My concern was not just that the surgery-removing a disk, for example-was very invasive

Research has visited a similar change of heart on the most traditional and seemingly innocuous recommendation for back pain-a day or two of bed rest. Surgeons have begun to call for greater use of more conservative measures, reserving surgery for those with persistent or progressive nerve symptoms. In America, the number of operations for low back pain increased 55 percent from 1979 to 1990, and surgery for spinal stenosis increased by 400 percent during the same period. The sole exception to this finding was Sweden, where there are plenty of surgeons, but they are paid for a forty- to forty-eight-hour week, not by the operation.

The determining factor was the per capita supply of orthopedic surgeons and neurosurgeons, with the United States at the top of the list. A recent review of eleven countries showed that surgery rates are not determined by how badly operations are needed. Even when tissue from the interior of the disk has herniated out, it is often resorbed on its own.

10 Third, damaged disks often improve spontaneously. Second, researchers who have done X rays, CT scans, and MRls on perfectly healthy people with no back symptoms at all have found protruding disks and other "abnormalities" in at least 20 percent of them. Numerous articles have appeared in medical journals noting that, while sometimes surgery is necessary to prevent nerve damage, in the vast majority of cases it is not and can often make things worse. Although operating on bulging disks may seem sensible and sometimes inevitable, research studies have shown three things: For many patients, surgery does not reduce their pain. I am not the only one to have noticed the problem. Some patients came back weeks or months afterward with various complications and had to be operated on again. The problem was that many patients seemed to have as much pain after surgery as before, sometimes even more. When I was in medical school, I cringed every time I had do a preoperative exam on a patient headed for back surgery. For most people, bed rest actually slows recovery.

Other studies have shown the same thing. But more patients in the active group had fully recovered in seven days than in the bed-rest group.

They asked a second group to avoid any bed rest between 9 A.M. and 9 P.M. Most patients in both groups improved significantly within a week, which is typical in acute back pain episodes. In a 1995 English study, doctors asked twenty patients with acute back pain-pain that had been present for a week or less-to rest in bed for forty-eight hours. A 1995 study of firefighters and police officers showed that, as hazardous as those professions are, those who also have children are nearly twice as likely to suffer from back problems.