used only briefly.
Most experts recommend staying in bed no longer than a couple of
study reported, however, that people who avoided bed rest altogether
simply tried to resume normal activities, without strain or stretching
exercises, recovered more quickly than those who were in bed for
short a period as two days. People who stay in bed a week or longer
even worse. Long-term bed rest results in loss of muscle tone and
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
physicians feel that healthy sleep patterns play a vital role in
from back pain. It is often difficult to get a good night's sleep
suffering from back pain, particularly because the pain can intensify
night. Lying curled up in a fetal position with the pillow between
knees or lying on the back with pillow under the knees may help.
promote sleep, avoid caffeine in the afternoon and evening, take
bath before bedtime, and practice relaxation techniques. It may
necessary to take medication to help manage nighttime pain or treat
Resuming Normal Activity Levels and Exercise
At the other extreme, exercising to treat acute back pain may be
unhelpful. In one study, recovery from acute back pain was slower
patients who exercised to improve flexibility than for those who
resumed normal activity, simply letting pain be the guide for how
movement they achieved. In general, normal activity should be resumed
gradual fashion as soon as the patient feels ready, reserving therapeutic
exercises until after the acute pain has resolved. An incremental
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
symptoms, but patients should never force themselves to exercise
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
however, to fully recover from back pain, particularly if it is
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.
study, for example, patients with back pain lasting for an average
months were assigned 8 one-hour exercise sessions over four weeks.
showed greater improvement in nearly every area, including reduced
and increased capacity, compared to patients who did not exercise.
more on exercise, see How Is Low Back Pain or Sciatica Prevented?,
NSAIDs and Acetaminophen
The most common pain-relievers are the nonsteroidal anti-inflammatory
drugs (NSAIDs). These drugs block prostaglandins, the substances
dilate blood vessels and cause inflammation and pain. There are
NSAIDs. Some of the most common are aspirin, ibuprofen, naproxen,
ketoprofen, but many others are now available (see below). Taking
with food can reduce stomach discomfort, although it may slow down
pain-relieving effect. All NSAIDs are capable of damaging the mucous
and causing ulcers and gastrointestinal (GI) bleeding when taken
periods. The elderly are at special risk for ulcers; younger nonsmoking
adults are at lower risk. Bleeding and ulcers can occur at any time,
or without symptoms. The risk for bleeding is constant as long as
patient is on these drugs and may even persist for about a year
taking them. No NSAIDs should be used for long-term pain relief
under a physician's direction. Ibuprofen has a lower risk than naproxen
and ketoprofen for GI bleeding. Aspirin has a risk similar to that
ibuprofen. Buffered aspirin (aspirin coated with an antacid) is
protective against ulcers. Other side effects include dizziness,
in the ear, headache, skin rash, and possibly depression. Kidney
has been reported in people taking NSAIDs, which resolves when the
are withdrawn. (Aspirin has little or no risk for this side effect.)
People with high blood pressure, severe circulation disorders, kidney
liver problems, and those taking diuretics or oral hypoglycemics
closely monitored if they need to take long-term NSAIDs. Because
reduce the clotting of the blood, anyone undergoing surgery should
taking the medication a week before the operation. Taking NSAIDs
fusion procedures may reduce the chances for success; more research
needed on this potential problem.
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,
enzyme that generates stomach-protective prostaglandins and which
NSAIDs block. Such drugs may allow high doses without the accompanying
gastrointestinal side effects.
Acetaminophen (Tylenol, Anacin-3, Panadal, Phenaphen, Valadol, and
brands) is the most common alternative to NSAIDs, although many
report less pain relief with acetaminophen than with an NSAID. It
an anti-inflammatory agent. Acetaminophen can be used alone or in
combination with NSAIDs with some success. Liver and kidney damage
potential serious side effects of acetaminophen. Alcohol use increases
risk for liver damage. Experts recommend taking no more than 8
extra-strength tablets each day.
A one-time injection of a corticosteroid into the area around the
column is sometimes administered to short-cut sciatic pain until
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.
Unless the pain is very severe, experts advise against routinely
prescribing pain killers containing opioids, such as morphine and
meperidine (Demerol), or oxycodone-release (Oxycontin), which they
do more harm than good. Injections of local anesthetics are occasionally
used and can be helpful for temporary relief of severe pain. A skin
containing an opioid called transdermal tentanyl (Duragesic) may
chronic back pain more effectively than oral opioids. Side effects
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.
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
damaged disc or vertebrae.
Spinal Manipulation and Chiropractic
Transcutaneous Electric Nerve Stimulation
Transcutaneous electric nerve stimulation (TENS) uses low-level
pulses to suppress back pain and can be particularly helpful for
with spinal stenosis. (It is not helpful for relief of sciatica.)
standard approach is to give 80 to 100 pulses per second for 45
three times a day; patients are barely aware of the sensation. Some
studies have not found this treatment to be any more beneficial
conservative therapy, although one study reported that patients,
pain was not relieved by surgery, experienced relief when they were
long-term stimulation (about 13 years). It appears to be more beneficial
for men than women.
One study reported that a course of cognitive-behavioral therapy
reduce chronic back pain and enhanced the patients' ability to deal
it. The primary goal of cognitive therapy in such cases is to change
distorted perceptions that patients have of themselves and their
to pain. Using specific tasks and self-observation, patients gradually
shift their fixed ideas that they are helpless against the pain
dominates their lives to the perception that pain is only one negative
and, to a degree, a manageable experience among many positive ones.
study, therapists also taught relaxation techniques and methods
posture. The sessions were two and a half hours each week for 12
More research is needed.
Acupuncture, which involves inserting small pins or exerting pressure
certain points in the body, has relieved pain in some people. One
well-conducted study found significant benefits from acupuncture
chronic low back pain, although another reported few benefits for
sciatica. Stress management and biofeedback techniques may also
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
spinal stenosis. Surgical treatments for low back pain rose from
in 1983 to 335,000 in 1994. It is important to note, however, that
few rigorous studies have been conducted on back operations, and
of those procedures were necessary. One study reported that 71%
who had surgery for sciatica experienced pain relief compared to
did not have surgery. For those with spinal stenosis, 55% of surgical
patients reported pain relief compared with 28% who chose not to
surgery. The best spinal stenosis candidates are those with a condition
known as block spinal stenosis. Surgery does not always improve
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
sciatica and spinal stenosis. Pain should be present for at least
weeks and be so debilitating that it interferes with normal functioning.
Emergency surgery may be needed for sciatic pain if it is accompanied
incontinence, which indicates that the bundle of nerves at the end
spinal cord known as the cauda equina are being pinched. In such
operation should be performed as soon as possible to avoid permanent
damage. Other indications include a progressive weakening in the
evidence of some physical abnormality of the spine, such as a bone
spinal stenosis due to bone growth. A patient should be sure that
surgeon has had significant experience with any procedure to be
Discectomy is the surgical removal of the diseased disc, thereby
pressure on the disc. In spite of the fact that the procedure has
done for 40 years, few studies have been conducted to determine
effectiveness. Scar tissue may develop after discectomy, which,
cases, can cause continued pain. A variation called percutaneous
discectomy (PAD) uses endoscopy (the use of a catheter * thin tube
employs tiny cameras and surgical instruments.) The tube has a device
the tip that cuts away some of the nucleus pulposus and a vacuum
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
matter that has gone beyond the disc and entered the spinal canal.
then, is not usually warranted for herniated discs, a primary cause
sciatica. Some experts argue that the procedure is rarely useful
patients often need repeat operations. A variation called percutaneous
automated discectomy uses a motorized probe that cuts off bits of
material, but it does not appear to offer additional benefits. Other
endoscopic procedures are also under investigation. Lasers have
investigated for use with discectomy, but results to date are
Laminectomy or Laminotomy
Operations that shave off part of a vertebra (laminotomy) or remove
it (laminectomy) may be used in spinal stenosis or spondylolisthesis
decompress the nerve or they may be used to remove benign tumors
spine. One study reported that the operation in children and young
can increase the risk for spinal deformity. Laminectomy requires
anesthesia and a two or three day hospital stay. Recuperation takes
six weeks. Although it often brings immediate relief from pain,
small risks to the operation and it is not always successful. Some
recurrence of back pain and sciatica occurs in half to two-thirds
In cases where abnormal positioning or vertebrae movement puts pressure
the nerves, such as spinal stenosis or spondylolisthesis, surgeons
fuse vertebrae together. (It is not clear, however, whether fusion
more effective for stenosis or spondylolisthesis than procedures
reducing disk pressure.) Fusion employs a bone graft or some other
to join the vertebrae together. One medical device called the BAK
Interbody Fusion System uses a tiny hollow metal cage, which is
into the disc space. Bone is removed from the patient and packed
the cage; over time the bone grows through the holes and around
device, fusing the vertebrae. In one study, the device was successful
72% of patients, who experienced decreased pain without any loss
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
administering an injected NSAID after a fusion procedures may reduce
chances for successful bone healing and union; until more research
been conducted, patients should use alternative painkillers after
procedure. Patients now often remain in bed only three or four days
disc surgery; studies indicate that such patients have the same
fewer complications than those who stay in bed for weeks. It may
to six weeks for full recovery. Gentle exercise may be recommended.
Chemonucleolysis (CNL) is not performed much in the U.S. although
common overseas. It is usually warranted only for sciatica caused
herniated disc that is not relieved by other standard treatments.
study indicated it might help some patients with sciatica caused
low-grade (but not severe) spondylolisthesis. The physician injects
herniated disc with chymopapain, an enzyme made from the papaya.
only two to three minutes. Chymopapain, a common ingredient in meat
tenderizers, softens the nucleus pulposus (the disc's gelatinous
thus reducing the bulge and relieving the pressure on the sciatic
Some experts argue that the procedure has little value, but in 17
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
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
by the piriformis muscle * is a controversial cause of sciatica,
experts do not believe that it plays any role. In one small study,
however, surgery to cut the piriformis muscle and thereby free the
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
Maintaining good posture is very important. This means keeping the
shoulders, and hips in a straight line with the head up and stomach
It is best not to stand for long periods of time. If it is necessary,
as much as possible and wear shoes without heels, preferably with
cushioned soles. Using a low stool, alternate resting each foot
Sitting puts the most pressure on the back. Chairs should either
straight backs or low-back support. If possible, chairs should swivel
avoid twisting at the waist, have arm rests, and adjustable backs.
sitting, the knees should be a little higher than the hip, so a
or hassock is useful to put the feet on. A small pillow or rolled
behind the lower back helps relieve pressure while either sitting
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
The seat should be reclined not more than 30* and, if possible,
bottom tilted slightly up in front. For long rides, one should stop
walk around about every hour and avoid lifting or carrying objects
immediately after the ride.
Be sure to have a firm mattress. If the mattress is too soft, a
plywood board can be put between the mattress and box spring. On
hand, some people have experienced morning backache from a mattress
is too hard. The back is the best guide.
Exercise as Prevention
Although exercise is important for recovery from back pain, there
studies proving that exercise prevents back pain in the first place.
fact, incorrect or long-term high-impact exercise is a cause of
Many experts believe, however, that by strengthening the muscles
trunk, the spine is better protected against injury. Physical activity
important, in any case, for health, and some experts also think
exercise helps pump fluid into dehydrated discs, helping to heal
Low-impact aerobic exercises, such as swimming, bicycling, and walking,
can strengthen muscles in the abdomen and back without over-straining
back. They may even help postmenopausal women maintain bone density
lower spine. People vulnerable to back pain should avoid activities
put undue stress on the lower back or require sudden movements,
football, rowing, ballet, and weight lifting. Jogging is usually
recommended, at least not until the pain is gone and muscles are
Exercises called lumbar extension strength training are proving
effective. Generally, these exercises attempt to strengthen the
improve lower back mobility, strength, and endurance, and enhance
flexibility in the hip and hamstring muscles and tendons at the
the thigh. (For examples of some good exercises for the back, see
below). It is important to note that all exercises for the lower
should be performed with caution. If any discomfort is experienced,
and check with a physician. Exercises that put the lower back under
pressure should be avoided until the back muscles are well toned.
exercises include leg lifts done in a prone (face-down) position,
leg sit-ups, and leg curls using exercise equipment.
Protection in the Work Place
A number of companies are developing programs to protect against
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
support belts reported more back pain than the workers who didn't
them. In any case, nearly half of the workers who were assigned
failed to wear them. Employers and workers, however, should make
effort to create a safe working environment. Office workers should
chairs, desks, and equipment that support the back or help maintain
posture. Anyone who engages in heavy lifting should take precautions
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
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
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
Stretching Lower-Back MusclesLie on the back and lift both knees
the chest. Keeping arms at the sides, slowly roll the knees over
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
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.
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
expensive component in the overall cost of back pain for workers'
compensation claims, as well, the institute notes. And back pain
responsible for more loss of work time and increased medical expenses
related to treatment than any other ailment, says Robert Shields,
osteopathic physician practicing general medicine in Plano, Texas.
"This is one of the most common problems I see in my medical
says. "Low back pain strikes 8 out of 10 adults at some point
Understanding Back Pain
Back pain comes in two forms, acute and chronic, and is most often
the lower back. Acute pain comes on suddenly and intensely, usually
doing something you shouldn't be doing or from doing it in the wrong
The pain usually lasts a short while. Chronic pain is recurring;
little movement can set it in motion and, for whatever reason, it
on and on for what can seem like an eternity.
Although back pain is usually preventable (See "Back to Exercise"
experts claim that 4 out of 5 Americans will experience it at some
their lives, given that the lower back supports most of the body's
The stability of the lower back depends on the integrity of the
bodies and the intervertebral disks.
To understand the many ways you can do injury to your back, consider
each of us has between 24 and 25 bones in and around our backs,
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
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
disks, and irritate the joints. While logic would point to injuries
sports or traumatic accidents as the cause of the pain, sometimes
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
problems such as kidney stones, kidney infections, blood clots,
Even with modern technology, however, the exact reason or cause
pain can be found in very few people, according to the Clinical
Guideline for "Understanding Acute Low Back Problems",
published in 1994
by the Department of Health and Human Services' Agency for Health
Policy and Research. X-ray examinations explain only a small proportion
the nonspecific complaints doctors receive.
Pain Management Options
Mettetal's troubles began 14 years ago when he nearly collapsed
excruciating pain searing down his leg. His initial
ruptured disk. Since then, even with four major surgeries to repair
problems, his pain has only worsened. Out of desperation, he has
medications, physical therapies, and pain clinics * all in an attempt
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
diagnosis and treatment of back pain in the United States. Since
causes are so varied, what works for one person might fail with
For most people, drugs work well to control pain and discomfort.
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
severe pain may require prescription medications such as oxycodone-release
(Oxycontin), acetaminophen with codeine (Tylenol with Codeine),
Peter Rheinstein, M.D., director of the medicine staff in FDA's
Health Affairs, says the many effective NSAIDs available on the
today means there is less need for narcotics. However, he cautions
all NSAIDs cause gastrointestinal bleeding, and advises that patients
suffering from other medical conditions need to consult with their
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
recently its therapeutic benefit has been questioned. In a study
in the 1996 issue of Spine, Finnish researchers experimented to
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,
remained in bed for the duration of the experiment.
"Most people think that a week of bed rest will take away the
David Lehrman, M.D., chief of orthopedic surgery at St. Francis
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
California, San Diego School of Medicine, says that bed rest for
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
disks that become painful from loss of fluid. "Exercise can
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.
Doctors recommend back surgery much less often now than in the past,
only for certain conditions that do not improve after other treatments
have been tried. FDA has approved or cleared medical devices such
Intervertebral Body Fusion device, Anterior Spinal Implant, and
Spinal Implant to treat degenerative disk disease and stabilize
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
continuous stream of electrical pulses. The implanted portion of
device consists of a pulse generator (which contains an internal
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
screening pulse generator, which are controlled by the physician
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
The needles are required to have proper labeling, and good manufacturing
practices must be followed. Manufacturers must include on the label
statement "for single use only" and provide information
material sterility and compatibility with the body. The needles
bear a prescription label restricting use to qualified practitioners
determined by individual states.
Harold Pellerite, assistant to the director of compliance in FDA's
for Devices and Radiological Health says, "I think today's
society is more
receptive to alternative medicine. This just points to the need
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
most back problems clear spontaneously. How can you tell if the
was relieved by a particular treatment or if it would have gone
the same period without treatment? "You really can't,"
Out of all these options, only two things have given Mettetal any
of relief * the Spinal Cord Stimulation System and acupuncture.
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
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,
bend, lift, and strain the wrong way. Even an unexpected awkward
be the onset of low back pain, and people who are in poor physical
condition or perform work that requires long periods of sitting
standing are at greater risk for back problems. These people also
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
or long periods of inactivity may make back
symptoms seem worse,
posture and body mechanics will ultimately reduce the stress on
To reduce the incidence of self-inflicted back problems:
Be careful. Learn to lift and lean properly. Avoid positions that
sudden, quick or jerky movements.
Exercise. Strengthening the muscles of the back and abdomen helps
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
your personal physician.
Carol Lewis is a writer in FDA's Office of Consumer Affairs.
A. Lie flat on your back. Hug your knees to your chest and at the
time, bring your chin to your chest. Repeat twice, holding for 15
B. Begin on your hands and knees. Simultaneously raise and straighten
right arm and left leg until they are parallel to the ground. Hold
seconds and come back slowly to a starting position. Repeat with
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.
for 10 seconds and slowly return to start. Repeat with left arm
leg, alternating 10 times. Gradually build up to 20 times.
D. Lie facedown, arms at your side and place heels under couch.
raise chest off the floor as high as you comfortably can. Hold for
seconds and return to start. Gradually increase to 20 times.
Strong lower-back muscles and abdominals work together in maintaining
pain-free and healthy back. These exercises will help strengthen
muscles of the lower back, but it is important that you begin your
exercises slowly and increase levels gradually. Always begin any
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
time, affects about 10% of the general population. The sources of
caused by conditions that compress, destroy, or irritate pain-sensitive
structures such as the annulus fibrosus, posterior longitudinal
and the capsule of the zygapophyseal joints. Involvement of the
nerve roots usually results in pain and neurologic findings in the
distribution of the nerve. Referred pain from visceral disease may
neck pain and may also be confused with primary shoulder disease
peripheral nerve entrapments. Common conditions thought to cause
are degenerative disc disease, with or without disc herniation,
degenerative arthritis of the zygapophyseal joints. Aside from patients
with disc herniations demonstrated on imaging studies and pain in
specific nerve root distribution, the relationship with degenerative
changes is not always clear. This is because degenerative conditions
common with aging and many times are incidental findings in asymptomatic
people. Specific conditions that have been studied but also are
understood are post-traumatic neck pain syndrome, commonly known
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
self-limiting condition and can be a long-term problem. [©
Introduction Epidemiology is the branch of medical science that
the causes, incidence, prevalence, and control of a disease in a
population. Although there are numerous epidemiologic studies of
pain, relatively few investigations of neck pain have been conducted.
There are several reasons for this, the most important being that
pain is not as common as low-back pain and, when present, is not
disabling; therefore, it doesn't have the same economic impact on
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
number of vital visceral structures, including the trachea, esophagus,
the carotid and vertebral arteries, and a musculoskeletal system
provides for support and motion of the head. The cervical spine
a series of seven separate bone elements, all with intricate articulations
and an elaborate system of ligaments and associated muscles. The
second cervical vertebrae are different in size and shape from each
and the remaining five vertebrae. However, all of the segments have
synovial joints. The anterior articulations of the vertebrae below
occur via intervertebral discs. Both the anterior and posterior
surrounded by a fibrous capsule and supported by ligaments and muscles.
These joints both allow and limit neck motion. The capsule, ligament,
muscles all contain an abundance of free nerve endings which are
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
and cervical nerve roots. Pathologic processes such as compression,
especially of the nerve roots, are a frequent source of neck pain
referred pain from the neck. Cervical nerves are both sensory and
that damage, in addition to pain, may cause numbness, tingling,
weakness, and reflex deficits in a specific location. Signs and
along the distribution of a cervical nerve root are called cervical
The cervical nerve roots C5, C6, and C7 are the most commonly involved
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
of the shoulder, and usually there is no demonstrable
any reflex abnormalities. Damage or irritation of C1, C2, and C3
result in reflex or motor deficits but can result in pain in the
the neck extending along the back of the head. Pain from neck sources
other than cervical nerve roots does not result in sensory, motor,
reflex deficits and the pain patterns are not as well defined. Pain
reproduction studies have investigated patients with neck pain but
evidence of specific nerve root involvement. Discography and zygapophyseal
joint injections were used, indicating that there are a variety
etiologies for neck pain. Other possible sources of neck pain, whose
importance has not been established, are the cervical sympathetic
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
neuroforamen (Figure 2a,b,c). Disc protrusion and osteophytes can
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
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
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,
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,
these conditions it is unusual for the only symptom to be in the
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
specified period of time, whereas prevalence is the number of cases
present at any one time. Most reports in the medical literature
prevalence studies. Since neck pain has many causes, and a number
factors such as age, sex, occupation, and cigarette smoking effect
occurrence, it is difficult to compare the results obtained from
research done on differing study populations. In addition, most
are based on questionnaires, so the cause of the pain cannot be
also, neck, shoulder, and upper-extremity pain are frequently considered
General Population Even with the limitations mentioned above, some
information -- mostly from Scandinavian countries -- is available.
pain occurs half as often as low-back pain and is slightly more
in women. In Norway, Bovim and colleagues, in a random sample
persons ages 18-67 years, found a prevalence of 13.8%. In a similar
in Finland, Makela and associates discovered neck pain in 9.5%
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
period between 1976-1980. In addition to neck pain being more
women, Makela also found that older patients, those involved
mentally and physically stressful jobs, and current smokers were
likely to have neck pain.
The most common post-traumatic neck pain syndrome is a whiplash
follows an automobile accident. The term was first used by Crowe
1928 in an unpublished report, then in an article by Davis in
later by Gay and Abbott in 1953. The original descriptions were
mechanism of injury rather than a disease process. Although many
object to its use, the term "whiplash" is routinely used
lawyers, and medical professionals in reference to a patient with
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
behind causing a hyperextension motion of the neck. The combination
seat belts and properly adjusted head restraints reduces the likelihood
Recently Grauer and colleagues have shown with cadaver studies
a simulated whiplash injury the neck forms an S-shaped curve with
hyperextension of the lower cervical spine and upper-level flexion,
followed by extension of the entire cervical spine. It would be
that if physiologic limits of motion are exceeded, than injury would
occur. This physiologic limit of motion was reached in the lower
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
Recently Jonsson and coworkers reported on 50 consecutive patients
with whiplash-type cervical spine distortions in automobile accidents.
6 weeks, 24 had persistent neck pain and underwent MRI imaging.
8 were found to have large cervical disc protrusions and had surgery.
patients had posterior fusions for instability based on lateral
and extension films. This report is in contrast to our own experience
that of others' where, despite careful evaluation of whiplash patients,
conclusive objective pathology is rarely found.
Borchgrevink and associates studied 201 patients with neck pain
following automobile accidents. The patients were randomly divided
two treatment groups. In one group, immobilization by means of a
collar and sick leave from work was provided. In the other, no
immobilization was used, no sick leave was given, and the patients
instructed to act as usual. At 6 months, the "act-as-usual"
more overall progress, as measured by subjective symptoms ratings.
researchers found, however, that 10% of this group still had severe
symptoms at 6 months, which emphasizes that neck pain following
automobile accident in many patients is not a self-limited condition.
The symptom complex most frequently seen is neck pain that may not
present immediately after the accident but begins in most patients
24 hours. Other frequent complaints are headache, dizziness,
paresthesia, and cognitive somatic and psychological sequelae.
This unrelated constellation of symptoms without objective evidence
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
complaints, expensive testing, and extensive symptomatic treatment,
of which have no proven value in altering the natural history of
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
neck pain seems to be related to normal work activity.
Specific injuries that may occur in the workplace include motor
accidents, falling from a height, and being struck on the head.
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
more likely to have neck complaints. If work activity is truly
cause the of the patient's complaints then a strong relationship
activity and the onset and persistence of the symptoms should be
For instance, it must be established that the symptoms began after
performing the activity and the complaints improve or completely
if that activity is eliminated. Usually the distinction between
causation and other factors is not clear because preexisting disease
activities that are not involved with work cloud the picture. In
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
specific task. In these situations, evaluation and treatment proceeds
with any other group of patients but causation usually cannot be
Herniated Intervertebral Cervical Discs
In contrast to studies of patients with neck pain as a syndrome,
herniated cervical disc is a specific diagnosis. The only published
that provides an incidence rate was done by Kondo and colleagues.
analyzed residents of Rochester, Minn, from 1950 to 1974 and found
annual herniated disc incidence of 5.5/100,000 people. The most
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
Kelsey and associates 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.
their clinical appearance, 20 were listed as probable and 28 as
disc protrusions. Fifty-two patients were men and 36 were women,
patients were in their 40s and 50s. The researchers compared cervical
protrusion patients with age- and sex-matched controls. A strong
association was found between protrusion and recurrent lifting of
objects on the job, cigarette smoking, and frequent diving from
Driving vibrating equipment and time spent in motor vehicles were
associated. Frequent twisting of the neck on the job and sitting
job were not associated with the clinical diagnosis of herniated
The association of lifting heavy objects and driving vibrating equipment
with prolapsed disc is not surprising, but the relationship with
is not as easily explained. Cigarette smoking has been implicated
impeding bone metabolism and in interfering with fracture repair,
nonunions in fractures, in arthrodesing procedures, and in increasing
rate of postoperative wound infections. A number of studies
identified smoking as a risk factor for low-back pain, and although
several explanations have been proposed, the mechanism has not been
Degenerative changes of the intervertebral discs cause disc-space
narrowing, osteophyte formation, and sclerosis of the vertebral
plates (Figure 4). These changes are easily seen on lateral roentgenograms
but are the response of the vertebrae to disc degeneration and so
after the process is well developed. Therefore, any study based
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
are paired and located behind the vertebral bodies, so they can
isolated by oblique views; and even then, one oblique view usually
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
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
symptomatic and asymptomatic people and are thought to be part of
normal aging process (Figure 6). Degenerative findings are considered
be pathologic when they produce symptoms. However, with the exception
patients with radicular pain, localizing neurologic deficits, and
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
44-year-old, asymptomatic female. B. Plain lateral roentgenogram
54-year-old female, indicating degenerative changes of zygapophyseal
joints most severe at C4-5 and intervertebral disc degenerative
One of the most perplexing clinical challenges is to distinguish
source of a patient's pain when degenerative changes are present.
review of 200 asymptomatic women, we found that by age 60 to 65,
70% of women had degenerative changes as seen on plain roentgenograms.
Boden found MRI abnormalities of the cervical spine in 19% of 63
asymptomatic volunteers. Fourteen percent occurred in subjects under
age of 40, and 28% in those over 40. Zapletal and colleagues
evaluated the atlanto-odontoid joint in 500 consecutive patients
underwent computed tomography of the brain or paranasal sinuses.
found no abnormalities before the fourth decade but thereafter the
prevalence increased steadily with age, so that by the ninth decade
60% had degenerative changes. In a separate article, Zapletal and
associates evaluated 355 occipital frontal radiographs of the
paranasal sinuses for evidence of osteoarthritis of the lateral
joints. Degenerative changes were found ranging from 5.4% in the
decade to 18.2% in the ninth. They emphasize that these degenerative
changes could be a source of upper neck pain and occipital headaches
Plain open-mouth roentgenogram showing unilateral degenerative changes
In 1982, Rothman stated, "It does not appear that cervical
degeneration is a brief self-limited disorder but rather a chronic
productive of significant pain and incapacity over an extended period
As discussed in the previous sections, degenerative disease of the
cervical spine and neck pain are not synonymous. Degenerative changes
often present in asymptomatic people, and in some people with neck
structural abnormality can be demonstrated. However, in our experience,
Rothman's statement holds true for patients with neck pain with
In 1987, we reported on a review of 205 patients initially seen
pain in an office setting. Patients with previous neck surgery,
objective neurologic deficits, malignancies, or rheumatoid arthritis
excluded. The patients were re-examined and interviewed an average
years (10 to 25 years) after the onset of their neck problems. In
patients, lateral roentgenograms were available for comparison between
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
had been injured and initially had severe pain were most likely
to have an
unsatisfactory outcome; however, no other clinical features were
in predicting the final result. Initially, 121 patients had injuries,
which 76 were due to motor vehicle accidents. Sixty-eight were involved
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
litigation. However, there was no statistical relationship between
level of satisfaction and the amount of pain or pain relief reported
The roentgenographic features measured were degenerative changes
intervertebral disc space, sagittal diameters of the spinal canal
disc space, and cervical lordosis. None of the roentgenographic
present initially or developed in the follow-up period correlated
pain or had any predictive value for pain relief.
Most important, this study emphasizes that neck pain is frequently
self-limited problem, and that many patients will have long-term
that may be moderately disabling.
Summary Neck pain is a common problem in our society and at any
affects about 10% of the general population. The actual cause of
problem is frequently difficult to determine. Neck pain in as many
one-third of patients is not self-limiting and may produce moderate
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.
There are only two situations that usually require immediate surgical
intervention for back and neck pain: (1) if there is a mass lesion
tumor or other disc material) pressing upon the major nerve roots
spinal cord, and (2) if there is spinal cord or nerve root compression
from a fracture or other major instability from injury. The following
the most commonly performed surgeries for these conditions:
Laminectomy. The surgeon cuts through the lamina (part of the bony
surrounding the spinal cord or nerve roots) in order to remove the
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.
success rate varies from 40 to 80 percent, based on the patients
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,
in order to stabilize the spine following a discectomy. Vertebrae
"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
This type of surgery is done if injury or disease has resulted in
instability of the spine, or in order to stabilize or straighten
abnormal curves of scoliosis.
Chemonucleolysis. In 1982, the FDA approved the use of Chymopapain,
is a substance injected into the disc space to dissolve the problem
Chymopapain is derived from the papaya plant and is related to the
substance in meat tenderizer. One advantage of this process is that
does not require an incision and can be less traumatic to your back
In the acute stages of back or neck pain, when muscles are spasming
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 hasnt resolved after
however, you will likely develop tolerance to these drugs (they
some of their effectiveness), you may feel significant unpleasant
effects (such as constipation), or you may find yourself becoming
all problems that outweigh the benefits. Anti-anxiety medications
minor tranquilizers) have also been used for people with acute pain,
mainly to decrease anxiety associated with the pain and to help
relax. In the long run however, these drugs have been found to have
more negative side effects such as addiction, chronic sleeplessness,
lowered pain threshold (increased sensitivity). Nonsteroidal
Anti-Inflammatory Drugs (NSAIDs) are frequently used for back pain
there is an inflammatory component to the pain, but over time, these
cause serious stomach upset if used frequently. Antidepressants
quite frequently to treat chronic pain of many types, including
necks. Antidepressants are typically prescribed at a much lower
pain management than for the actual treatment of depression. These
have the advantage of being nonaddictive, and there are now many
in this drug class that allow for the selection of one that has
beneficial effect for you with the least side effects.
Local anesthetic nerve blocks and trigger point injections are used
interrupt the pain-spasm-pain cycle, which can prolong your pain
by keeping you tense and anxious. These blocks can help relieve
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
especially helpful for sciatica, the leg pain secondary to disc
Another newer type of block, less common but apparently as safe,
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
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
most useful when combined with exercise and other resources from
management center. You should not look to nerve blocks for your
treatment for pain, but regard them as part of a comprehensive treatment
Other Physical Treatments
Your doctor may prescribe more conservative (less potential for
forms of treatment for you, such as braces. These are formfitting
that look like corsets and help support and immobilize the spine.
braces hold the chin at a level or slightly lowered position and
support the neck muscles and cervical area. Braces are usually used
the healing phases immediately following an injury or surgery. If
used continually after this initial phase however, they may lead
atrophy and more pain, especially when the brace is not worn. This
because the brace begins to take over the supportive work of the
themselves and your body begins to depend on the brace, instead
underlying muscles, to hold your head or body up.
Traction is used to straighten and stretch the soft tissue around
facet joints in order to straighten the spine. This may be helpful
pulling the vertebrae slightly apart to allow a herniated disc in
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
TENS (transcutaneous electrical nerve stimulation) devices can perform
useful function by providing an alternate tingling sensation to
that blocks the pain signal to the brain. Point stimulation, a newer
of electrical stimulation, may work similarly to acupuncture in
pain relief. All forms of electrical stimulation can be placed at
points or at the site of pain.
Heat can be applied in several different ways. Hot towels or heating
applied directly to the pain site or hot baths can increase blood
soothe tensed and spasming muscles. Moist heat generally penetrates
deeply; several microwavable hot packs are now available, allowing
quicker application and convenience. Diathermy stimulates deep muscle
by means of an electric current applied lightly to the surface of
skin. Ultrasound also elevates tissue temperature by penetrating
into the muscle with high-frequency sound waves.
Popular heat-generating devices are two hands. Massage can be an
way to warm and relax a tight muscle by stimulating increased blood
to the area. But if you or your massage therapist press too firmly
spasming muscle, the spasm can get worse. Try a hot bath or heating
first. Any time you feel a sharp pain when using massage, back off.
Cold can also be beneficial for back or neck pain, particularly
condition has been determined to include an inflammatory process.
people have found that ice seems to "numb" the painful
area, providing at
least temporary relief. Gel packs are now available that can be
heated, depending on what feels the best to you. Some gel packs
especially made not to freeze solid, but to stay at a consistency
gelatin so that the pack can conform to your back. For some, lightly
rubbing the painful area with an ice block until numbness occurs
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
activity, by paying attention to posture and positioning. You may
remember a parent saying "sit up straight" or "dont
slouch" and how you
would try to adjust to his or her expectations. When you have a
neck injury, poor posture may create excess strain (caused by gravity)
that keeps your pain at an unbearable level. Several different types
health care professionals can teach you how to stand, sit, and walk
ways that reduce the strain on your spine and thereby reduce pain.
physical and occupational therapists teach movement classes that
useful for you, often called "back school," to teach you
and safe ways of moving. For example, men may carry wallets in their
pants pocket, which can cause one side of their buttocks to sit
than the other, creating tension and pain. Some styles of shoes
create awkward body postures, leading to back pain. Physical therapists
can also suggest cushions or other devices that can help you improve
ability to do daily activities with less pain. Occupational therapists
perform an analysis of your workstations (desk, sink, and so on)
you design a more ergonomically correct system (a system that works
for you as an individual).
Sometimes back and neck pain sufferers find relief for acute or
pain by using the services of a chiropractor, a highly trained health
professional who uses spinal manipulation or adjustment to correct
misalignment caused by disease and injury. A chiropractor works
specific vertebra, manually moving one segment at a time to bend,
or stretch the vertebral joint, helping to reposition it. A newer,
some believe safer, approach by some chiropractors involves the
use of a
special tool called an activator, which "taps" the misaligned
increase mobility and avoids the traditional manipulation techniques
commonly used. When there is nerve root compression, as with a herniated
disc, chiropractors will determine this condition first through
of diagnostic tests (such as X rays, CAT scans, or straight leg
before they attempt to manipulate your spine. If nerve-root compression
present, they may elect other forms of treatment, such as traction
or other traction devices. A chiropractor may also refer you to
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
as electrical stimulation techniques, acupuncture, or massage. They
work closely with your regular general practitioner to monitor your
medication and diet. Chiropractors are also aware of the importance
regular exercise and will often prescribe exercises that enhance
neck flexibility, strength, and range of motion to supplement regular
As with other medical treatment, research is still inconclusive
the effectiveness of chiropractic treatment. Ask your doctor or
for a recommendation to a reputable chiropractor in your area. Carefully
discuss your back or neck problem with your doctor or chiropractor
you begin any treatment. Manipulation can make some problems worse,
as fracture of a vertebra resulting from the brittle bones of
TESTS FOR BACK PAIN
From: The Back Pain Sourcebook
may be standard treatment for one back may not be standard for
another. While there are several tests for back problems, its
wise to ask
yourself and your practitioner a few questions before embarking
series of diagnostic procedures. Foremost, do you absolutely require
procedure? Are there risks involved? Is the procedure painful, and
there side effects? Did you know that except for life-threatening
emergencies, you are the person to authorize tests, not your doctor?
individuals fail to inquire about a test; they simply accept that
doctor has ordered it. Doctors are aware that they have a legal
to explain potential hazards or risks, but if they arent forthcoming
information, its up to you to ask. Many times you must sign
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
your back problem. Some procedures are more frequently used than
The X ray still remains a standard test with most practitioners.
doctors bother with X rays while there are so many more sophisticated
high-tech choices for detecting spinal disorders? Primarily, X rays
relatively low in cost and are a prudent choice both physically
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
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
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
the Agency for Health Care Policy and Research recently released
suggesting that expensive tests used to diagnose low back pain may
useless unless symptoms indicate fractures, tumors, infections,
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
requires removal of all jewelry. The greatest concern with X rays
exposure to radiation. If youre pregnant, carefully weigh
factor. If your back trouble disappears within a few weeks, you
other tests. On the other hand, if the pain intensifies and your
worsens, the X ray is just the beginning in your search.
A computed axial tomography reveals high-quality cross-sectional
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
or clicking of the scanner as the machine rotates. Sometimes the
technician will help you change positions to obtain a better image.
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
pregnant, you may want to consider skipping this diagnostic test,
discuss alternatives with your doctor. The CAT scan remains a good
for evaluating herniated disks, spinal stenosis, or injuries to
Tumors, degenerative bone diseases, and spinal infections are visible
Compared with the X ray, CAT scans are costly, but they are a much
tool for evaluating more invasive problems related to the spine.
Magnetic resonance imaging, a noninvasive test conducted without
radiation, is considered a gold mine in high-quality testing. The
must lie quietly in a large, body-length tube while being scanned.
procedure can run from an hour and a half to two hours. Its
scan visualizes tissue with a magnetic field recording that uses
high-speed computers to provide very clear images of the spine and
tissue. The MRI is effective for visualizing soft-tissue disorders,
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
are monitored by a computer, which processes the images on a video
for interpretation. While your entire body lies perfectly still
tube, the scan examines only the area of your spine in question.
not scan the entire body. The room is very quiet, and you can hear
sounds of the scanner machine. The technician produces the images
special equipment. You have no direct contact with the equipment.
are no known harmful effects with an MRI.
Claustrophobia may be a concern, since you are cooped up inside
The MRI cannot be conducted on women with intrauterine devices (IUDs)
individuals with metal implants or pacemakers. The estimated cost
MRI is considerable: around $1,000.
An electromyogram is an invasive test administered by a specialist.
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.
will be asked not to smoke for twenty-four hours prior to the test
refrain from caffeine intake for several hours before. Inform your
if you are taking medications.
An electromyograph machine detects and measures response. A needle
inserted into the selected area. A sharp, brief pain ensues each
needle electrode is reinserted. The muscle or nerves electrical
is measured during rest and contraction and is displayed on a screen.
procedure may be a bit uncomfortable and lasts approximately one
Blocks, an injection of corticosteroids administered into the site
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.
example, a pinched nerve is not remedied, blood supply is cut off,
resulting in permanent tissue damage. The injection cuts the swelling
that the blood supply can flow normally. A block will not change
structure of the problem, such as a pinched nerve, but it will buy
allowing the body to heal. If successful and statistically
and 85 percent are the block allows for a modicum of normality
body heals. If the block is not successful, the individual must
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,
physiatrist can perform these procedures.
The procedures consist of injecting corticosteroids with a solution
the spine. Alternately, the steroid may be taken orally. The steroid
remains in your body for approximately six weeks. Some individuals
very little pain, others insist the procedure is painful. For the
dealing with long-term pain, there may already be a nerve sensitivity
the area, thus creating an uncomfortable experience. If the individual
responds well to the injection, relief comes within seventy-two
not, a second or third injection from a different approach may be
successful. Sometimes there is no response. Some physicians administer
blocks in a series of three injections. But since the solution remains
your body for six weeks, this may not be necessary. The only rationale
a second block is if the first one doesnt 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,
individual must remain awake to communicate his or her response
needle. The needle must be moved, and, because anything in this
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 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
This invasive procedure examines the fluid-filled sac that lies
nerves and spinal cord in your spinal canal. The myelogram at one
used in locating and identifying such problems as a herniated
intervertebral disk, tumors, or injuries to the nerve roots branching
the spinal cord. Today, an MRI scan is performed either in place
prior to a myelogram, since the myelogram is an invasive procedure
carries a slight risk of adverse reaction. An MRI may be a more
procedure, although in some cases a myelogram and CAT scan give
Instruction to avoid food but to take plenty of liquids is given
the test. You may be given a sedative or injection to relax. You
facedown, and the site of the procedure is anesthetized with a local
anesthetic. A longer needle then protrudes into the spinal canal
small amount of fluid is taken from the spine and sent to the lab
analysis. The position of the needle is monitored by a fluoroscope,
is connected to a screen. A contrasting X-ray dye is injected into
fluid-filled space that surrounds the spinal cord. You are tilted
fluoroscope so that the dye can be observed. X rays follow. The
absorbs the water-based dye.
You must sit up or lie with your head elevated for six to eight
after the procedure. Although youll leave the hospital or
clinic the same
day, plan to rest a few days after this procedure. Some complain
is a painful experience, while others report a headache afterward,
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
the exact location and degree of herniation.
A discogram is a surgical staging test to try and identify which
disks are problematic or abnormal. It is frequently painful, and
surgeons or anesthesiologists and radiologists perform it. There
is a risk
of disk infection in one in five hundred procedures.
A bone scan is a procedure in which an injection of radioactive
travels through the bloodstream to attach itself to the bone. This
material moves to areas that are either actively breaking down bone
making new bone. It shows up in large amounts in areas of abnormal
and detects the early signs of bone cancer, infection, or fractures.
bone scan helps evaluate unexplained bone pain or abnormalities
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.
the radioactive substance is injected into your veins, you must
approximately three hours for the material to distribute throughout
body. Drinking a massive amount of water is required to clear the
radioactive material not involved with the bone tissue. The actual
takes about one hour, as you lie on your back and the camera moves
back and forth above your body. Infants, pregnant women, and breastfeeding
mothers are not good candidates for this procedure. A bone scan
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
From:The Back Pain Sourcebook
first thing many of us do when in pain is reach for a drug. This
understandable; after all, we have been conditioned as a society
for the quickest form of relief. But while relief might be just
away, be cautiously aware that back pain is not cured by taking
Drugs give only temporary relief. Be careful when taking narcotics
your back problems. They are not a solution.
If you have any questions about the drug you have purchased over
counter or that your doctor has prescribed, by all means, consult
physician or pharmacist. Yes, your local pharmacist is a wonderful
of information when it comes to the pills you swallow. Ask for a
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
pharmacist can offer more information on the subject or give you
Drugs for treatment of backaches generally fall into three categories:
anti-inflammatories (or nonnarcotic analgesics), painkillers, and
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
work for reducing fever. They are not anti-inflammatories. In other
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.
to take an aspirin for all sorts of common ailments, including fever,
aspirin has very effective anti-inflammatory properties. Ibuprofen,
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
chemicals involved in the production of inflammation and pain. They
effective for mild to moderate pain, but can irritate the stomach
cause nausea, and in rare cases cause kidney damage. They can also
trouble with gastritis and ulcers.
Narcotics are powerful painkillers and may be prescribed for pain
Science has searched for pain relief for many centuries. Opium is
the oldest painkillers known to humankind. In the 1800s morphine,
after Morpheus, the Greek god of dreams, was first purified from
decreased opiums nasty side effects and increased its painkilling
properties. In the beginning, morphine was used as an anesthesia
operations. Patients needed to be anesthetized with rather large
which led to other problems. (As you know, both opium and morphine
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
any amount of time, possible abuse of the drug and addiction need
monitored, preferably by yourself, and if not, by your doctor.
As the users 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
moderate painkiller that may, if taken in large quantities, upset
stomach, but it is not addictive.
Side effects of narcotics include addiction, sedation, and loss
drive if taken long term.
Many physicians avoid muscle relaxants. Muscle relaxants work on
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
you. The extended use of these powerful relaxants can produce depression,
and one of the side effects is drowsiness. Muscle relaxants are
Drugs for Depression
Depression understandably may be wedded to long-term pain and is
associated with sleeping difficulties. Serotonin, a chemical produced
the brain, is also associated with depression, chronic pain, and
disturbances. Certain antidepressants are used to help serotonin
the brain return to normal. Antidepressants take a few weeks to
working. They dont activate overnight.
Newer antidepressants on the market, like Tricyclse, are not habit
forming. Side effects may include weight gain, grogginess, dry mouth,
in some cases, constipation.
How many times have you taken a drug like tetracycline, gone and
a few rays, and come home with spots all over your body? A reaction
drug? Not really. Tetracycline is photosensitive and does not mix
with sunshine. Nevertheless, this frightening side effect is often
noted by the hurried physician or busy pharmacist. Of course, the
print on the prescription advises you not to go in the sun. But
So whats the point? When taking drugs for pain, know their
effects, and what they mix and dont mix with. Frankly, your
probably doesnt have the time, or may not even know everything
to know about the drug. But there are drug references to help you,
youll find them in libraries as well as pharmacies. The following
excellent guides to help you understand the drug or drugs you are
Traditional Types of Surgery
From:The Back Pain Sourcebook
surgery is rapidly changing. The following surgical techniques have
been around for some time. If these are your options, familiarize
with them before going under the knife.
The laminectomy, considered by some the standard of back surgery,
performed for some thirty years. A laminectomy is a removal of the
posterial portion of the ring of bone that surrounds the nervous
the spinal canal. Laminectomies are performed to relieve compression
the spinal cord, caused by a bone displaced due to an injury or
from disk degeneration. Performed under general anesthesia, the
problem should, theoretically, be corrected. But this doesnt
happen. As with Irve, the laminectomy did not relieve pain, and
problem was not corrected. Sometimes the surgeon does not remove
the laminae but has no way of knowing this until after the patient
recovered from surgery.
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
of the pelvis. The concept is that living bone will grow over the
your back and fuse together.
There are many types of fusion surgery. Some techniques involve
hardware, such as screws or rods, to the back or front of the spine
to stabilize them. This surgery is very extensive. St. Marys
in San Francisco has recently developed a percutaneous fusion technique
that has been successful in over sixty patients at this time.
Microsurgery uses a microscope so that the incision site is only
long. This is not a percutaneous procedure, its major surgery,
pain is less severe than with other dramatic surgeries. Nerves to
spinal muscles arent cut, ligaments to the spine arent
cut, and tissue
damage is reduced. The surgeons field of vision is more restricted
in a traditional laminectomy. The doctor must be sure of the exact
location where the disk is impinging on the nerve; otherwise, symptoms
reappear due to missed parts of the disks. There is less operative
with a microdiscectomy and more rapid return to daily activity.
A foramenotomy is performed to provide a passageway for the spinal
from spinal stenosis. The small openings in the vertebrae, called
allow the spinal nerves breathing space. With spinal stenosis, a
of the space within the spinal column causes the nerves to become
constricted and swell. With a foramenotomy, the bone around the
shaved, allowing for breathing space for the nerves and blood to
Chymopapain or Chemonucleolysis
Chymopapain, once a controversial treatment, still appears to be
With many newer, less invasive surgeries on the horizon, chymopapain
become less popular. Chymopapain, an enzyme derived from the papaya
acts like a meat tenderizer on the nucleus of the herniated disk.
involves partial destruction of the nucleus, as the nucleus of a
disk is digested by the injection of chymopapain. The procedure
shrinks the protruding area of the disk, thus lessening pressure
A number of complications plagued chymopapain in the beginning:
spasms, neurological damage, and allergic reactions. As chymopapains
popularity rapidly peaked in the early 80s, many physicians
rapid but inadequate training, underscoring the need for more thorough
understanding. Today, chymopapain is skillfully used as a treatment
some doctors. Its less expensive than other procedures and
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
When Spine Surgery Is Absolutely Indicated
If you have sudden loss of bowel, bladder, or nerve control, call
doctor immediately or get to an emergency room. You may be suffering
a longtime injury that has suddenly worsened, cutting the blood
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
Laparoscopic procedures are proving successful in certain types
surgical procedures and some percutaneous procedures. Laparoscopic
surgery may soon be a better and more cost-effective option for
The Back Implants
The back spinal implants, still new and not widely available, is
fusion surgery to stabilize motion in the spine. Bak implants, similar
large, hollow screws with holes in them, are usually implanted in
inside the spine. They are made from titanium metal. Bak implants
put in posteriorly or laparoscopically. They are used to stabilize
The Controversial Pedicle Screws
Pedicle screws are used to stabilize the spine after spinal injury
correct severe spinal curvatures and other abnormalities. In many
they have replaced other methods of spine stabilization, such as
rods, and hooks. The controversy surrounding the pedicle screws
they have not been approved by the FDA but are still widely used.
the law, before orthopedic screws can be marketed as pedicle screws,
manufacturers must submit scientific data to the FDA establishing
these devices are safe and effective. Limited studies of pedicle
have been ongoing for a number of years, and the FDA has approved
the screws for the purposes of these studies. According to the Back
Association of Americas April 1993 newsletter, the studies
screws have not been completed and the manufacturers have not accumulated
enough data to show, one way or another, whether the screws are
this mean the pedicle screws are unsafe? Some hold that there 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
wires once used.
Staving off Back Surgery
Youve done everything possible, and like Judith and Hank,
surgery is the
last alternative for you. Here are a few tips to help you prepare
surgery and to return to a healthy, productive life after the surgery:
Search for the right medical team and get a second opinion. Ascertain
the spine surgeon has a pain clinic, a physical therapist, a
neurosurgeon, a psychologist, physiatrist, osteopath, or chiropractor
Ask your surgeon to have the surgery explained to you. Ask about
success rate and risk. Talk about your fears, how you manage pain,
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,
the requirements of your recovery period.
Discuss with your practitioner what happens if you need another
A second surgery is not so uncommon.
Follow up with back exercises and changing patterns. Dont
surgeon to do any more than perform surgery. It will be up to you
carry on with your back exercises and change lifestyle patterns
undermined your back. Most doctors agree that changing postural
and exercising can drastically reduce your chances of needing surgery.
From:WebMD Electronic Library Collection
During the past decade, the American public's interest in alternative
medicine has skyrocketed. The evidence for this trend is everywhere
the media, in the growing number of popular books on "wellness"
non-traditional therapies for illness, and in booming sales of supplements
The magnitude of this trend was highlighted in a report by David
Eisenberg, M.D., of Harvard Medical School published in a 1993 issue
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
comparable to non-reimbursed expenses incurred for all hospitalizations.
The growth in the use of alternative medicine has been accompanied
subtle changes in the attitudes of both patients and physicians.
still widely used, the term "alternative medicine" has
falling out of favor in recent years. Many who work in the field
the term reinforces the old and divisive (and inaccurate) stereotype
desperate and naive patients foregoing promising mainstream therapies
favor of unproven or "alternative" therapies offered by
This view began to change with the publication of a 1988 study by
Cassileth, Ph.D. Cassileth's survey suggested that, for the most
unconventional therapies in the United States are offered by licensed
physicians or other credentialed health care practitioners who believe
the therapies they offer, who are not charging excessive fees for
treatment, and who are treating patients of above-average education
income. Further, these patients are likely to be more deeply engaged
the average patient in exploring their choices. Significantly, in
large majority of cases, these patients also choose to remain under
care of a mainstream physician. Generally, patients who completely
mainstream medicine do so only because doctors have said there is
more they can do for them.
More and more patients are finding that alternative medicine has
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
either/or proposition. Rather, they seek to make informed, personal
choices about how to integrate both. For this reason, "complementary"
"integrative" medicine have become the favored designations
A vast array of approaches fall under the heading of complementary
medicine. Some, such as acupuncture and Ayurveda (the traditional
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
applied to medicine. Chiropractic and homeopathy are examples of
that arose in the West * alongside orthodox medicine * that view
processes much differently than mainstream medicine. Mind-body therapies
(e.g., stress reduction techniques, biofeedback, meditation) comprise
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
herbs can potentiate the effectiveness and lessen the side effects
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
harmless. They run the gamut in terms of their potential for harm,
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
are considered to be intrinsically health promoting regardless of
one is ill or not. As Michael Lerner has pointed out in his book
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
can, at the very least, bring about a transformation in the way
illness and your own body. These approaches can also affect the
is perceived, and there is evidence they may actually affect the
the illness itself in some cases. Nutritional approaches (if not
to extremes) and physical approaches, like massage, exercise and
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
prescription drugs. Extreme dietary approaches can also lead to
weight loss and nutritional imbalances.
The Research Evidence for Complementary Therapies
Generally, there is little hard research evidence for the effectiveness
complementary therapies. This does not mean that these approaches
useful * just that the question is still open. As these approaches
researched, they either tend to move into the mainstream, as is
happening with a range of mind-body therapies and acupuncture, or
essentially abandoned, as has largely happened with laetrile, the
cancer "cure" derived from apricot pits.
But cultural and institutional considerations also play a role in
what is and what is not considered "alternative." Almost
by definition, a
therapy is considered "alternative" if it is not taught
schools, even if there is good research evidence for efficacy as
for acupuncture, chiropractic and some herbal therapies. For example,
strength of the research for the effectiveness of homeopathy for
conditions is quite compelling, yet because there is no rational
scientific mechanism to explain its action, it is still dismissed
researchers. And though the research on promising herbal therapies
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
Choosing a Complementary Therapy
Most mainstream physicians are of little assistance when it comes
providing guidance to patients in the area of complementary medicine.
the same time, there is an explosion of media "hype" and
ventures touting non-toxic cures for illnesses ranging from acne
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
physician. If you decide to stop using mainstream medicine, do so
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
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
condition so that you will have a context for comparing therapies
It is very common for a patient to hear about a complementary therapy
has been helpful for someone else and to expend considerable effort
locate that therapy for themselves. While it's useful to hear from
individuals who feel they have been helped by a given therapy, keep
mind that people who were not helped are less likely to talk about
those who experienced dramatic positive results. The person you
about may be one out of a hundred who actually benefited from the
Most medical conditions are self-limiting * they get better eventually
even without treatment. Other conditions, including some serious
like multiple sclerosis, can wax and wane regardless of treatment.
these cases knowing that someone improved when using an alternative
tells you nothing, because it could have happened even without the
Also remember that people who use these therapies often use a number
them at once in addition to Western medicine. Therefore, it is often
impossible to know exactly which therapy or combination of therapies
There are a number of useful resource books that may be of great
understanding the field of complementary medicine and in choosing
therapies. Some of these are listed in the "Resources"
The Internet can be a valuable tool for locating information about
range of complementary therapies available. If you have access to
computer, look at the Internet sites that provide information about
condition. But beware that the web is full of unreliable information.
Remember * just because it appears on the web doesn't mean it's
Medically oriented sites generally provide the most reliable information,
but these rarely discuss complementary therapies. If they do, they
likely to err on the side of conservatism when it comes to complementary
medicine. If a medically oriented site says a given complementary
is unproven, it means only that * it's unproven, not necessarily
Internet sites established by patient advocacy or support groups
very good sources of information about complementary therapies.
groups can give you a sense of which therapies people are finding
The same is true of support groups. Hearing from many people who
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
any information, on the web or in print, which describes "miraculous"
outcomes or "cures" for conditions that mainstream medicine
incurable, or encourages patients to leave mainstream medicine in
an alternative approach.
When evaluating information on the web or in print, look for references
research studies. It is fairly common for whole books to be based
small study! Look for numerous citations to different studies. It
nature of research that studies are often contradictory and that
large body of research can begin to yield definitive answers. Studies
human subjects are much more important than studies in animals or
tubes (sometimes called in vitro studies).
You can also perform an on-line search for the medical literature
using PubMed, a service developed by the National Library of Medicine
Resources for Internet address). Many hospitals in large cities
patient libraries that perform this kind of search for you, usually
fee. Staff members in these libraries can also be quite helpful
locating information for you.
If there is little research evidence for the therapy, you might
yourself the following questions:
What is the context from which the therapy arose?
Is the therapy science-based? Is the scientific foundation widely
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
with a long history of use?
Is the therapy a "secret formula," or does the proponent
Choosing a Practitioner
Once you have settled on a therapy that you would like to try, the
step is finding a practitioner. For some therapies this may not
necessary. You can make modest changes in your diet, for instance,
begin a moderate exercise regimen unassisted. But if your condition
serious, the therapy is complex or if the lifestyle change is a
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
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,
or homeopathic remedies are available over the counter, but these
"formulas" may bear little resemblance to the prescription
would write for you since they are highly individualized treatments.
never rely on "recommendations" by employees of health
food stores * their
training in the use of herbs and supplements usually comes from
representatives, not schools of naturopathy!
When seeking a practitioner, a personal referral is best, but it
wise to talk to many people with the same condition until one name
up two or three times. Support groups are also good places to find
kind of information as are local branches of support organizations.
Referrals can also be obtained from another practitioner whose opinion
If these kinds of direct referrals are not available, the state
national credentialing organization for that discipline will often
referrals. "New Age" newspapers found at natural food
bookstores may contain ads and listings for local practitioners,
If all else fails, try the telephone book!
Once you have located a candidate, don't be shy about interviewing
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.
you have cancer, find out if they have worked with other people
same kind of cancer.
Get a sense of their attitude concerning mainstream medicine and
would be willing to work with your doctor.
If for some reason you decide not to work with that practitioner,
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
with you to coordinate care from different sources. Be prepared,
for the possibility that you will not be supported in your decision
complementary medicine. You may be told you are wasting your time
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
able to locate research studies on a complementary therapy you find
interest, show these to your doctor. For some people, the support
physician in this area is important enough that they will decide
out a doctor who will be supportive.
Increasing numbers of open minded practitioners on both sides of
alternative-conventional medicine divide are coming to understand
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,
up to the patient to put these pieces together. The challenge can
daunting, but the task is not impossible and the rewards are well
Internet address for PubMed:
An Ancient Alternative Treatment
From:The Back Pain Sourcebook
1971, while in China, New York Times. correspondent James Reston
received acupuncture for pain relief after an emergency appendectomy.
Restons rave reviews brought acupuncture out of the framework
philosophy and into the daily American press. His postoperative
was hailed by the Western media. Restons reporting brought
into American living rooms at the same time diplomatic doors slid
between China and the United States.
While acupuncture has been a healing art in China for over 3,000
its entrance onto foreign soil wasnt easy. Many Western practitioners
were admittedly fascinated by the accounts of acupuncture used as
anesthesia and analgesia. But the Chinese philosophy of body dysfunction
is very different from the accepted Western view of how the body
Western medicine is based on the Cartesian philosophy that the body
represents one functioning system and the mind another. Chinese
assumes the body is a whole and that all parts of it are connected.
Chinese medicine postulates that health is achieved and disease
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
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
other to exist. Once the vital energy, or chi, is disrupted along
the bodys fourteen meridians or pathways that correspond to
organs, the acupuncturist corrects the imbalance by putting needles
specific acupuncture points on the body.
When the flow of energy is interrupted, the bodys energy unit
needs to be
tuned up, or balanced. Pain is simply a blockage of this vital energy,
unlike a traffic jam. When your car is stuck in traffic it cannot
and the energy in your body works on the same principle. Once the
blocked, it needs help to circulate. Acupuncture addresses underlying
causes dealing with circulation by treating local points. The cause
problem in your back, for example, may stem from muscle spasms,
a musculoskeletal misalignment. Because everything in the body is
connected, acupuncture treats several points. Back pain and neck
respond well to acupuncture, but while the relief in most cases
immediate, it may not be long lasting. This depends on the problem.
Joy believes her back might well have been cured from the beginning
acupuncture. She stumbled into an acupuncture clinic after trying
An active woman, Joy worked from sunup to sundown on a ranch. There
long, arduous hours of climbing, digging and shoveling, and actively
keeping her body and mind fit. Shes fond of saying that she
rest at night and never had trouble sleeping.
An unfortunate disagreement altered the working relationship Joy
her landlord, so she moved on. For the next year she traveled up
the state. Her lifestyle altered radically from active to sedentary:
sitting, driving, drinking a lot of coffee, and chain-smoking. Bad
coupled with lack of movement made Joys back feel tense and
Joy had a hard time finding work and became depressed. She felt
uptight, and tense. Money scarce, she rented a small room. Lack
exercise and poor eating habits intensified Joys backaches.
Joy returned to physical work. She began cleaning houses, vacuuming
rearranging furniture. A compulsive cleaner, Joy went home tired
crawled into bed with a backache. She smoked and drank more coffee
Trying to remedy her back problems, Joy tried stretching and back
exercises. For a few months she did Pilate's, a bodywork program
stretching and machines, but then couldnt afford to stay with
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
Beinfield and Efrem Korngold, on acupuncture. It made more sense
than anything shed read in a long time.
She decided to give acupuncture a try and without an appointment
into an acupuncture clinic. Joy credits the acupuncture practitioner
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
time in months."
Joy continued her acupuncture for nearly three months, combined
Chinese herbs. She credits both the herbs and acupuncture with healing
back and aligning her body. Joy no longer smokes, and shes
the day when she will no longer desire caffeine. Back problems,
well understands, are lifestyle issues, and acupuncture treats the
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.
The sooner the back problem is treated, the faster the condition
Acupuncture works best as part of a series of treatments. In China,
series of ten is traditional. Depending on your acupuncturist and
particular problem, you might have two or three treatments a week
with, tapering off to once a week. It all depends on your condition
how your back responds.
Acupuncture is administered by inserting very fine sterile needles
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
not unpleasant and comes from herbs. Herbs are often used in combination
with acupuncture treatment. Some acupuncturists send you home with
odd-looking concoction to brew up and drink several times a day.
concoction is typically bitter, and for many, it is difficult to
Herb capsules tend to be a more popular form.
How do herbs affect low back pain? According to acupuncturist and
herbologist Larry Forsberg at the Chinese Medicine Works in San
herbs are used a great deal in low back pain, because in Chinese
other organs, such as the kidneys, are implicated in low back problems.
The herbs strengthen the implicated organ. Acupuncture works from
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
needles are attached to a little box that stimulates the points
enhances the treatment. It is not painful. Sometimes moxa, a
strong-smelling herblike substance, is used to heat the painful
heat is not applied directly on your back; rather, the acupuncturist
it above the area being treated.
While the prospect of having needles stuck in various meridian points
sound daunting to some, the treatment is actually relaxing. Many
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
acupuncture treatment, youre 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. Ive had treatments for
that was when treatment was recommended two or three times a week.
want to ask how many treatments your acupuncturist thinks you will
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
acupuncture for back-related pain.
Acupuncturists do not have to be licensed doctors, so you may want
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
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
Sourcebook, by arrangement with Lowell House.
From: The Back Pain Sourcebook
back pain sufferers turn to bodywork in their search for an
alternative practitioner for their particular problem. Sometimes
combine bodywork with traditional modalities of treatment. Bodywork
come into its own over the last two decades, and techniques vary
The following chapter discusses the most popular types of bodywork
ancient practices that you may encounter in your search. Rest assured,
well-meaning friends who have experienced satisfactory relief from
school will swear that it is the solution to your own back problem
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
decision. The differences and similarities among bodywork techniques
subtle; all aim to realign or retrain the body to function naturally.
insightful founders of these healing methods Feldenkrais,
Rolf each understood that the emotional and nervous system
organized or rearranged to heal the physical musculature. They believe
that the individual has the ability to engage in new learning, no
how ingrained bad habits are. Sensory re-education is at the heart
several types of bodywork; in other words, you feel it.
This chapter is not meant to promote a particular school of work.
simply offers information on some of the alternatives in dealing
back, posture, and structural problems. Bodywork does not cure a
disk" or "spinal stenosis," but it does help in understanding
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
centuries, others for decades. Always seek a practitioner who is
not a student or someone in training.
How expensive is bodywork? That depends what you compare it with.
compare several bodywork sessions with surgery, the cost is ridiculously
low. If you compare it with a session with your chiropractor, the
similar or slightly higher. Bodywork traditionally requires more
session, and ongoing work can be expensive if your insurance does
cover it. Nevertheless, for the individual who benefits from it,
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 its all hocus-pocus,
individuals who have benefited from this approach before you make
Dr. Ida Rolf, a pioneer in bodywork, was a former organic chemist.
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
deforms the skeleton.
Rolfs theory postulates that when the bodys structure
basic chemical changes take place within it that improve overall
Rolfing works in 10-session segments. Rolfer and teacher Neal Powers
thats 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
last 3 sessions methodically realign the body along its natural
axis. Rolfing straightens the body by correcting the relationship
major body segments (the head, shoulders, thorax, pelvis, and legs)
vertical alignment. In the last decade, Rolfing techniques have
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
with intense, digging-in pressure, splits the bundles. Similarly,
orthopedic massage realigns fibrous tissue, but instead of digging
orthopedic massage rolls the tissue and allows the bundled tissue
apart like an onion.
Rolfers perform deep manipulation of the connective tissue called
collagen. The collagen changes from the hands-on energy applied
becomes more pliable.
In a sequence of hands-on manipulation, Rolfers move the tissue
toward symmetry and balance that the body demands. Sufficient force
stretches and moves the tissue. Pain may be momentarily intense.
is not as subtle as other types of bodywork. Sometimes people being
recall a traumatic episode associated with the body and often emotion
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 is a hundred-year-old paramedical system of correct
mechanics, correct muscle function, and correct posture based on
fundamental research developed by Dr. Bess Mensendieck. It has widespread
popularity in Europe, specifically Denmark, Sweden, Norway, and
Netherlands. Its comprehensive approach and practice is credited
for the low statistics in back surgery.
Dr. Mensendieck was born in 1861 to American parents in New York
father, a civil engineer, traveled extensively with his family.
Mensendieck was gifted both artistically and musically, and made
successful concert debut in Paris before studying sculpture. It
often awkward bodies of her sculpture models that made her aware
human form. With a keen eye she began observing children, men, and
She attended medical lectures on the muscles and finally quit sculpting
attend the University of Zurich to obtain her medical degree. She
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
correcting the common abuses of the body. Dr. Mensendieck set up
around Europe and in the 1930s opened her first school in the United
The Mensendieck system works on the premise that if movements are
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
grace. It is a unique and comprehensive approach, utilizing exercise
rehabilitation to address occupational stresses, sports-related
postoperative recovery, as well as chronic back and joint pains
by bad posture and musculoskeletal diseases. Mensendieck requires
equipment. A session starts by examining ones posture in a
demands motivation and perseverance to unlearn faulty postural habits,
such as slumping in front of the TV, that put pressure on the sciatic
The Alexander technique is a rethinking of how we perform all of
everyday activities, specifically the activities that we take for
The educationally based technique is subtle and was founded a century
by a young Australian actor. Alexander found himself plagued with
hoarseness and ultimately laryngitis onstage. Rest restored his
stress weakened it. Alexander reasoned that he must be doing something
cause this. Plotting a course of a discovery, over a three-year
Alexander studied himself while reciting lines. He spent hours in
a three-way mirror, and found that while speaking he tightened his
which caused his head to be pulled back and down into his spine.
result was pressure and strain along the entire back.
Alexander refers to sessions as lessons and to the patient as the
Eyes are always open, you are fully clothed, and its up to
the student to
pay attention. Alexander believed that in order to produce awareness,
head and neck must be lifted off the spine instead of collapsing
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
Alexander teachers do not follow formal lesson plans. Half of a
be on a table, with the other half taking place while the student
about a daily activity playing flute, washing dishes, or
produces the pain.
The technique re-educates people to use their own body in a more
way. It is so subtle that one doesnt 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
the torso. Lessons, tailored to the individuals needs, comprise
of thirty sessions and run between $30 and $55 each. There is no
this gentle technique. Youll find variations of it incorporated
schools across the country.
Peter de Zordo began practicing Trager fourteen years ago. A practitioner
at the Trager Institute in Mill Valley, California, he says that
a sensory experience. Trager effects change through passive body
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
mentastics. Mentastics refers to the mind. In Trager, the mind is
Trager was training to be a boxer when he discovered his exceptional
ability to work with his hands while rubbing down his trainer. Trager
boxing to take care of his hands and began the long pursuit that
eventually took him to medical school. What distinguishes Tragering
other bodywork is the focus and intent of the practitioners
Tragers focus and intent are not specifically directed toward
conditions in the body tissue, muscles, joints, or skin, like Rolfing,
toward reaching the unconscious mind. It has taken Trager over fifty
to expand and develop his technique.
Trager mentastics is a system of effortless movements to enhance
bodys sense of lightness, freedom, and flexibility. Rhythmic
stretching movements encourage the body to let go. Through a series
movements swinging, stretching, pressing, and rocking the
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
for each session. Trager carries no risk and is gentle. Costs range
$50 to $75 a session, depending on the practitioner.
Moshe Feldenkrais, a mind-body holistic health practitioner, was
engineer who worked on the French atomic-research program. A judo
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
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
great deal of pain results from patterns of movement that involve
unnecessary muscle tension. Insightfully, he felt people could "learn
learn" to move in a free and graceful way. Feldenkrais held
people lose the grace, freedom, and joy in movements that they had
infants and small children. He understood that the relationship
movement with thinking, feeling, and sensing can effect changes
behavior, and he coined this "functional integration."
A Feldenkrais session communicates to the brain precise movements
change habitual patterns and provides new information to the neuromuscular
system by gentle touch, movement variation, and verbal guidance.
practitioner gently lifts, halts, and supports the head, arms, legs,
and chest as you are guided through slow, easy movements. Touch
Prior to his death, Feldenkrais worked with individuals affected
multiple sclerosis and cerebral palsy, claiming that his method
improve the health and well-being of anyone having trouble with
In some circles he was considered a holistic guru. For Feldenkrais,
There is no risk involved with this method. Feldenkrais can be taught
group setting or individually. Group classes start at around $8,
individual classes may start at $35 and go up from there.
Judith Aston came to Ida Rolf for treatment after an automobile
Originally trained as a dancer, she was told she should give up
career. She went on to study Rolfing, but felt that similar results
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
gym on symmetrical Nautilus equipment, for example, works against
bodys natural symmetry. So instead of projecting symmetry
as the ultimate
goal, Aston-Patterning encourages body parts to cooperate with one
through a system of education through movement. Aston-Patterning
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
and sequence of Aston-Patterning sessions depends on the individuals
need. Aston-Pattering practitioners work with a variety of back
problems particularly in individuals who, like Judith, were told
couldnt perform a certain activity again due to injury. The
include both massage and movement work, so the client has immediate
feedback about how to release tension in the body. Price ranges
to $85 a session.
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
Rolfing, but also includes verbal interactions that focus on the
individuals personality traits and attitudes toward life.
emphasizes structural balance and movement education. It also incorporates
deep-tissue massage, facial restrictions, postural alignment, and
awareness. Its goal is to realign the body and release chronic tension
A herniated disk that did not respond to traditional healing modalities
resulted in Mathews exploration of alternative possibilities.
He had some
success with a healing center, where he was taught to relax his
body, to breathe, and to practice visualization. And he felt better,
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
three times a week, Mathews posture and body mechanics altered
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
days of back pain.
Introduced in 1923 in New York by Joseph Pilates, the Pilates method
resistance control exercise that has long been the best-kept secret
dancers, singers, and movie stars. Pilates works with muscle resistance
the way muscles are designed to function, not against their natural
mechanics. The Pilates method utilizes mental and physical training
teach people how to work from the inside out. Because the method
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
a set of springs. The apparatus has no relationship to machines
in a gym,
though the exercises strengthen supporting muscles in the body.
exercise is designed to stretch and strengthen all the muscles and
joints to release tension.
This holistic method allows each individual to work at his own pace.
each piece of apparatus permits over a dozen different types of
movements, several work specifically to strengthen the spine and
muscles. An individual works independently with an instructor, and
program is designed for each persons appropriate physical
has become very popular in the last few years. Risk are minimal,
ignorance of how to use the equipment the only potential problem.
can be done in a group or in semiprivate or private classes. Depending
where classes are taken, prices may vary. Typically, a private session
range from $30 to $55, while a twelve-week session of lessons can
between $300 and $500.
Many years ago, I watched an elderly Chinese man perform a cross
graceful dance and a martial art. Fascinated with the slow, meditative
movement, I approached the unassuming gentleman, who told me he
practicing tai chi. I learned that he was an ancient master and
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 couldnt seem to concentrate and found my mind
the trees. I quit, and through the years, as tai chis popularity
noticed individuals practicing tai chi on the beach or in parks,
that at another time I might be a more attentive student. Twenty
later, in another time and place, tai chi reappeared in my life.
Authoring a book is stressful. Sitting at a computer screen or in
library challenges ones back, eyesight, and head. Halfway
book, I realized I badly needed to balance my stress and confinement
the computer. I returned to the graceful martial art of my youth
tai chi class one night a week. I marveled at how relaxed I felt
first few sessions.
One of the oldest martial arts, tai chi is also considered the mother
the martial arts. Tai chi was designed to make manifest the I Ching,
Book of Changes. No one knows who wrote the I Ching, but the ancient
declares that everything in nature houses a yin and yang, two energies
that are found everywhere in the universe. Originally, the book
as a meditation tool and to predict the future, but the philosophy
later developed into movement, or tai chi. Tai chi charges that
in nature shows the balance of two energies. Tai chi uses the names
animals to describe the movements and their relationship to the
A movement like the Crane reflects the yin, or retreating and less
substantial energy, while Carry the Tiger to the Mountain reflects
yang, or strong, forceful, forward energy.
Both nature and the self, like a life force, consist of both energies.
chi holds that bringing these two energies in to harmony benefits
health both mentally and physically.
Tai chi originated centuries ago in China to improve endurance,
flexibility, and balance. The tai chi practitioner understands that
beings are constantly changing and always working through inner
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
based on working inside ones system, the mind and body. With
tai chi controls our thoughts: inside the body, it works to control
energy, or chi. Tai chi is a top-down method. It connects the mind
top to the body at the bottom. It works simultaneously on the mind,
To practice tai chi, you must become aware of your body and how
You cannot practice tai chi without first becoming conscious of
physical presence. Because most of us use our body incorrectly,
works with warm-up exercises to acquaint us with how the body should
function in movement. Hip rotation and waist and arm rotations warm
body. Tai chi rotates all the joints in the body. Chinese medicine
believes that if the energy is static or blocked in the joints,
ensues. When the joints open, one feels better, and the aging process
slowed. Tai chi is a gentle martial art that must be practiced to
This graceful discipline is as reflective as it is vigorous. The
one of relaxation and pleasure. I think of tai chi as the universe
harmony. As we constantly change and shift, we must learn to balance
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
and body must move together to maintain that fragile balancing we
strive for. There is little risk involved with tai chi. Cost varies,
classes range from $8 to $10, perhaps higher in some cities. Group
sessions may be cheaper, as private may be more expensive. Tai chi
practiced anywhere, inside or outside.
Traditional Chinese medicine is a unified healing system that has
over the past 3,000 years. It covers acupuncture, herbal therapy,
exercise, and diet. In traditional Chinese medicine, prevention
treatment of disease is stressed by strengthening the bodys
self-regulation, thus restoring the bodys balance within.
Chinese medicine postulates that the life energy chi, or
along invisible body pathways called meridians. The chi is the life
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
acupressure/finger pressure, to unclog the energy paths by manipulating
the pressure points, thus balancing the body.
Acupressure, an ancient therapy for tension and pain relief, uses
points as acupuncture. The distinction between acupressure and acupuncture
is that needles are used in acupuncture, and a gentle but firm pressure
the hands is the basis for acupressure. Acupressure is the older
two techniques. Acupressurists postulate that the power and sensitivity
the human hand is most effective in relieving tension related to
In order to relax muscular tension and balance the vital forces
body, acupressure uses a system of points. Acupressure sessions
only on relieving discomfort but on responding to these tensions
toxicities in the body before they develop into an illness. The
of acupressure has developed primarily through a combination of
and hands-on experience. A session runs between $20 and $30 and
This method of finger pressure has been used widely in Japan for
thousand years. During the Tokugawa period in Japan, the shogunate
organized a school of massage for the blind in order to give them
profession. From that time until the Second World War, anma, or
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
palms, thumbs, feet, and sometimes knees to apply a rhythmic pressure
the body. By using finger pressure on the acupuncture points, shiatsu
stimulates the chi to flow through the bones, nerves, arteries,
Moderate pressure applied all over the body stimulates the flow
While there may be moments of intense pressure, shiatsu promotes
of well-being and relaxation. The environment is relaxing and peaceful.
Shiatsu can help your backache by stimulating your life-blood energy
While shiatsu applied correctly has little risk, some folks dont
the intense pressure. There can be moments where the pressure borders
pain, but once released, the pain gives way to relief. Ask your
practitioner to adjust the finger pressure if it is too intense.
may not be as relaxing as a Swedish massage, which uses stroking
movements, but the result is one of rejuvenation and balance. An
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
Reflexology is a Western pressure point therapy that focuses on
It asserts that our feet truly connect us with the earth. Our feet
foundation, yet we remain unaware of them. Reflexology holds that
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
may find components of these techniques in back schools around the
country. If your physician directs you toward a conservative approach
treatment, back school will certainly be included. The following
doesnt cover the whole curriculum when it comes to back schools
country, but it does give a perspective on how back education helps
Copyright © 1995 by the RGA Publishing Group, Inc. From The
Sourcebook, by arrangement with Lowell House.
This section covers a variety of things you can do for yourself
increase your health, speed your recovery, ease pain, or aid
rehabilitation. Included are materials on lifestyle and behavior
diet, exercise, body-mind approaches, and similar self-care measures.
selected these materials because they are accepted by both traditional
alternative medical establishments and have proven helpful to many
These approaches can be adopted or modified to whatever extent you
From Our Self-Care Advisor
A collection of "do's and don'ts" and self-care options
and treating low back pain. Also provides suggestions for when to
your healthcare provider when you back is hurting.
Exercise and Fitness
From: Health Pages
Good advice about exercises you can do to prevent a repeat back
Yourself When You Have Backache
From: Backache: What Exercises Work
This helpful article tells you how to go about everyday activities
the best posture for your back. It covers everything from making
to washing dishes, child care, and gardening.
Links & Support Resources
After reading the previous sections of your report, we encourage
take this knowledge and use it as a springboard to enter the research
support networks out there focused on your health concern. The following
resources may include suggested reading, newsletters and support
research and advocacy organizations, agencies, and government bureaus.
Organizations and Internet Sites
Links and Support Resources:
From: WebMD Electronic Library Collection
An annotated list of organizations and websites to go to for more
Copyright © 1995 by the RGA Publishing Group, Inc. From The
Sourcebook, by arrangement with Lowell House.
Branch, C. L. 1994. Low Back Pain. Kansas City: American Academy
Imrie, D. 1984. Goodbye Back Ache. New York: Fawcet Book Group.
Kerkaldy-Willis, W., and C. Burton, eds. 1992. Managing Low Back
ed. New York: Churchill Livingstone.
McKenzie, R. 1993. Treat Your Own Back. 6th ed. Waikanae, New Zealand:
McKenzie, R. 1993. Treat Your Own Neck. 2nd ed. Waikanae, New Zealand:
Macnab, I. 1994. Neck Ache and Shoulder Pain. Baltimore: Williams
Oliver, J. 1994. Back-Care: An Illustrated Guide. Boston:
Wei, N. 1995. Low Back Pain: What You Need to Know and What You
About It. Frederick, MD.: N. Wei.
Wilson, A. 1994. Are You Sitting Comfortably?: A Self-Help Guide
Sufferers of Back Pain, Neck Strain, Headaches, RSI, and Other Associated
Health Problems. London: Optima.
Online Information Can Be Found At:
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
pulposus. The New England Journal of Medicine, 6/5/97
Getting to the root of back pain. Johns Hopkins Medical Letter,
Laser discectomy performs poorly in randomized trial. The Back Letter,
Lumbar supports and education for the prevention of low back pain
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.
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
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
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
Paul C. Shellito, M.D., Surgery
Harvard Medical School; Associate Visiting Surgeon, Massachusetts
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
Copyright © Nidus Information Services, Inc., 175 Fifth Avenue,
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