MOST BACK PAIN GOES AWAY by itself. If yours doesn't, here is a list of the kinds of doctors and therapists to whom you might turn for a diagnosis, and some of the treatment options that might be considered. Neither list is all-inclusive.
DOCTORS AND THERAPISTS
Internists. Internists are generalists and can distinguis between the kind of back pain that needs to be sent on to a surgeon and the other kind. If your regular doctor happens to be an internist, visiting him or her will probably be less expensive -- and perhaps psychologically more comfortable -- than seeing a specialist. The downside is that internists, like surgeons, usually have not had much training in non-operative therapies for back pain. How effective they are at prescribing that kind of therapy -- even if they are willing to prescribe it at all -- will depend on the individual.
Orthopedic surgeons. Orthopedists specialize in surgery for muscle and skeletal problems, and so do a lot of back operations. But if you are thinking of referring yourself to an orthopedist for your aching back, remember that he or she is a surgeon, and therefore might very well have more of a tendency than other physicians to turn to surgery when confronted with a hurting back.
Neurosurgeons. Neurosurgeons specialize in surgery involving the nervous system. Like orthopedists, they do a lot of back operations.
Physiatrists. Not to be confused with psychiatrists, who specialize in the psyche, physiatrists are M.D.s who specialize in physical conditions requiring chronic and rehabilitative care. Because their training orients them toward non-surgical therapies, physiatrists might be a good choice for the back patient who doesn't need surgery but wants something more than the routine prescription for anti-inflammatory medication.
Osteopaths. Doctors of osteopathy are M.D.s who have also been trained in manipulating the spine. They are not surgeons, and they are fairly rare in this area.
Chiropractors. Chiropractors are not M.D.s, but they know quite a bit about the back. Their specialty is manipulating the spine; they do not prescribe drugs or do surgery.
Physical therapists. Physical therapists also are not M.D.s, but they are licensed health-care professionals and can be quite expert at back-pain diagnosis as well as treatment.
Physical therapy. "The backbone of the treatment for spina disorders is non-operative and is physical therapy," says orthopedic surgeon Paul Asdourian, medical director of the H. M. Finney Spine Center at Union Memorial Hospital.
Dr. Asdourian's statement reflects a shift in philosophy among those who deal with bad backs: As surgery and bed rest have fallen from favor as treatment for all but a few such cases, physical therapy is increasingly seen as the answer -- or at least an answer -- for the great number of back-pain cases that do not require immediate surgery.
In line with the change in philosophy toward back-pain treatment, physical therapy itself has changed, to become more exercise-oriented. "The trend is more toward conditioning," says therapist Walter Mady, partner in Mady-Mules Physical Therapy and Sports Rehabilitation. And the conditioning may be strenuous: A recent Danish study suggested that chronic low back pain does better with intensive exercise than with moderate exercise or with mild exercise combined with heat therapy and massage.
Mr. Mady is probably typical of the new order when he says his approach is first to find out what's causing the pain, then to use traditional passive therapies for moderating pain, and finally to begin a program of exercise and education in "proper biomechanics" -- how to lift, move, sit and walk in ways that are good for the back.
"Our philosophy is really prevention," he says. Back patients have to learn how to be their own therapists; "to me that's the key."
In Maryland, unlike some other states, people can refer themselves to physical therapists. Whether their insurance will then cover the therapy is another question; call first.
Surgery. Surgery is the treatment back patients fear the most -- but it's the one they're least likely to need. Back surgery is done less often than in the past, and only one out of 10 back-pain patients he sees are candidates for it, says Sumio Uematsu, associate professor of neurosurgery at the Johns Hopkins University School of Medicine.
Ruling out those cases where back pain is caused by some non-back condition -- a pelvic infection, perhaps, or a tumor -- the single surgical case is likely to involve a ruptured disc. Discs are the elastic structures that lie between the spine's vertebrae, forming an essential cushion. If they burst out of their casing and extrude out of their proper space -- that is, rupture -- they can press on spinal nerves and cause, in some cases, permanent damage.