Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: TUESDAY, October 11, 1994 TAG: 9410180021
SECTION: EXTRA PAGE: 1 EDITION: METRO
SOURCE: SANDRA JACOBS KNIGHT-RIDDER NEWSPAPERS
DATELINE: LENGTH: Long
That graceful softball dive has left you nearly immobile. Your back is wracked with spasms. Every movement is its own brand of torture.
Gone are the days when a doctor pumped you full of painkillers and sent you to bed for weeks, put you in traction or wheeled you straight to surgery. Experience and high-tech imaging techniques have cast doubt on these old methods.
``We've come to rethink the causes of back pain,'' said Richard Compton, program director of the University of Miami Comprehensive Pain and Rehabilitation Center at South Shore Hospital in Miami Beach.
This translates into fewer painkillers and fewer surgeries - now believed to benefit only a very small percentage of back-pain sufferers. What's new: a lot more exercise for treatment. And preventive exercise to maintain a strong, healthy back is a point on which even doctors and chiropractors agree.
Even for those in extreme pain, the newly popular first line of treatment is movement and stretching. The good news is, your aching back probably will heal. Most flare-ups get better within a few weeks, even if left alone.
If you are one of those lucky, limber souls who think this story isn't for you, read on: Some 80 percent of adults feel back pain eventually. It is the second most common reason for visiting a doctor, after the common cold, and the leading cause of work-related disability.
Pain usually begins in the late 30s and early 40s, when wear and tear and bad habits begin to take their toll.
Contrary to common thought, a single triggering incident rarely is the cause.
``It's usually an accumulation of doing things the wrong way over time - poor posture, sedentary lifestyle, sitting and typing, improper lifting,'' said Mary Ann Towne, director of rehabilitative services at Cleveland Clinic Florida in Fort Lauderdale, Fla. ``And there are not a lot of quick fixes.''
Vulnerable backs can be made strong and supple by exercise - just two hours a week, on the living-room rug. But you must keep it up for life, experts say.
For the rest of us, a few minutes of regular stretching and strengthening may save buckets of cash and tears. The idea is to bolster the body's defense against back episodes by improving strength and flexibility.
Most back pain is not caused by flaws in the spine's architecture, but in the muscles and ligaments that support the spinal column. A weakness - from misuse, lack of use or quirk of nature - can cause pain.
For decades, back pain was assumed to be linked to bulges and ruptures in the discs, those cushions between vertebrae with hard shells and jellylike insides. When discs bulge or break, their contents can press against nerves, painfully. A logical medical response has been surgery: cut the bulging portion and some of the bone around it.
But a recent study of 98 people with no back pain showed that 52 percent had at least one disc bulge; in 38 percent, more than one disc was abnormal. When it comes to back pain, then, disc irregularities may be coincidence, not cause.
The study used magnetic resonance imaging, computerized images of body tissues, a technique widely available in the past decade. The study, published in July's New England Journal of Medicine, also suggested that bulges increase with age.
A ruptured disc or one pressing on a nerve - MRIs show this - may cause pain or weakness in legs. Some doctors recommend surgery.
Others - including Dr. David Lehrman, a Miami Beach orthopedic surgeon - recommend physical therapy first, even for probable herniated discs. (``Herniated disc'' is the common, though not very descriptive, term for all degrees of protrusions.)
Lehrman puts patients on a six-week regimen before even taking an MRI. He said 95 percent of patients with back pain heal with exercise therapy. Others point out that severe pain from a leaked disc also may go away as the material dries up.
Lehrman advises even patients in great pain to get out of bed and start moving. If he indulges a day or two of bed rest, patients are taught to stretch right there on the mattress.
``I don't let anyone lie in bed like a lox,'' he said.
Although medications are out of style with most back specialists, some prescribe a mild muscle relaxant or anti-inflammatory or shot of cortisone.
At the University of Miami's pain center, patients are weaned off the Demerol, Valium, even morphine prescribed to them before they arrived, Compton said. The drugs can be addictive and bring depression, passivity and weight gain - all deterrents to exercise, he said.
``When you tell patients about not using medication they are scared to death and rightly so,'' Compton said. ``But as soon as you start activity, the body produces its own pain-blocking endorphins.''
The fear that comes with back pain can create its own problems: the body tenses, muscles tighten. That tension, over time, can make muscles stiff, exacerbating pain. If one muscle or ligament isn't working well, other muscles work overtime - distorting and putting pressure on the spine.
At a typical rehab center, patients may come daily or a few times a week at first, for sessions that stretch and strengthen not only the back, but also the leg and stomach muscles that help hold up the spine. Exercises are used to reverse the injury - if bending hurts, exercises stretch in the opposite direction.
The patient-powered approach is as effective as any other, a recent study suggests. Doctors at the Seattle-area Group Health Cooperative of Puget Sound were categorized into three groups according to how frequently they prescribed pain drugs and bed rest.
Patients of the lowest-prescribing doctors were more likely to say that they ``fully understood'' how to take care of their back after visiting their doctors.
Moreover, a month after their initial visit, only 30 percent were still limited moderately or severely in their activities - compared to 37 percent in the middle group and 46 percent of those whose doctors most frequently turned to drugs and bed rest.
Patients whose doctors did less, but taught more about self-care, cost significantly less: $428 for a year vs. $768 in the highest group.
The study was done by the Seattle-based Back Pain Outcome Assessment Team, a U.S. government initiative to clarify the best ways to treat back pain's costly drain on productivity and medical resources.
Although the team has not published final conclusions of its five-year effort, an early report noted that low back pain treatments ``seem to be more a function of the health-care provider than the patient and his or her signs and symptoms.''
Cost concerns about overuse of surgery and MRIs - and doubts about their effectiveness - already has made doctors pause.
``Doctors are thinking twice before prescribing expensive surgery,'' said Compton.
Physical therapy, if prescribed by a physician, is covered by most insurers. Surgery is increasingly difficult to win approval for from insurers or HMOs.
By some estimates, only 1 or 2 percent of those with back pain should have surgery. Dr. Linda Sternau, a surgeon at the University of Miami and Mount Sinai Hospital, puts the number at somewhere under 10 percent. She almost certainly operates when potential nerve damage is signaled by loss of bowel or bladder control, a sudden and profound leg weakness or a gradual weakness that gets worse instead of better.
Surgery also is considered for patients with a narrowing of the spinal column - sometimes natural to aging. But not every case of narrowing or ``stenosis'' translates into pain.
Almost anyone else should not consider surgery until after a few weeks of physical therapy, Sternau said. But those in pain should see a primary physician before going to a rehab center, so abdominal aneurysms, arthritis and other serious ailments can be ruled out.
If disc surgery is necessary, Sternau makes only a 1-inch incision to remove the disc fragments; rarely does she remove bone. Patients return to work in a week, she said.
by CNB