* Exercise As 60 per cent of PLIDs cure themselves (usually within four months), the simplest solution is to work with the natural healing process. The true experts in musculoskeletal problems are, of course, osteopaths and chiropractors, and they recommend combining rest with gentle exercise. "But rest does not mean lying flat on your back, nor sitting", says osteopath John Hoggard, "as both may cause the muscles to go into spasm. The back should ideally be kept moving."
Dramatic evidence of the value of exercise has come from a recent clinical trial done by Norwegian orthopaedic surgeons. They gave more than 60 patients either fusion surgery or exercise therapy, and asked an independent expert to assess the patients' condition a year later. The comparative success rates reported were astonishing: 70 per cent for the surgery patients, but 76 per cent for the exercise patients. Even more remarkably, the exercise patients had done just "three daily physical exercise sessions for three weeks [plus responding to] a recommendation to use the back and bend it" (Spine, 2003; 28: 1913-21).
* Manipulation Gentle osteopathic or chiropractic manipulation is the second line of defence. The goal is to reduce muscle spasm, and take the load off the PLID by improving the mobility of the surrounding vertebral joints. The most recent review of the clinical evidence for low-back pain in general has reported that "manipulative procedures result in more rapid pain and functional relief compared with other conservative therapies" (Spine, 1995; 20: 615-9).
PLID is claimed to be especially responsive to the specialised micromanipulative techniques of the cranial osteopaths. Their aim is to increase blood supply to the disc, thus encouraging more rapid self-repair.
* Acupuncture Given its proven analgesic effects, acupuncture is an obvious candidate for PLID. However, the clinical evidence to date is somewhat mixed. In a recent Australian trial of chronic low-back pain, acupuncture reduced pain by only 10 per cent, compared with 50 per cent from manipulation (Spine, 2003; 28: 1490-502). On the other hand, German doctors have reported pain reduction of up to 77 per cent after 12 acupuncture sessions, compared with only 29 per cent after sham acupuncture (Pain, 2002; 99: 579-87). Another German team found no differences between real and sham acupuncture (Pain, 2002; 96: 189-96).
Taking the evidence as a whole - albeit a decade ago - British researchers concluded that, on balance, acupuncture had been shown to provide "a high degree of symptomatic relief" (J Altern Complement Med, 1997; 3: 55-76).