Watch Your Back

Medical Researchers Are Learning More About How to Treat Back Pain--and How Not to. Here's What to Know and a List of the Area's Top Back Experts.

By: Leslie Milk

FOR 40 YEARS, MY SPINE AND I HAD only a nodding acquaintance. I didn't bother it; it didn't bother me.

Then one afternoon I finished giving a luncheon speech, stepped down from the podium, and was in excruciating pain.

Two hours later, I was in an orthopedist's examining room. He prescribed a muscle relaxant, a pain reliever, and a week of bed rest with pillows under my knees. After a fuzzy seven days, I felt fine.

Years went by before my spine spoke up again. This time, I felt twinges when I tried to sleep on my left side or lift anything heavier than a grocery bag. The twinges turned into chronic aches and then became sharp pains.

My orthopedist sent me for an MRI, which revealed a herniated disk in my lower back between the fourth and fifth lumbar vertebrae.

For the next few years, I managed the pain with anti-inflammatory medication, heat, ice, and stretching and strength exercises. There were occasional sessions of physical therapy when the awkward gait I unconsciously adopted to protect my back caused me to strain a knee.

After a particularly bad spell, I went for a series of steroid injections into the epidural space in my spine. That helped for a while, but soon the pain was back.

The pain--and the fear of bringing it on--began to affect my life. Could I manage a long plane flight? Would dancing or carrying laundry send me to the ice packs?

I had reached the point of decision many back-pain patients face. Was it time for surgery?

FOUR OF FIVE ADULTS SUFFER LOWER-BACK PAIN at some time in their lives, according to the American Academy of Orthopedic Surgeons (AAOS). After the common cold, back pain is the most frequent cause of missed workdays in adults under the age of 45 and the most common reason that people visit doctors.

Most sufferers are not able to point to a specific action or injury that precipitated the pain. "You could bend over to pick up a pencil and have the same problem as someone who picks up a load of bricks," says Dr. Ira Fisch, a Bethesda orthopedic spine surgeon.

Back problems used to be the province of blue-collar workers. Now they are also becoming more common among office workers, says chiropractor David Fishkin, director of the Center for Low Back Pain in Bethesda. With the exception of lifting, "sitting puts the greatest pressure on the spine," he says. Physical inactivity weakens the muscles that support the spine.

Spinal disks, pads of jelly-like material surrounded by a tough outer layer, are often where doctors look first. Think of the spine as a stack of bagels (the vertebrae) with jelly doughnuts (the disks) in between. Put too much pressure on the bagels and the doughnuts get squished.

When a disk protrudes past the vertebrae, it is called a bulging disk. When the disk cracks and some of the gelatinous material pushes out, it is a ruptured or herniated disk.

The most vulnerable are those in the lower back, where the space between the vertebrae is smallest and the pressure from sitting, standing, and walking is greatest.

Disks act like shock absorbers, elastic components that make it possible for the spine to bend and flex. When they weaken or dry out--a function of aging as well as degenerative disk disease--ease of movement and range of motion decreases. What causes back pain is inflammation of the nerves in the disk or of the nerves the disk presses against.

Some medical experts think that, in some cases, disks may get a bad rap. According to Dr. James Panagis, head of the orthopedic program at the National Institute of Arthritis and Musculoskeletal and Skin Diseases, researchers aren't totally sure what a "normal" back looks like.

Some disk herniation may be present in healthy backs. If the architecture of the spine allows room for the disk to protrude without touching any nerves, the herniation may be painless.

"Lower-back pain is hard to diagnose and treat," Fisch says. The source of what we experience as "back" pain could originate anywhere in the pelvic area, while leg pain could be caused by back problems.

Eighty-five percent of patients with lower-back pain cannot be given a precise diagnosis, according to a February 2001 New England Journal of Medicine article by Dr. James Weinstein, head of orthopedics at Dartmouth Medical School, and Dr. Richard Deyo, professor of medicine at the University of Washington.

Most back pain gets better with conservative treatment, says DC orthopedist Peter Moscovitz. He will ask for an MRI or CT scan only if there are clinical signs in the history or physical examination that suggest something sinister like cancer or disease may be causing back pain.

Weinstein and Deyo agree. "The association between symptoms and imaging results is weak. Thus, nonspecific terms, such as strain, sprain, or degenerative processes, are commonly used," they say.

AMONG OTHER CONDITIONS THAT can cause lower-back and leg pain are these:

**Osteoarthritis. Cartilage on the end of the hip bones helps the hip joint move smoothly. When this cartilage wears thin, as a result of aging or injury, the joint becomes stiff and inflamed.

**Osteoporosis. Bones get weaker as we age. Post-menopausal women are at greatest risk for fracture of the lumbar, or lower, vertebrae.

**Bursitis. Small sacs called bursae act as cushions between bones, tendons, and muscles. When the bursae in the hip become inflamed, they cause pain that may radiate down the outside of the leg.

**Spinal stenosis. The space in a vertebra--akin to the hole in a bagel--can narrow and press on nerves or the spinal cord.

**Sciatica. The largest nerve in the human body is the sciatic nerve. It branches from nerve roots in the lower spine and threads its way into the buttocks, down the hip, and along the back of the leg. Arthritic bone spurs or a herniated disk can press or pinch the sciatic nerve, causing pain, weakness, or numbness.

**Spondylolysis. A stress fracture of one of the vertebrae, usually in the lumbar area.

**Spondylolisthesis. Degenerative disk disease can so weaken a vertebra that it slips forward and presses on a nerve.

**Spinal infection. Fever, chills, weight loss, and other symptoms along with back pain can indicate infection.

**Cancer. "In many patients whose lowerback pain is due to infection or cancer, the pain is not relieved when the patient lies down," according to Deyo and Weinstein.

Depending on whether a back-pain patient consults an orthopedist, neurologist, rheumatologist, or doctor of chiropractics, different tests will be administered, possibly leading to different diagnoses.

I am a case in point. X-rays show some osteoarthritis in my left hip. An MRI indicates a herniated disk, also on the left side. Pain down the outside of my left hip and leg may mean a dash of bursitis.

BILL THOMPSON WAS RIDING THE Metro to work last fall when he turned slightly and his back went into spasm. The muscles in his lower back had contracted and locked. Thompson couldn't straighten up. A friend helped him to the street and into a taxi.

Thompson, 33, until recently a graphic designer at The Washingtonian, had to lie across the back seat until he reached his doctor's office. It took two hours for a muscle relaxant to take effect so he could go home.

In high school, Thompson had hurt his back playing baseball. He was sore for a few days. After college, he was tending bar when he leaned over to pick up a keg of beer and couldn't straighten up. A chiropractor got him back on his feet.

Those bouts of pain were nowhere as intense as what he experienced on the Metro. This time, he spent a few days in bed before beginning physical therapy.

Most back patients benefit from a combination of anti-inflammatory medication, physical therapy, and lifestyle changes. Patients are counseled to make their work environments spine-friendly, to stretch and exercise, and to walk, stand, sit, and lift properly.

Fisch also administers steroid injections, a common treatment for persistent pain. The injections are most effective for sciatica and bursitis, he says.

FISCH PRESCRIBES PHYSICAL THERapy for all his back-pain patients--even if the pain is almost gone. "They need a program to stabilize the spine and they have to be taught how to take care of their backs," he says.

Thirty-five percent of the patients sent to Physical Therapy Services in DC have lower-back problems, says therapist Carole Lewis. She uses heat, ultrasound, electricity, mobilization, and massage to loosen "knots" in ligaments and soft tissue.

She suggests exercises to strengthen muscles that support the back. Lewis also studies a patient's body mechanics.

"I had a patient who was limping because she had bumped her knee. I knew it was going to irritate her back. People don't realize that the body compensates," Lewis says.

Thompson felt well enough to resume normal activities after two months of therapy. Then he was in a yoga class to strengthen his back when it went into spasm again. This time recovery was faster.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases at NIH is funding the first major study in the world comparing the risks and benefits of discectomy versus nonsurgical treatments for patients with herniated disks, spinal stenosis, and spondylolisthesis.

Dartmouth's Dr. Weinstein heads up the $14-million study. He hopes that it could affect the way health-care systems determine what they'll pay for. The way it works now, doctors are reimbursed at a much better rate for surgery.

I wanted any alternative to surgery. Since I was in pain, I could not start an exercise program like Pilates or yoga. I needed relief. That meant acupuncture or chiropractic. I began chiropractic treatment with Dr. David Fishkin.

Chiropractors use several forms of manipulation. I lay face down on a hinged table that bent in the center to stretch and decompress the vertebrae in my lower back. Fishkin applied pressure to loosen tight muscles, increase blood flow, and retract a disk that was pressing on nerves.

Fishkin also may use a two-part Lordex decompression-and-strengthening system. First, Fishkin programs the equipment to provide the right degree of pressure. Then the patient is harnessed to a metal table that opens in the middle like a dining table with leaves. During my 30-minute session, I lay on my back with a pillow under my head and a foam wedge under my knees while the two sides of the table pulled apart and went back together, alternately stretching and relaxing my spine. It felt wonderful.

After that, I moved to a seated weight machine that isolates the lower muscles of the back. The machine resembles Nautilus equipment used in health clubs, but this had more straps and bars to ensure I was in the proper position, and it was calibrated by hand to provide the exact amount of therapeutic resistance I needed.

Lordex therapy may not be covered by insurance. A course of 20 to 30 sessions costs $3,400.

In my case, Fishkin's approach was mostly low-tech. He observed my gait, measured the length of my legs, and determined that my right leg was shorter than my left. The difference was minute but enough to affect my balance and my back. A rubber insert in my right shoe corrected the imbalance.

After each session and whenever I was in pain, Fishkin advised application of ice to reduce inflammation and calm the nerves.

Most experts suggest applying cold for the first 48 to 72 hours after you hurt your back. After that, some practitioners stick with cold, some switch to heat, and others advocate alternating. "Use whatever feels good," says Moscovitz.

Fishkin recommended I get an adjustable air mattress and sleep with a body pillow between my knees. My desk chair at work has good support, but I also needed a foot rest.

Within a few months, I was sufficiently pain-free to begin rehabilitation exercises. I understood that I would continue to have flare-ups. Lower-back problems are rarely cured--they are managed.

F ISHKIN WARNED THAT AGING AND wear and tear on my arthritic hip could increase my back problems unless I changed the way I sit, stand, and walk and strengthened the muscles that protect my spine.

He sent me to J.P. Montalván at FitnessWise, a gym in Bethesda specializing in post-rehabilitation. Montalván concentrates on exercises to strengthen trunk muscles--abdominals and low-back muscles--which increases stability. Stretching increases flexibility. Because Montalván believes that the body adapts to exercise, he changes the workout routine frequently to challenge and build different muscles.

Like Fishkin and Lewis, Montalván works on body mechanics. "No one with back pain has good posture," he says.

Thanks to Fishkin, Montalván, and adherence to a stretching and strengthening regimen, surgery is no longer a consideration for me. Not everyone is so lucky.

S USAN TAYLOR'S EXPERIENCE IS THE kind that gives prospective surgery patients pause.

Taylor, a program manager at the General Accounting Office, is in her late fifties. She had a few youthful brushes with back pain. Then in 1973 she fell down a flight of stairs.

Taylor was holding her baby daughter, Lanie, when she fell. She curled herself around the baby to protect her. Taylor's spine hit the stairs over and over. It took weeks before she could get out of bed.

A year later she was diagnosed with degenerative disk disease. Taylor resisted surgery. She tried conservative treatments--including 13 steroid injections in a two-year period--but was never pain-free.

By 1984, she began experiencing numbness in her legs. She was taking eight to ten pills a day to combat pain and muscle spasms. When she could no longer feel her feet touching the ground, both an orthopedist and a neurologist told her she had run out of options.

T HERE ARE THREE PRIMARY SURGIcal procedures to alleviate back pain:**Discectomy, to remove pieces of disk that protrude or have broken off.

**Decompressive lumbar laminectomy, to remove bone spurs and rough edges on the vertebrae, increasing the space in the spinal canal (the hole in the bagel).

**Spinal fusion to strengthen the spine by removing a degenerating disk and putting bone chips between the vertebrae to create a solid section of bone.

There have been refinements in spinal surgery since Taylor had it done. Discectomies and laminectomies can be done endoscopically, with less scarring. And surgeons performing spinal fusions no longer need to chip away at a patient's hip to harvest bits of bone, says Dr. Thomas C. Schuler, president of the Virginia Spine Institute in Reston and the Redskins' spine specialist. Last July, the Food and Drug Administration approved Bone Morphogenic Protein for spinal surgery. BMP is a protein that tells the body to produce bone cells.

Taylor's surgery--she had all three procedures done at once--was a success. After four months of recovery and physical therapy, she was able to go back to work.

Because she waited so long to have surgery, she did suffer nerve damage. She trips frequently because her left foot doesn't come up high enough to clear steps. She has developed scar tissue at the fusion site and in the hip that donated bone for the fusion. Degenerative disk disease continues to create problems.

Is Taylor better off having had surgery? "Absolutely," she says. Does she still suffer chronic pain? "Absolutely."

T HERE IS NO DOUBT THAT SURGERY worked for Mark Michael. A competitive swimmer in high school and college, Michael, now 41 and a co-owner of Occasions caterers, started playing basketball ten years ago. He loved it, but he paid a price; the day after playing, he hurt. Two or three times a year, the pain was serious enough that he couldn't get out of bed. After a few years, Michael saw an orthopedist. He was told that his basketball career was over.

Keep your weight down, stretch daily, and try to reduce the stress in your life, the doctor said.

Most of the time, Michael felt fine. But his pain recurred. The next time he saw the orthopedist, he had an MRI. He had a herniated lumbar disk. He and his doctor were convinced that it was manageable.

Then Michael had an on-the-job accident. He was setting up for a client's wedding in Middleburg when he realized a summer storm was coming.

Suddenly, "it got very loud," he remembers. A tornado had touched down, collapsing the tent and sending everything inside it--including Michael--flying. He was hit by a tree branch, injuring his spine in the neck area and breaking a cervical vertebra.

After about five weeks wearing a cervical collar, he seemed fine again. Then a year later, he developed a new back pain that had him worried. This time, the pain radiated from the middle back down.

Michael tried acupuncture, stretching, and a positive attitude. Nothing helped. He went for another MRI and discovered that another lumbar disk had herniated. This time a chunk of the disk was pressing on his spinal cord.

Five weeks after the MRI, Michael had a laminectomy at Union Memorial Hospital in Baltimore. "They pulled that piece out," he says. The relief was immediate. He was back at work three days later.

Michael was an ideal surgery candidate, according to the guidelines Fisch employs. He had a clearly defined problem and showed no sciatica. However, Michael isn't cured. He still has an at-risk spine, and he works hard not to aggravate it. But he is well enough to be training for a triathlon.

I F IRA FISCH HAD HIS WAY, ELEMENtary-school kids would have lessons in body mechanics--how to sit, stand, walk, and lift without overarching the spine.

Prevention is the key to being pain-free. Exercise, stretching, and weight control reduce the burden on the back, and back-friendly work environments help.

Attitude can count considerably, I have discovered. In the past, fear of pain has caused me to tense or move awkwardly, increasing the likelihood that my back would start hurting.

Like many people with chronic back pain, Susan Taylor's challenge is to live her life without allowing her back to dominate her every move. Last month, her daughter Lanie was married. Taylor discarded her sensible shoes and went down the aisle in high heels.

Some things are worth a little pain.

Photograph by Gary Breckheimer/Corbis

Heat or Ice?

*MOST BACK PAIN IS SHORT-LIVED AND WILL GO away even if untreated. If you have strained your back by twisting or pulling a muscle or tendon, overusing muscles, or improperly lifting a heavy object, both the National Institute of Neurological Disorders and Stroke and the Mayo Clinic recommend the following:

** In acute cases, one or two days, at most, of bed rest on a firm surface or mattress. Most experts advise against bed rest in the majority of cases, because inactivity slows recovery.

** Taking over-the-counter anti-inflammatory and pain medication.

** Heat or ice. Most experts suggest applying an ice pack for the first 48 to 72 hours to relieve pain and inflammation. After that, some practitioners stick with cold, some use heat, and others advocate alternating (20 minutes of cold, 20 minutes off, 20 minutes of heat, 20 minutes off). These are comfort measures rather than cures, says DC orthopedist Peter Moscovitz. Use whatever feels better for you.

** Once the pain has subsided, resume exercise. A combination of cardiovascular and weight-bearing exercises strengthen the back and leg muscles, taking pressure off the spine. Stretching increases flexibility. You may be advised to abandon running or racket sports in favor of more back-friendly pursuits like swimming or biking. "High-impact exercise increases compression forces on the spine," says personal trainer. Montalván. High-impact sports also increase the risk of re-injury.

** If your back hurts during any activity, don't do it. "Working through the pain" can lead to more injury.

How to Prevent Back Injuries

MOST LOWER-BACK PAIN CAN BE PREVENTED. Here's how:

** Exercise regularly. Writing in the New England Journal of Medicine, Dr. Richard Deyo and Dr. James Weinstein recommend a combination of cardiovascular exercise and weight training to strengthen the back and legs. Experts also recommend stretching to increase flexibility.

** Try to keep your spine neutral in daily activities--sitting, standing, driving. Bending far forward or arching backward is hard on the back.

** If you work at a desk, it helps to take breaks and walk around. Sitting puts the most pressure on the back of any activity besides lifting. People who sit in one position for long periods have more back pain than those whose work is often interrupted. Desk chairs should have lumbar support. A foot rest may take pressure off your back.

** Control your weight. Extra weight puts an added burden on the spine.

** Don't smoke. Smoking accelerates disk degeneration.

** If you have to lift something heavy, wear a back support and lift from your legs, not your back.

** Relax. Stress makes you tense up, increasing the risk of injury.

Spine Specialists These Health Professionals Have Your Back Covered.

NO ONE TREATMENT FOR BACK PAIN WORKS FOR EVERYONE.

Some patients find relief with more-conventional care offered by orthopedists, rehabilitation doctors, or physical therapists. Some may also visit a chiropractor or acupuncturist. This list of back-pain experts includes both medical doctors and alternative therapists.

Physicians who are listed here were selected by their peers. We sent questionnaires to 5,000 randomly selected area physicians asking them what doctors they would send members of their families to. These are the orthopedists, neurosurgeons, pain-management specialists, and rehabilitation doctors who received the most votes and who treat backs.

Physical therapists, chiropractors, acupuncturists, and osteopaths were recommended by the physicians on this list as well as by their peers.

ORTHOPEDISTS

Orthopedists diagnose and treat back pain. All orthopedists are surgeons, who may operate on everything from knees to hips to hands; some specialize in the spine and repair fractures, remove bone spurs and diseased disks, and perform spinal fusions. Many use conservative treatments, including medication and physical therapy, before surgery.

**Jeffrey A. Abend, Silver Spring; 301-681-5400

**Mohit Bhatnagar, Olney, 301-774-0500; Montgomery Village, 301-977-6777; Columbia, 410-992-7800; Silver Spring, 301-598-9715

**Peter D. Bruno, McLean; 703-442-8301. Special interest in sports medicine.

**Ronald Childs, Fairfax; 703-573-7168

**Marc D. Connell, Chevy Chase; 301-657-1996. Special interest in sports medicine.

**Marc B. Danziger, Down-town DC; 202-835-2222. Special interest in sports medicine.

**Vincent G. Desiderio, Downtown DC, 202-659-9836; Northwest DC, 202-686-1286

**Joel D. Fechter, Silver Spring, 301-681-7100; Bowie, 301-262-6262. Special interest in sports medicine.

**Ira D. Fisch, Bethesda; 301-530-1010. Special interest in spine surgery.

**Melinda M. Gardner, Northwest DC; 202-244-0706

**Gabriel Gluck, Manassas; 703-361-3590

**Michael Goldsmith, Chevy Chase; 301-657-9876

**Richard M. Grossman, Chevy Chase; 301-657-1996. Special interest in sports medicine.

**Stephen Haas, Chevy Chase; 301-657-1996. Special interest in sports medicine.

**Denis R. Harris, Northwest DC; 202-362-4787. Special interest in sports medicine.

**David C. Johnson, National Rehabilitation Hospital, 202-291-9266; Northwest DC, 202-966-2256. Special interest in sports medicine.

**H. Edward Lane III, Fairfax; 703-573-7168

**William Lauerman, Georgetown University Hospital; 202-444-8766. Special interest in spine surgery.

**Louis E. Levitt, Downtown DC; 202-835-2222. Special interest in trauma.

**Robert C. Loeffler, Silver Spring; 301-681-5400

**Stephen T. Michaels, Silver Spring; 301-565-3301. Special interest in spine surgery.

**Peter A. Moskovitz, Downtown DC; 202-333-2820

**Brett R. Quigley, Rockville; 301-340-9200

**Stanley R. Rothschild, Northwest DC; 202-244-0706

**Thomas F. Ryan, Chevy Chase; 301-652-6612. Special interest in sports injuries.

**Steven C. Scherping Jr., Georgetown University Hospital; 202-444-8766. Special interest in spine surgery.

**Philip L. Schneider, Kensington; 301-949-8100. Special interest in spine surgery.

**Benjamin Shaffer, Chevy Chase; 301-657-1996

**Christopher P. Silveri, Fairfax; 703-391-0111

**Todd R. Sloan, Chevy Chase; 301-656-4317

**John K. Starr, National Rehabilitation Hospital, 202-291-9266; Northwest DC, 202-966-2256. Special interest in spine surgery.

**James E. Tozzi, National Rehabilitation Hospital, 202-291-9266; Northwest DC, 202-966-2256. Special interest in spine surgery.

**Ian M. Wattenmaker, Reston, 703-435-6604; Leesburg, 703-771-2558. Special interest in spine surgery.

**J. Richard Wells, Chevy Chase; 301-652-6612. Special interest in sports medicine and spine surgery.

**Sam W. Wiesel, Georgetown University Hospital; 202-444-8766. Special interest in spine surgery.

NEUROSURGEONS

Neurosurgeons operate on patients whose back pain is caused by trauma, tumors, disease, or abnormalities in the spine, spinal cord, or the nerves or blood vessels within the spine or spinal cord.

**Bruce J. Ammerman, Northwest DC; 202-966-6300

**Edward Aulisi, Northwest DC, Bethesda, Rockville, Georgetown University Hospital; 301-718-9611. Special interest in spine surgery.

**Charles J. Azzam, Woodbridge, 703-551-4113; Annandale, 703-205-6210

**John Barrett, Rockville, Bethesda; 301-718-9611. Special interest in spine surgery.

**Anthony Caputy, Fairfax, Northwest DC; 202-741-2735

**F. Donald Cooney, Northwest DC, Bethesda; 301-718-9611. Special interest in spine surgery.

**Francisco Ferraz, Arlington, Sterling; 703-845-1552

**Kathleen French, Fairfax; 703-641-4877

**Robert M. Gorsen, Annandale; 703-573-4700

**Fraser Henderson, Georgetown University Hospital; 202-444-4972. Special interest in spinal-cord tumors.

**Donald Hope, Reston, Fairfax; 703-560-1146. Special interest in spinal-cord surgery.

**Jeff Jacobson, Northwest DC, Bethesda; 301-718-9611. Special interest in spine surgery.

**Arthur I. Kobrine, Northwest DC; 202-293-7136

**Gary Magram, Inova Fairfax Hospital for Children; 703-970-2600

**Kevin McGrail, Georgetown University Hospital; 202-444-4972

**James Melisi, Reston, Fairfax; 703-208-0820. Special interest in spine surgery.

**Nathan Moskowitz, Olney, Frederick, Rockville; 301-309-0566

**Octavio Polanco, Chevy Chase; 301-657-2550

**Alexandros Powers, Bethesda, Rockville; 301-718-9611. Special interest in spine surgery.

**Charles Riedel, Arlington; 703-248-0111

**Frederic T. Schwartz, Chevy Chase; 301-652-6621

**Laligam Sekhar, Annandale; 703-641-5911

**Donald C. Wright, Bethesda, Northwest DC; 301-718-9611. Special interest in spine surgery.

PHYSICAL AND REHABILITATION MEDICINE SPECIALISTS

Physical-rehabilitation specialists, also known as physiatrists, are medical doctors who provide treatment and therapy for a serious back injury or a chronic back problem that doesn't require surgery. Unlike physical therapists, physiatrists can diagnose a problem and treat it, if necessary, with cortisone injections or other medications.

**Michael April, Rockville; 301-231-5600. Special interest in acupuncture.

**John Aseff, National Rehabilitation Hospital; 202-877-1916. Special interest in soft-tissue pain.

**Arthur Barletta, Clinton; 301-877-6110

**Robert D. Bunning, National Rehabilitation Hospital; 202-877-1660

**M. Theresa Carlini, Springfield; 703-866-3004

**Inder M. Chawla, Takoma Park, 301-891-5393; Olney, 301-774-5200; Northwest DC, 202-872-1855; Sibley Hospital, 202-537-4158; Landover, 301-306-0300. Special interest in chronic pain.

**Abraham Cherrick, Falls Church, 703-998-8824; Alexandria, 703-971-4604; Inova Alexandria Hospital, 703-504-3535

**C. James Duke, Silver Spring; 301-754-2855

**Kathleen Fink, Bethesda; 301-581-8030

**Ali G. Ganjei, Alexandria, 703-664-7285; Fairfax, 703-391-3642

**Roger V. Gisolfi, Alexandria; 703-664-7285

**Kathryn Grant, Arlington; 703-558-6507

**Mark Klaiman, Northwest DC, Bethesda, 301-493-8103. Special interest in chronic pain.

**Philip Marion, Takoma Park; 301-891-0616

**Andrew McCarthy, National Rehabilitation Hospital; 202-877-1686. Special interest in neurologic rehabilitation.

**Andrew V. Panagos, Bethesda; 301-493-8103. Special interest in chronic pain.

**Wan Shin, Inova Fairfax Hospital; 703-204-6086. Special interest in acupuncture.

**David P. Sniezek, Downtown DC, 202-296-3555; McLean, 703-506-8471. Special interest in acupuncture and chiropractic.

**Neil Spiegel, Rockville; 301-231-5600

**Kathrin Swoboda, Children's National Medical Center, 202-884-3094; Fairfax, 571-226-8381

**John Toerge, National Rehabilitation Hospital and Georgetown University Hospital, 202-444-1257; Bethesda, 301-581-8030. Special interest in sports injuries and muscular-skeletal injuries.

PAIN-MANAGEMENT SPECIALISTS

Pain-management specialists are neurologists, anesthesiologists, and other physicians who treat chronic pain. They may employ manipulation, physical therapy, medication, and--in the case of anesthesiologists--epidural and trigger-point injections.

**Babak Arvanaghi, Suburban Hospital; 301-896-2699

**Abraham Cherrick, Falls Church, 703-998-8824; Alexandria, 703-971-4604; Inova Alexandria Hospital, 703-504-3535

**William Chester, Rockville; 240-453-9182

**John F. Dombrowski, Sibley Hospital; 202-537-4186

**Robert Gerwin, Bethesda; 301-656-0220. Neurologist.

**Jody Ellen Green, Bethesda; 301-652-0042. Neurologist.

**Howard Heit, Fairfax; 703-698-6151

**John Huffman, Holy Cross Hospital, Silver Spring; 301-681-3020. Concentration in anesthesiology.

**Marc Loev, Hagerstown, Rockville; 301-881-7246

**Veronica D. Mitchell, Georgetown University Hospital; 202-444-2090

**Leeann Rhodes, Washington Hospital Center; 202-877-3442

**Eduardo A. Salcedo, Suburban Hospital; 301-896-2699

**Gerald Scheinman, Shady Grove Adventist Hospital; 301-279-6324

**Carl Sylvester, Sibley Hospital; 202-537-4186. Concentration in anesthesiology.

**John Tam, Shady Grove Adventist Hospital; 301-279-6324

**Lester Zuckerman, Chevy Chase, Rockville; 301-881-7246. Concentration in anesthesiology.

PHYSICAL THERAPISTS

Physicians often refer patients with back pain to physical therapists to help them regain strength after injuries. Physical therapists design exercise programs and teach proper body mechanics.

Here are the most-recommended physical therapists and centers for back pain:

**Kensington Physical Therapy; 240-403-0909

**Medical Illness Counseling Center, Chevy Chase; 301-654-3638

**National Rehabilitation Hospital, Northwest DC and 17 satellite locations in DC, Maryland, and Virginia.; www.nrhrehab.org.

**Physical Therapy Services, Downtown DC; 202-775-1777. Carole Lewis is recommended.

**Physical Therapy and Sports Assessment, five locations in DC and Maryland; www.ptsac.com

ALTERNATIVE PRACTITIONERS

Depending on the diagnosis, back-pain sufferers may find relief from alternative approaches such as massage, biofeedback, Pilates, yoga, or bodywork techniques such as Alexander or Feldenkrais.

Three of the better-known specialties--chiropractic, osteopathy, and acupuncture--are frequently used for back pain. It is hard to come up with a list of "best" practitioners in these specialties, since they tend to be small practices with radically different philosophies. Among chiropractors, for example, you'll find disagreement about the best approach to the same back problem, depending on which school the healer attended.

Word of mouth, from friends and family, is a good way to find a practitioner. You might also ask your physician, although few doctors refer to or work with alternative practitioners. An exception is at George Washington University Medical Center, where their Center for Integrative Medicine offers acupuncture, herbal medicine, chiropractic, Alexander, and more; call 202-833-5055, or see www.integrativemedicinedc.com.

For more names of acupuncturists, see the Web sites of the National Certification Commission for Acupuncture and Oriental Medicine (www.nccaom.org) or American Association of Oriental Medicine (www.aaom.org, click on Referral Search). These are the two most respected associations for acupuncturists.

For chiropractors, check out the American Chiropractic Association, www.amerchiro.org.

Osteopaths, like chiropractors, use manipulation to heal back pain; they can also prescribe medication. The American Osteopathic Association (www.aoa-net.org) can provide referrals to its members.

The best approach is to find a practitioner convenient to you, and to call and ask how often, and how successfully, he or she has treated your specific condition.