It starts with a twinge, an ache or a pull. Like the proverbial straw that broke the camel's back, that ache in your lumbar region or between the shoulders is most likely cumulative, a result of structural imbalances that started long ago with the feet, the gait, the posture, and have become integrated into the body over time.

Back complaints are common among us bipeds: 80 percent of Americans suffer from back pain at some point in their lives, and $50 billion annually is spent treating it.

When the pain flares up we do not care about the systemic cause. We just want it gone. Most of us simply reach for a bottle of pills and hope it goes away. But that kind of short-term relief often just kills the messenger and masks the underlying cause, leading to more pain.

English novelist Charles Kingsley might well have been talking about back pain when he wrote "Pain is no evil unless it conquers us." Here are some nonsurgical options for fighting back.

Physiatry.

A physiatrist is a doctor who specializes in physical medicine and rehabilitation, focusing on restoring function to patients with injuries to muscles, bones, tissues and nervous system. Physiatry has two main branches:

Assessment and rehabilitation for those who have source injuries such as stroke, spinal cord injury, or amputations.

Diagnosis and treatment of musculoskeletal or nerve problems of the spine or extremities from overuse, trauma or sports.

"We first establish a diagnosis, through history, exam, and, if needed, MRI or X-Ray, EMG (a nerve test), or other tests. We try to break down spine pain into categories," explains Dr. Scott Bainbridge, a spine specialist. "Is it a joint problem in the spine or pelvis? If there is tingling or weakness in the extremities, is it stenosis or an acute disc herniation?"

Every spine program is individualized, but includes two general types of exercise. The first involves the strengthening of the deep, or core, muscles. Pilates and yoga are often recommended to this end because they are effective and enjoyable, thus making good long-term options, Bainbridge says.

The second component is aerobic exercise, customized to the patient. "For example, a stenosis patient may do well exercising with the spine in a flexed position, as with bicycling; a disc problem might do better with walking or with an elliptical training machine."

While medications are often used to manage pain, other, more natural, methods can help. "Some dietary changes are also recommended," says Bainbridge. "Alcohol, nicotine, simple sugars, processed flour, and trans-fats have been found to be inflammatory to the body while vitamin D, colorful foods high in antioxidants, and foods high in omega 3 fatty acids are anti-inflammatory. Regular aerobic exercise and stress management, and a better diet, are all excellent foils for managing pain."

In a serious, unresponsive condition, an injection of corticosteroid combined with numbing medication can be administered around the nerve root or into a joint. "This is not only a therapeutic tool, but also helps confirm the diagnosis," Bainbridge says.

Chiropractic.

Chiropractic, offering a nonsurgical, drug- free option to eliminate back pain and inflammation, is considered a complementary and alternative method to treat and correct disorders of the spine and nervous system.

"Chiropractic is not spinal manipulation, it is spinal adjustment," explains chiropractor Carolyn Bartley. "Adjustments are unique to chiropractic and primary in treating back pain."

Chiropractic treatment can include nutrition (natural and anti-inflammatory diets), nonsurgical spinal decompression, cold laser (low-level light laser), rehabilitative exercise, ice/heat therapy, ultrasound, and TENS (transcutaneous electrical nerve stimulation).

According to published medical studies, chiropractic is both effective and economical in treating back pain.

"We look at the whole person, because back pain can come from any number of sources-stenosis, infections, endometriosis, piriformis syndrome, to name just a few. The location of the pain may have nothing to do with the actual source of the pain," says Bartley.

Muscle Activation Technique.

Looking at muscle weakness rather than tightness is the key in correcting imbalances that can lead to pain, according to this approach. Developed by biomechanics specialist and former Denver Broncos consultant Greg Roskopf in the mid-1990s, Muscle Activation Technique (MAT) is a science-based system that relies on neuromuscular physiology to explain its efficacy.

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