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Back Pain and Sciatica

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of back pain.

Alternative Names

Herniated Disk; Sciatica

Medications and Alternative Treatments

The most commonly prescribed medications for the treatment of back pain are nonsteroidal anti-inflammatory drugs (NSAIDs). These agents block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. Evidence suggests that short term use brings effective relief in patients with acute back pain. Their benefits for chronic back pain are less certain.

There are dozens of NSAIDs. The most common are the following:

  • Over-the-counter NSAIDs include aspirin, ibuprofen (Advil, Nuprin, Motrin IB, Rufen), naproxen (Aleve), ketoprofen (Actron, Orudis KT).
  • Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox), flurbiprofen (Ansaid), diclofenac (Voltaren), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), nabumetone (Relafen), dexibuprofen (Seractil), indomethacin (Indocin).
  • Topical NSAIDs delivered in gels, creams, or patches are proving to reduce arthritic pain and pose less of a risk for gastrointestinal complications associated with oral NSAIDs. Topical forms that contain diclofenac (Pennsaid, Oxa Sat) are now available outside the US. Others showing promise contain the NSAIDs eltenac, ibuprofen, or ketoprofen. One interesting agent combines and NSAID with fish oil compounds, which have anti-inflammatory effects.

Regular use of even over-the-counter NSAIDs may be hazardous for anyone and has been associated with the following side effects:

  • Ulcers and gastrointestinal bleeding. This is the major danger with long-term use of NSAIDs. (Indomethacin poses a higher risk than many others for this adverse effect.)
  • Increased blood pressure. Most NSAIDs appear to pose this risk, with higher risks observed with piroxicam (Feldene), naproxen (Aleve), and indomethacin (Indocin). (Sulindac has the smallest effect and aspirin as no risk.) People with hypertension, severe vascular disease, kidney, or liver problems and those taking diuretics must be closely monitored if they need to take NSAIDs.
  • May delay the emptying of the stomach, which could interfere with the actions of other drugs. The elderly are at special risk.
  • Dizziness.
  • Tinnitus (ringing in the ear).
  • Headache.
  • Skin rash.
  • Depression has also been noted.
  • Confusion or bizarre sensation (in some higher-potency NSAIDs, notably indomethacin).
  • Possible higher risk for miscarriage (particularly if the NSAID is taken for more than a week or around the time of conception).
  • Kidney abnormalities have been reported in people taking NSAIDs, which resolve when the drugs are withdrawn. Any sudden weight gain or swelling should be reported to a physician. Anyone with kidney disease should avoid these drugs.
  • There is a small risk for liver abnormalities.

Note on interactions: Of great concern is research suggesting taking NSAIDs with aspirin might reduce the benefits of aspirin or other heart protective drugs. Diabetics taking oral hypoglycemics may need to adjust the dosage if they also need to take NSAIDs because of possible harmful interactions between the drugs.

NSAID-Induced Ulcers and Gastrointestinal Bleeding

Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) is the second most common cause of ulcers and the rate of NSAID-caused ulcers is increasing. Ulcers caused by nonsteroidal anti-inflammatory drugs (NSAIDs) are more likely to bleed than those caused by the bacteria H. pylori. NSAID-related bleeding and stomach problems may be responsible for 107,000 hospital admissions and 16,500 deaths each year. Because there are usually no gastrointestinal symptoms from NSAIDs until bleeding begins, physicians cannot predict which patients taking these drugs will develop bleeding. Among the groups at high risk for bleeding are elderly people, anyone with a history of ulcers of GI bleeding, patients with serious heart conditions, alcohol abusers, and those on certain medications, such anticoagulants ("blood thinners"), corticosteroids, or bisphosphonates (drugs used for osteoporosis).

Preventing Ulcers or Rebleeding Induced by NSAIDS. If NSAID-induced ulcers or bleeding are identified, the first steps are the following:

  • Test for H. pylori and if infected take antibiotic treatments.
  • Try switching to alternative pain relievers. The first choice at this time are coxibs, usually celecoxib (Celebrex). It should be noted, however, that although they have a lower risk for ulcers and bleeding than standard NSAIDs, they are not entirely safe for the GI tract.

People who still need to take NSAIDs may try the following:

  • Use the lowest NSAID dose possible.
  • Try adding a proton-pump inhibitors (PPIs). Studies suggest they lower the risk for NSAID-induced ulcers but cannot completely prevent them. Brands include omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprozole (Protonix).
  • Try misoprostol or Arthrotec. If other agents are inappropriate, misoprostol protects against the major intestinal toxicity of NSAIDs. It was the first drug approved for preventing NSAID-induced ulcers. It is equally or even more effective than some of the PPIs, but it does not heal existing ulcers and has more side effects than PPIs. Patients tend to stop using it. Arthrotec is a combination of an ulcer protective agent called misoprostol and the NSAID diclofenac. One study found that patients taking Arthrotec had 65% to 80% fewer ulcers than those who took NSAIDs alone.
  • One small study on animals suggested that taking L-arginine (an amino acid found in health stores) may help protect against damage from NSAIDs. As with all alternative agents, this product is not government regulated and more research is needed to confirm its benefits.

A 2002 study compared the coxib Celebrex with an NSAID (diclofenac) plus Prilosec in patients who had NSAID-induced bleeding. Unfortunately, there were no significant differences in rebleeding rates, which were high (about 5% within six months). Pain relief was about equal. More research is needed to determine whether other combinations may prove to be better options for these patients.

Stomach disease or trauma
An ulcer is a crater-like lesion on the skin or mucous membrane caused by an inflammatory, infectious, or malignant condition. To avoid irritating an ulcer a person can try eliminating certain substances from their diet such as caffeine, alcohol, aspirin, and avoid smoking. Patients can take certain medicines to suppress the acid in the stomach causing the the erosion of the stomach lining. Endoscopic therapy can be used to stop bleeding from the ulcer.

COX-2 Inhibitors (Coxibs)

Celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra) are known as COX-2 (cyclooxygenase-2) inhibitors, or coxibs. They inhibit an inflammation-promoting enzyme called COX-2. Others, such as etoricoxib, are under investigation. Meloxicam (Mobicox) is a related drug known as a preferential COX-2 inhibitor.

Evidence is increasing that the coxibs are significantly less harmful to the gastrointestinal (GI) tract than common NSAIDs, but they still pose some risk. In an important 2003 study, Celebrex had a significantly better safety record in the GI tract than NSAIDs and had lower rates of ulcers even in patients who needed to also take aspirin prevent heart attacks. Another 2003 study also suggested that rofecoxib was safer for the GI tract than NSAIDs. Some early evidence also suggests that, like NSAIDs, they may be partially protective against colon cancer and possibly even Alzheimer's disease.

In spite of their potential promise, some researchers believe that inhibiting COX-2 may have some negative side effects over the long term. The effects of these drugs on the heart particularly require clarification. The following are possible adverse effects or complications:

  • They still pose a risk for gastrointestinal bleeding, although it is lower than with standard NSAIDs.
  • Some studies have reported a higher incidence of heart attacks in patients taking Vioxx compared to those taking standard NSAIDs. There were limitations to these studies, however, and 2003 study of 67,000 elderly patients found no higher risk compared to patients taking other NSAIDs or none of these drugs. Some (but not all evidence) suggests that the COX-2 inhibitors may increase the risk for blood clots. On the other hand, some studies have suggested that the anti-inflammatory effects, at least in Celebrex and meloxicam (Movicox), may have beneficial effects on blood vessels that would be heart protective.
  • Celebrex or Vioxx can increase in blood pressure, with Vioxx having the greater effect.
  • A few cases of neurologic side effects (hallucinations) have been observed with higher doses of Celebrex or Vioxx.
  • Coxibs may have some adverse effects on kidney function, particularly in elderly people, which is similar to the effects of standard NSAIDs. Liver abnormalities, which are side effects of many drugs, have also been reported with coxibs and need further follow-up.
  • They may have negative effects on pregnancy and fertility.
  • Some severe allergic reactions have been reported in patients taking valdecoxib (Bextra). People allergic to sulfa drugs may be at particular risk. Anyone who develops a rash after taking these agents should stop taking them immediately.
  • Patients who are sensitive to aspirin should discuss coxibs with their physician. Some may be safer for these individuals than others.

Coxibs can interfere with other drugs taken concurrently. Patients taking anticoagulant drugs such as warfarin may experience a higher risk for bleeding with the use of these agents. The use of coxibs can interfere with many other drugs taken concurrently, including lithium, methotrexate, and many others taken for heart disease, high blood pressure, or epilepsy. Patients should discuss all other medications with their physician. Patients should discuss all other medications with their physician.

COX-2 inhibitors are also significantly more expensive than traditional NSAID, costing about $80 per month, compared to about $15 for an NSAID like naproxen. Although they pose a lower risk for ulcers than NSAIDs, this risk is small for most NSAID users, so choosing coxibs may be justified only in patients with evidence of GI bleeding. More research is needed.

Tramadol

Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea but does not cause severe gastrointestinal problems, as NSAIDs can. Some patients experience severe itching. A combination of tramadol and acetaminophen (Ultracet) is now available and provides more rapid pain relief than tramadol alone and more durable relief than acetaminophen alone. Side effects are the same as for each of these agents.

Opioid Pain Relievers

Narcotics, pain-relieving and sleep-inducing drugs that act on the central nervous system, are the most powerful medications available for the management of pain

There are two types of narcotics:

  • Opiates, which are derived from natural opium (e.g., morphine and codeine).
  • Opioids, which are synthetic drugs. They include oxycodone (Percodan, Percocet, Roxicodone, Oxycontin), hydrocodone (Vicodin), and oxymorphone (Numorphan). A skin patch containing an opioid called transdermal fentanyl (Duragesic) may relieve chronic back pain more effectively than oral opioids. A small, patient-controlled device (SynchroMed) that is implanted under the skin in the abdomen and delivers pulses of opioids to the spinal canal is also undergoing testing.

Common side effects include anxiety, constipation, nausea and vomiting, dizziness, drowsiness, paranoia, urinary retention, restlessness, and labored or slow breathing. Addiction is a risk, although less than is commonly believed when these medications are used for pain relief. In fact, when prescribed properly, use of opioids for chronic pain can be safer in some cases than on-going use of NSAIDs. Unfortunately, opioid abuse among young people is a major concern. Unless the pain is very severe, experts advise against routinely prescribing opioids.

Injections

Injections of different substances are sometimes used to treat low back pain caused by nerve impingement. The injection is usually an epidural, which is directed into the spaces between the outer membrane of the spine and the vertebrae. None of these substances cure the problem.

  • Corticosteroids. A one-time injection of a corticosteroid (commonly called a steroid) is directed as close to the injured location as possible. Corticosteroids reduce inflammation and this approach may short-cut sciatic pain until the body heals itself. This is a temporary, not permanent, solution. Studies that measure the benefits of steroids on sciatica or low back pain, however, are conflicting. In fact there is some evidence that patients can experience a rebound effect within a few months and the pain returns. Some experts have also raised concerns that even a single injection can cause serious and painful side effects, including meningitis and inflammation, although such risks are very low.
  • Hypertonic saline (salt water solution). Epidural injections of saline are being investigated for breaking up scar tissue. One 2001 study compared targeted injections of saline and steroids directed at the nerve root. Although steroid injections had more immediate benefits, both offered improvement, and by three months, patients who had saline injections experienced less pain than the steroid group. A 2003 study found that epidural corticosteroid injections provided no greater benefit than saline injections for patients with sciatica.
  • Local anesthetics. Injections of anesthetics such as xylocaine or bupivacaine may help some patients, although studies on their benefits are mixed.
  • Botulinum. Injections of botulinum toxin (Botox) in the lower back are under investigation. Very small amounts of the bacterial toxin, which is commonly used to smooth out wrinkles, temporarily paralyze muscle tissue. Some research suggests they may be very helpful in relieving chronic low back pain and sciatica caused by piriformis syndrome. Studies have reported that Botox relieved pain by at least half in between 60% and 78% of patients, compared to between 12% and 28% who reported the same benefit from placebo. The participants experienced no adverse effects. In a 2001 study, however, the benefits of Botox injections did subside by six months.

Antidepressants

A 2002 review of studies concluded that antidepressants may lessen pain severity in some patients, although they had little effect on daily functioning. Some experts suggest that treating people for depression who have both low back pain and depression may be even more beneficial and cost-effective than back treatments. Certain antidepressants, called tricyclics, can even be effective painkillers in non-depressed people with chronic back pain. They include amitriptyline (Elavil, Endep), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), nortriptyline (Pamelor, Aventyl), and maprotiline (Ludiomill). It should be noted that tricyclics can have severe side effects. Nonetheless, experts believe there is a useful role for these drugs that warrants further investigation.

Muscle Relaxants

A combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants such as cyclobenzaprine (Flexeril), diazepam (Valium), carisoprodol (Soma), or methocarbamol (Robaxin) are sometimes used for patients with acute low back pain. Evidence as reported in a major 2003 review supported their effectiveness in relieving non-specific low back pain, but experts in the study warned that these drugs should be used cautiously, since their effects occur in the brain, not the muscles. They also added that more comparison studies are needed to determine if they are more effective then common pain relievers. For example, a 2003 study of patients in the emergency room reported no additional pain relief when Flexeril was added to ibuprofen. Patients also experienced a number of central nervous system side effects. Drowsiness and other side effects are common. Some of these drugs, such as Soma, can be addictive and do little more than produce sleep. Of further concern, in some people the tensed back muscles may be protecting the damaged disc or vertebrae, in which case muscle relaxants could be harmful.

Investigative Agents

Tumor-Necrosis Factor (TNF) Modifiers. TNF modifiers interfere with specific components of tumor-necrosis factor, a powerful immune factor that is important in the inflammatory process and may play role in nerve dysfunction and pain that occurs in sciatica. In one early study, one of these agents, infliximab (Remicade), was associated with significant improvement in sciatica. More research is warranted.

Lidocaine Patch. Lidocaine, a local anesthetic, is available in patch form (Lidoderm) and has been used specifically for herpes zoster pain. Early studies are suggesting that it may provide significant relief for people who suffer from low back pain with very few adverse effects, even with continuous use of four patches a day. If further studies support its benefits, the patch could prove to be an important treatment

NO-NSAIDs. NO-NSAIDs are drugs that combine NSAIDs and nitric oxide (NO), a substance that enhances blood flow to the stomach and increases levels of protective mucus and bicarbonate. These agents show particular promise in providing pain relief and reducing the risk for GI problems and warrant additional investigation.

Herbal Remedies

There have been claims for a number of herbal and so-called natural remedies for relief of back pain. Most herbal remedies that are effective contain active ingredients, just as standard medications do, that relieve pain, relax muscles, or increase circulation. In such cases, they are also likely to have similar side effects. For example, in one trial, the herbal pain reliever white willow bark (Assaliz) was as effective as the COX-2 drug rofecoxib (Vioxx). Willow bark contains the active ingredient found in aspirin and so, theoretically, may have the same adverse effects as NSAIDs. A German study on pain management reported that herbal products containing black current leaf or oils, evening primrose, and borage may be useful and safe for pain due to inflammation. According to another German study, harpagophytum (a South African herb commonly called devil's claw or grapple plant) may be useful for back pain.

Because there are no government regulations of these products, neither the effectiveness nor safety of herbal products can be guaranteed.

Warnings on Alternative and So-Called Natural Remedies

Alternative or natural remedies are not regulated and their quality is not publicly controlled. In addition, any substance that can affect the body's chemistry can, like any drug, produce side effects that may be harmful. Even if studies report positive benefits from herbal remedies, the compounds used in such studies are, in most cases, not what are being marketed to the public.

There have been a number of reported cases of serious and even lethal side effects from herbal products. In addition, some so-called natural remedies were found to contain standard prescription medication. Most reported problems occur in herbal remedies imported from Asia, with one study reporting a significant percentage of such remedies containing toxic metals.

The following website is building a database of natural remedy brands that it tests and rates. Not all are yet available (www.consumerlab.com).

The Food and Drug Administration has a program called MEDWATCH for people to report adverse reactions to drugs and untested substances, such as herbal remedies and vitamins (800-332-1088).

Mind-Body Techniques

According to a 2001 review of studies, only intensive programs that include both psychological and physical rehabilitation therapies were successful in reducing chronic low back pain and improving function. A number of effective approaches to low back pain--called collectively mind-body techniques--employ psychological, behavioral, or physical methods to promote relaxation and reduce stress. Although many may be helpful, evidence is lacking on the specific approaches that would be most successful and which patients would most likely benefit.

Stress Reduction. Stress reducing techniques, including relaxation methods and meditation, may be helpful. One study, for example, reported that meditation was beneficial in reducing pain and improving mood among chronic pain sufferers who had not responded to traditional care. Another found that after three weeks, patients who were in pain after back surgery had less discomfort and slept better after practicing relaxation imagery techniques while listening to music for 25 minutes a day.

Cognitive-Behavioral Therapy. Studies report that a course of cognitive-behavioral therapy helps reduce chronic back pain or at least enhances the patient's ability to deal with it. The primary goal of this form of therapy in such cases is to change the distorted perceptions that patients have of themselves and their approach to pain. Using specific tasks and self-observation, patients gradually shift their fixed ideas that they are helpless against the pain that dominates their lives to the perception that pain is only one negative and, to a degree, a manageable experience among many positive ones. In one study, therapists also taught relaxation techniques and methods to improve posture. The sessions were two and a half hours each week for 12 weeks. More research is needed.

Patient Education and Support Groups. A 2002 study reported that patients with chronic low back pain who participated in an expert-moderated e-mail support and discussion group had less pain and disability after 12 months. An Australian massive public-health campaign that educated patients and doctors about the importance of staying active and dispelled fears about long-term impairment from back pain dramatically reduced disability and worker compensation claims.

Massage Therapy

A number of well-conducted studies have supported that benefits of massage therapy for patients with chronic or acute back pain, especially when it is combined with exercise and patient education. In fact, one analysis in 2003 suggested it may reduce the costs of care. However, it is usually not covered by insurance.

Spinal Manipulation

Spinal Manipulation for Uncomplicated Acute Low Back Pain. Spinal manipulation may be useful for acute back pain that persists beyond two to three weeks. There are a number of variations, but one example of a spinal manipulation technique is the following:

  • The patient first lies on his or her side.
  • The practitioner grasps the exposed shoulder and either the hip or knee and then presses the upper and lower portions of the body in opposite directions, so that the torso rotates.
  • The shifting vertebrae make a cracking or popping sound, indicating that they have exceeded the normal range of motion.
  • Often this results in a greater sense of ease and mobility. (The effect, however, may be temporary.)

Controversy exists over whether on-going manipulations after a first visit work any better for relieving pain than simply gradually resuming normal activity. Some patients consider spinal manipulation to be highly effective for chronic low back pain as well. A major 2003 analysis, however, reported that current evidence did not support the benefits of spinal manipulation over general medical care or physical therapy for either acute or chronic back pain. (It was better than sham therapy, however.) A large study is underway to determine its value for both acute and chronic low back pain.

Chiropractic or Osteopathy. Spinal manipulations are typically performed by chiropractors, but osteopathic doctors also perform them.

  • One in three people with low back pain seek treatment from a chiropractor. Chiropractic was founded in the US in the late 1800s and has been associated throughout its history with shamanism and folklore as well as with potentially genuine health benefits. There has not been a clear consensus even among its own practitioners about its specific goals. Nevertheless, there is a strong movement within the practice aimed at a scientific and realistic approach. The specific goal of chiropractors is to perform spinal manipulations to improve nerve transmission. Many studies have now confirmed that patients feel more satisfied with their chiropractic care than with treatment from general practitioners. (An analysis of studies reported that chiropractic treatment was beneficial, but not much better than sham treatments. Interestingly, standard medical treatments had worse results than both chiropractic and sham treatments.)
  • Osteopathy was also founded in the 1800s and also involves physical manipulation as its core approach to healing. Unlike chiropractic, however, osteopathy uses manipulation of the bones, muscles, and tendons to optimize blood circulation. In addition, the general direction of osteopathy over the years has widened to employ a broader range of treatments that now approach those of standard medicine. One 1999 study reported that osteopathy was as effective as medical treatment in relieving low back pain and patients required far less medication and physical therapy. Osteopathic treatment was also far less expensive.

Positive Emotional Effects. Both chiropractors and osteopaths offer verbal assurance and a precise treatment regimen. The direct physical connection through spinal manipulation reinforces the patient-practitioner relationship. The emotional effects of such connections may be as important for healing as the treatments themselves. Chiropractors offer a further psychological advantage, which is availability to their patients. Many medical doctors believe that because low back pain is self-limited and resolves the patient can wait for an appointment. A chiropractor, however, is more likely to see a patient promptly.

Adverse Effects. Mild and temporary side effects from spinal manipulation are common. The potential for serious adverse effects from low back manipulations is low. It should be strongly noted, however, that serious complications (including stroke or spinal cord or neck injury) have been reported with manipulations of the neck. Although little research has been done on such complications, an English survey indicated that they are more frequent than commonly thought.

Some chiropractors overuse x-rays, particularly those of the full spine, which may have long-term harmful consequences.

Patients should also be aware that some chiropractors use alternative treatments that have not been proven or rigorously studied. All patients should require objective evidence on the benefits of their treatments.

Other Noninvasive Procedures

Vertebral Axial Decompression. Vertebral axial decompression (VAX-D) may reduce pain and improve function in patients with chronic low back pain, including sciatic pain that radiates down the leg. The patient lies face down on a special table, clutching hand grips and wearing a pelvic harness. Movable parts of the contraption exert a traction-like action that alternately decompresses the spine, then relaxes, over one-minute intervals. Each session lasts about 30 minutes, and 10 to 20 sessions on successive days are often required. The procedure is thought to alleviate pain and enhance healing by relieving pressure within the discs, promoting the in-flow of oxygen, fluids, and nutrients to the spinal column. Some evidence supports its benefits, with reported success rates of around 70%. It is not yet covered by most insurers, however, and more studies are needed to confirm its benefits.

Acupuncture. Acupuncture is now a common alternative treatment for certain kinds of pain. It involves inserting small pins or exerting pressure on certain "energy" points in the body. When the pins have been placed successfully, the patient is supposed to experience a sensation known as Teh Chi, which brings a feeling of fullness, numbness, tingling, and warmth with some soreness around the acupuncture point. Unfortunately, rigorous studies of acupuncture are difficult to perform, and most evidence on its benefits is weak. In any case, it may be specifically helpful for certain patients with back pain, such as pregnant women, who must avoid medications. Anyone who has acupuncture should be sure it is performed in a reputable location with experienced practitioners who use sterilized equipment.

Click the icon to see an image of acupuncture.

Percutaneous Neuromodulation Therapy. A technique called percutaneous neuromodulation therapy (PNT) employs a small device delivers electrical stimulation to deep tissues and nerve pathways near the spine. It has shown some initial promise for relief of chronic back pain and may also improve mobility and sleep. Treatment sessions are conducted in the doctors office and last about 30 minutes. The device only became available in 2002, so experience is very limited. A correct pattern of stimulation appears to be important for optimal relief and needs to be determined.

Electric Nerve Stimulation. Transcutaneous electric nerve stimulation (TENS) uses low-level electrical pulses to suppress back pain. A variant, percutaneous electrical nerve stimulation (PENS), applies these pulses through a small needle to acupuncture points. The standard procedure is to give 80 to 100 pulses per second for 45 minutes three times a day. The patients are barely aware of the sensation. Although a 2002 analysis of trials could find no direct evidence of benefit, small studies have reported some relief for chronic low back pain from either TENS or PENS. It is not known if these effects are long lasting. Neither approach is helpful for relief of acute low back pain in most patients.

Muscle Stimulation. Two investigative procedures called automated or electrical twitch obtaining intramuscular stimulation (ATOIMS or ETOIMS) are showing promise. ATOIMS uses an automated mechanical device that vibrates the muscle using a tiny pin. (The sensation is described as similar to a mosquito bite.) ETOIMS uses an extremely mild electrical current. They can also be used together. Both approaches cause the muscles to twitch and then relax then the process is stopped. Discomfort is minimal. Small studies are reporting some help in relieving a number of condition the cause chronic pain, including low back pain.

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