Nonoperative treatment of back pain

Hot or cold: Hot or cold packs – or sometimes a combination of the two – can
be soothing to chronically sore, stiff backs. Heat dilates the blood vessels,
improving the supply of oxygen that the blood takes to the back and reducing
muscle spasms. Heat also alters the sensation of

pain. Cold may reduce inflammation by decreasing the size of blood vessels
and the flow of blood to the area. Although cold may feel painful against the
skin, it numbs deep

pain. Applying heat or cold may relieve

pain, but it does not cure the cause of chronic back pain.

Exercise: Although exercise is usually not advisable for acute back pain, proper
exercise can help ease chronic pain and perhaps reduce its risk of returning.
The following four types of exercise are important to general physical fitness
and may be helpful for certain specific causes of back pain:

Flexion: The purposes of flexion exercises, which are exercises in which you
bend forward, are to 1) widen the spaces between the vertebrae, thereby reducing
pressure on the nerves; 2) stretch muscles of the back and hips; and 3)
strengthen abdominal and buttock muscles. Many doctors think that strengthening
the muscles of the abdomen will reduce the load on the spine. One word of
caution: If your back pain is caused by a herniated disc, check with your doctor
before performing flexion exercises because they may increase pressure within
the discs, making the problem worse.

Extension: With extension exercises, you bend backward. They may minimize
radiating pain, which is pain you can feel in other parts of the body besides
where it originates. Examples of extension exercises are leg lifting while lying
prone and raising the trunk while lying prone. The theory behind these exercises
is that they open up the spinal canal in places and develop muscles that support
the spine.

Stretching: The goal of stretching exercises, as their name suggests, is to
stretch and improve the extension of muscles and other soft tissues of the back.
This can reduce back stiffness and improve range of motion.

Aerobic: Aerobic exercise is the type that gets your heart pumping faster and
keeps your heart rate elevated for a while. For fitness, it is important to get
at least 30 minutes of aerobic (also called cardiovascular) exercise three times
a week. Aerobic exercises work the large muscles of the body and include brisk
walking, jogging, and swimming. For back problems, you should avoid exercise
that requires twisting or vigorous forward flexion, such as aerobic dancing and
rowing, because these actions may raise pressure in the discs and actually do
more harm than good. In addition, avoid high-impact activities if you have disc
disease. If back pain or your fitness level makes it impossible to exercise 30
minutes at a time, try three 10-minute sessions to start with and work up to
your goal. But first, speak with your doctor or physical therapist about the
safest aerobic exercise for you.

Medications: A wide range of medications are used to treat chronic back pain.
Some you can try on your own. Others are available only with a doctor's
prescription. The following are the main types of medications used for back
pain.

Analgesics: Analgesic medications are those designed specifically to relieve
pain. They include over-the-counter acetaminophen (Tylenol1) and aspirin, as
well as prescription narcotics, such as oxycodone with acetaminophen (Percocet)
or hydrocodone with acetaminophen (Vicodin). Aspirin and acetaminophen are the
most commonly used analgesics; narcotics should only be used for a short time
for severe pain or pain after surgery. People with muscular back pain or
arthritis pain that is not relieved by medications may find topical analgesics
helpful. These creams, ointments, and salves are rubbed directly onto the skin
over the site of pain. They use one or more of a variety of ingredients to ease
pain. Topical analgesics include such products as Zostrix, Icy Hot, and Ben Gay.

1 Brand names included in this booklet are provided as examples only, and their
inclusion does not mean that these products are endorsed by the National
Institutes of Health or any other Government agency. Also, if a particular brand
name is not mentioned, this does not mean or imply that the product is
unsatisfactory.

NSAIDs: Nonsteroidal anti-inflammatory drugs (NSAIDs)2 are drugs that relieve
pain and inflammation, both of which may play a role in some cases of back pain.
Aspirin, ibuprofen, naproxen, and naproxen sodium are examples of NSAIDs. They
are often the first type of medication used. All NSAIDs work similarly: by
blocking substances called prostaglandins that contribute to inflammation and
pain. However, each NSAID is a different chemical, and each has a slightly
different effect on the body.

Some NSAIDS are available over the counter, while more than a dozen others,
including a subclass called COX-2 inhibitors, are available only with a
prescription.

All NSAIDS can have significant side effects, and for unknown reasons, some
people seem to respond better to one NSAID than another. Any person taking
NSAIDS regularly should be monitored by a doctor.

2Warning: NSAIDs can cause stomach irritation or, less often, they can affect
kidney function. The longer a person uses NSAIDs, the more likely he or she is
to have side effects, ranging from mild to serious. Many other drugs cannot be
taken when a patient is being treated with NSAIDs because NSAIDs alter the way
the body uses or eliminates these other drugs. Check with your health-care
provider or pharmacist before you take NSAIDs. Also, NSAIDs sometimes are
associated with serious gastrointestinal problems, including ulcers, bleeding,
and perforation of the stomach or intestine. People over age 65 and those with
any history of ulcers or gastrointestinal bleeding should use NSAIDs with
caution.

Other Medications: Muscle relaxants and certain antidepressants have also been
prescribed for chronic back pain, but their usefulness is questionable.

Traction: Traction involves using pulleys and weights to stretch the back. The
rationale behind traction is to pull the vertebrae apart to allow a bulging disc
to slip back into place. Some people experience pain relief while in traction,
but that relief is usually temporary. Once traction is released, the stretch is
not sustained and back pain is likely to return. There is no scientific evidence
that traction provides any long-term benefits for people with back pain.

Corsets and braces: Corsets and braces include a number of devices, such as
elastic bands and stiff supports with metal stays, that are designed to limit
the motion of the lumbar spine, provide abdominal support, and correct posture.
While these may be appropriate after certain kinds of surgery, there is little,
if any, evidence that they help treat chronic low back pain. In fact, by keeping
you from using your back muscles, they may actually cause more problems than
they solve by causing lower back muscles to weaken from lack of use.

Behavioral modification: Developing a healthy attitude and learning to move your
body properly while you do daily activities – particularly those involving heavy
lifting, pushing, or pulling – are sometimes part of the treatment plan for
people with back pain. Other behavior changes that might help pain include
adopting healthy habits, such as exercise, relaxation, and regular sleep, and
dropping bad habits, such as smoking and eating poorly.

Injections: When medications and other nonsurgical treatments fail to relieve
chronic back pain, doctors may recommend injections for pain relief. Following
are some of the most commonly used injections, although some are of questionable
value:

Nerve root blocks: If a nerve is inflamed or compressed as it passes from the
spinal column between the vertebrae, an injection called a nerve root block may
be used to help ease the resulting back and leg pain. The injection contains a
steroid medication and/or anesthetic and is administered to the affected part of
the nerve. Whether the procedure helps or not depends on finding and injecting
precisely the right nerve.

Facet joint injections: The facet joints are those where the vertebrae connect
to one another, keeping the spine aligned. Although arthritis in the facet
joints themselves is rarely the source of back pain, the injection of
anesthetics or steroid medications into facet joints is sometimes tried as a way
to relieve pain. The effectiveness of these injections is questionable. One
study suggests that this treatment is overused and ineffective.

Trigger point injections: In this procedure, an anesthetic is injected into
specific areas in the back that are painful when the doctor applies pressure to
them. Some doctors add a steroid medication to the injection. Although the
injections are commonly used, researchers have found that injecting anesthetics
and/or steroids into trigger points provides no more relief than "dry needling,"
or inserting a needle and not injecting a medication.

Prolotherapy: One of most talked-about procedures for back pain, prolotherapy is
a treatment in which a practitioner injects a sugar solution or other irritating
substance into trigger points along the periosteum (the tough, fibrous tissue
covering the bones) to trigger an inflammatory response that promotes the growth
of dense, fibrous tissue. The theory behind prolotherapy is that such tissue
growth strengthens the attachment of tendons and ligaments whose loosening has
contributed to back pain. As yet, studies have not verified the effectiveness of
prolotherapy. The procedure is used primarily by chiropractors and osteopathic
physicians.

Complementary and alternative treatments: When back pain becomes chronic or when
medications and other conventional therapies do not relieve it, many people try
complementary and alternative treatments. While such therapies won't cure
diseases or repair the injuries that cause pain, some people find them useful
for managing or relieving pain. Following are some of the most commonly used
complementary therapies.

Manipulation: Spinal manipulation refers to procedures in which professionals
use their hands to mobilize, adjust, massage, or stimulate the spine or
surrounding tissues. This type of therapy is often performed by osteopathic
doctors and chiropractors. It tends to be most effective in people with
uncomplicated pain and when used with other therapies. Spinal manipulation is
not appropriate if you have a medical problem such as osteoporosis, spinal cord
compression, or inflammatory arthritis (such as rheumatoid arthritis) or if you
are taking blood-thinning medications such as warfarin (Coumadin) or heparin (Calciparine,
Liquaemin).

Transcutaneous Electrical Nerve Stimulation (TENS): TENS involves wearing a
small box over the painful area that directs mild electrical impulses to nerves
there. The theory is that stimulating the nervous system can modify the
perception of pain. Early studies of TENS suggested it could elevate the levels
of endorphins, the body's natural pain-numbing chemicals, in the spinal fluid.
But subsequent studies of its effectiveness against pain have produced mixed
results.

Acupuncture: This ancient Chinese practice has been gaining increasing
acceptance and popularity in the United States. It is based on the theory that a
life force called Qi (pronounced chee) flows through the body along certain
channels, which if blocked can cause illness. According to the theory, the
insertion of thin needles at precise locations along these channels by
practitioners can unblock the flow of Qi, relieving pain and restoring health.

Although few Western-trained doctors would agree with the concept of blocked Qi,
some believe that inserting and then stimulating needles (by twisting or passing
a low-voltage electrical current through them) may foster the production of the
body's natural pain-numbing chemicals, such as endorphins, serotonin, and
acetylcholine.

A consensus panel convened by the National Institutes of Health (NIH) in 1997
concluded that there is clear evidence this treatment is effective for some pain
conditions, including postoperative dental pain. Although there is less
convincing evidence to support using acupuncture for back pain and some other
pain conditions, the panel concluded that acupuncture may be effective when used
as part of a comprehensive treatment plan for low back pain, fibromyalgia, and
several other conditions.

Acupressure: As with acupuncture, the theory behind acupressure is that it
unblocks the flow of Qi. The difference between acupuncture and acupressure is
that no needles are used in acupressure. Instead, a therapist applies pressure
to points along the channels with his or her hands, elbows, or even feet. (In
some cases, patients are taught to do their own acupressure.) Acupressure has
not been well studied for back pain.

Rolfing: A type of massage, rolfing involves using strong pressure on deep
tissues in the back to relieve tightness of the fascia, a sheath of tissue that
covers the muscles, that can cause or contribute to back pain. The theory behind
rolfing is that releasing muscles and tissues from the fascia enables the back
to properly align itself. So far, the usefulness of rolfing for back pain has
not been scientifically proven.