For something that affects four out of five Americans at one time or other, it's amazing what we don't know about treating a bad back.

Should we head for the surgeon? The chiropractor? The acupuncturist? Exercise or bed rest? Heat or ice?

Often the answer boils down to something simple: whatever works.

Ellen Webb, 45, is a busy Roland Park, Md., mom with three small children. She controls her recurring lower back pain by practicing yoga and doing sit-ups to keep her abdominal muscles strong.

"I aspire to do 100 a day," she says. "I probably do 50."

If her lower back starts to feel achy, she does more sit-ups. It's not a treatment doctors and physical therapists always recommend, but it works for her.

"Everybody is so different," she says. "Know your own back."

Those are words that should be engraved over the door of everyone who has ever suffered from back pain, considering the work time lost (10 million Americans daily) and the cost ($20 million to $50 million annually, according to government estimates). Low-back pain is the second most common symptom people present to their family doctors, and the most common reason they visit orthopedic surgeons and neurosurgeons. And all that for a condition usually healed by time as much as anything.

Prime season

It's prime back-attack season. Homeowners are raking leaves, gardeners are cleaning out beds and mulching, and many who exercise regularly during warmer weather are turning into weekend athletes. An ounce of prevention now is worth a pound of anti-inflammatories, heating pads and massages later.

Preventing a back attack • Exercise regularly to achieve and maintain good physical condition. • Do specific exercises for your back, such as hamstring stretches and abdominal exercises. • Lose excess pounds. • Stop smoking. • Lift with your legs, not your back. • Don't lift or bend and twist at the same time. • If you have to lift or carry something heavy, hold it as close to your middle as possible. • When you must lift, bend or twist, do it deliberately. Don't rush. • Don't sit for long periods of time without getting up and moving around. • Stretch before and after exertion or exercise. • Deal with irritated back muscles before you have a full-blown back attack. Use heat, ice, over-the-counter anti-inflammatories, massage or rest. • Get help with back-stressing chores.

Dr. Aleksandar Curcin, co-director of the Spine Center at Sinai Hospital in Baltimore, believes the back is a disregarded area of the body — at least as far as prevention is concerned. He suggests a low-key approach to routine maintenance. Some simple sit-ups, back arches, windmills and pelvis tilts can go a long way to avoiding a bad back. (Pelvis tilts stretch out the lower back: You lie on the floor on your back with your knees bent and your feet on the floor, tighten your abs and press your lower back on the floor, hold a few seconds and slowly relax. Repeat. )

"Fifteen or 20 minutes of stretching and gentle strengthening exercises three times a week (will do it). It's not necessary to be doing crunches," Curcin says.

The back is vulnerable because the spine is such a complicated mechanism. Normal wear and tear and chemical changes caused by aging can affect its discs adversely. And the core muscles that support the spine are involved in just about everything we do; it's easy to overstress them, particularly if they're weak.

Prevention techniques

The American Academy of Orthopedic Surgeons recommends regular exercise such as walking or swimming, standing and stretching once an hour if your job involves sitting, and using the proper techniques to move heavy objects. (Lift with your legs.) Extra pounds and poor posture put extra strain on your back. Smoking is also a risk factor, although it isn't clear why. One reason may be that smoking lessens the amount of oxygen going to the musculoskeletal system.

There are various contributing factors to back strains and sprains, says Dr. William Tipton, executive director of medical affairs for the Illinois-based association. "Overweight, poor muscle condition and lack of flexibility. It all speaks to one thing: exercise."

Wendy Hoy, a physical therapist with Physiotherapist Associates in Lutherville, Md., suggests approaching seasonal chores with care and common sense.

"Spread out tasks," she says. "Take a break. Do them over two or three days if possible. Recruit the kids to help. If there's a history of back pain, take an anti-inflammatory first. If ... there's any irritation or discomfort, stop and ice. Stretch before and after."

Hoy believes in stretching everything to prevent lower back injuries, not just the legs. "Arms, shoulders, chest, hamstrings. The whole body. The spine is affected by everything we do."

But let's assume you've been doing your hamstring stretches and picking things up correctly (by squatting rather than bending), and your back still goes out while you're on a ladder cleaning gutters. If you've strained the large supporting muscles near the spine, it can be a cyclic problem. They start to spasm, which causes pain, which causes the muscles to spasm again.

Treatment options

Ninety percent of such back attacks get better on their own, says Curcin, so usually there is no need to rush to call your doctor. Try over-the-counter anti-inflammatories such as Advil or Aleve with food (if you can tolerate them) and take your pick: heat or ice.

Curcin starts backache patients with heat because he thinks it's more soothing to a spasming muscle, but suggests people do whatever gives them relief. Hoy likes ice because it reduces inflammation. Forget the old adage about ice for the first 48 hours and heat after. Do whatever makes you most comfortable. Gentle massage can also help.

Doctors no longer prescribe bed rest for lower-back pain. Rather, they say take it easy for a few days, avoid re-injuring your back, and try a little gentle walking on a flat surface when you can. If the pain persists longer than a week or two, or if it radiates down your leg or you have numbness or tingling down your leg, then call your doctor. These can be signs of more serious conditions.