Ever since a hard fall while horseback riding as a teen, Cathryn Jakobson Ramin has had intermittent back pain.
It got worse through the years. While traveling the country to promote her first book, Ramin found herself clutching a podium when giving a speech–and not out of nervousness. She missed a train to Philadelphia because she could not make it up the 3 large steps it would take to board. A long-desired trip to Machu Picchu seemed hopeless.
Ramin’s search for better treatments, paired with four decades as an investigative journalist, resulted in her latest book, “Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery.”
The book’s conclusions are a sweeping indictment of a $100 billion industry: There’s a dearth of evidence supporting medical and surgical interventions in many cases of back pain, she says, from surgery to injections to opioids.
How back pain is treated has broad implications for the more than 77 million people in the U.S. who have experienced it. For about 20% of them, symptoms persist in the long term as a chronic condition.
Back pain is the most frequent cause of job-related disability and a leading contributor to missed work days, according to the National Institute of Health. The condition seems to be getting worse in the U.S.: in 2010, it jumped to third place in a ranking of most burdensome diseases in terms of mortality or poor health.
Ramin talked to MarketWatch in New York City about where back pain comes from, what helps and what does not and who precisely is profiting from all of this.
Below is an edited version of the conversation.
MarketWatch: People assume when someone is ill or has a condition that it can be alleviated with medication or surgery. With back pain, is that the case?
Cathryn Jakobson Ramin: No. Back pain was medicalized very blatantly by numerous stakeholders in a really large industry.
It wasn’t until the early 1980s that there was a surgical apparatus manufactured that would make it possible for the average orthopedic surgeon to do a spine surgery without catastrophic outcomes.
Back pain was something that was a part of life, something which would pass, didn’t need nor should have medical intervention.
But that changed due to the invention of that particular piece of instrumentation, followed by a tremendous number of devices that continue to come onto the market these days, all of which make tremendous amounts of money for the device manufacturers, for the hospital, for surgeons and for device manufacturers, for insurance companies.
The numbers have grown significantly through the years, with more and more spinal fusion procedures, although there has never been good evidence supporting those procedures or epidural steroid injections or standard, insurance-paid, cookie cutter physical therapy.
Patients are expending tons of money, they don’t get good outcomes and they don’t get past the problem.
Cathryn Jakobson Ramin is the author of the May book “Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery.”
MW: Your book examines the range of back pain interventions out there. Which ones does it cover?
CJR: The first half of the book is heavy duty investigative reporting, looking at all of what is normally provided to patients, whether that’s physical therapy, chiropractic, injections, MRI, surgery, opioids, other drugs, all of those. And each one of those is examined and debunked for extreme lack of evidence.
The second half of the book is entirely devoted to what does work.
MW: Did you try some of these? What was your experience, and how much did you spend on them?
CJR: Over the years I have done several sessions of physical therapy, each one of those being four or five different meetings with a physical therapist.
I had tried every type of exercise, joined a gym, had a coach, done Pilates and yoga, been to chiropractors, had massage, all kinds of medical massage–all pricey, none of it paid for by insurance. I had spent thousands and thousands of dollars, over several years, which most people don’t have.
However, the problem was that it did not help me. Every day that you can’t go to work and you can’t go play basketball with your children and you can’t go on a journey, you must stay home because you can’t stand to sit in a vehicle, every single time you do that, that’s opportunity cost.
Chronic pain conditions, which comes back pain, last longer than three months.
MW: Where does back pain come from? Is all back pain created equal?
CJR: There are conditions that are structural, that involve the skeleton. Those things need surgery, it is not elective.
However, for many people, and the readers of this book, what we’re talking about is a cranky back that requires exercise.
What is also very important is the concept of central sensitization, a very important idea that’s overtaking this industry and the way that people think about handling not only back pain but other pain. In the case of chronic back pain, the problem is no longer in the spine, it is not in the bones, it is in the brain.
The notion is that in order to have the ability to get past the pain, you’re going to need to convince the brain that the emergency is over.
Among the reasons exercise works well isn’t just that you’re moving around and you’re convincing yourself you can proceed, but that you’re letting your brain get the message that there’s no emergency, you can turn it off. It’s really not just the physical, that’s the thing.
MW: Is it just any kind of exercise?
CJR: In the expansive range of exercise classes which exist, there’s dozens and dozens of new names for exercise classes, right? A whole lot of them are really rigorous, and folks like that, especially younger people.
That is all fine for everybody who does not have a back problem. CrossFit is fine for people who do not have back problems, except for the very best location for a chiropractor to install is across the road from a CrossFit unit, since people get hurt all of the time.
But what people just don’t realize is if you’ve got a problem with your back, it generally means that you have failed to balance out your muscles properly. What you’re looking for, beyond anything else, is a way to begin using the muscles that need to be used to support your spine, and those muscles aren’t where you think they are.
When you start looking for ways to exercise, you’re looking for approaches that are going to build those glutes and build your heart and improve your posture.
We speak in the book about finding a “back whisperer,” and we discuss other approaches, such as Feldenkrais, Iyengar yoga, tai chi, and Alexander technique.
It’s tough to do alone, because back pain patients cheat. People with back pain cheat terrifically, and I do that myself. It hurts.
When you’re in physical therapy, you hear very often ‘If it hurts, stop.’ Well the one thing about back pain, which I am just terribly sorry to say, if you go by ‘If it hurts, don’t do it,’ you’re not doing anything–you’re getting on the couch.
Everything will hurt in the beginning, and it is a matter of learning the difference between acute pain and ‘this is hard exercise’ pain, and that’s very tough for people to discern independently. So they really need to be in the hands of someone who’s going to guarantee them that there’s no chance of them dying while doing this.
MW: You mention that exercise also cause back problems, right?
CJR: Right. Because in group exercise classes, typically there is no way the instructor will have the ability to maintain that detailed an eye. If you’re not doing it right you’re not helping yourself at all; you’re wasting a lot of time and a lot of money.
MW: What are the costs of these interventions that are effective?
CJR: It is dependent upon where you are, it really does.
In the book I talk a lot about Stuart McGill, he is a spine biomechanist, now retired but for several years at University of Waterloo in Canada. He invented something called ‘The Big Three,’ a pair of three exercises that actually balance and strengthen the muscles that need to be strong. And they are free.
Feldenkrais can be very reasonable — $20 a session or less. It’s inexpensive, it will get them moving, it may allow them sufficient mobility so that they can move into various other kinds of exercise.
MW: Why are all these procedures and remedies being done if there isn’t good evidence for them?
CJR: It’s just business. It’s a business, and it does not take under consideration the welfare of the individual. Across the board in medicine this is happening, it is just that spine medicine is the poster child for what’s wrong.
But I should point out that all of this is changing, and changing rapidly. In the time period I wrote the book, we went from basically very few people with no willingness to say there’s a problem with prescribing opioids. Now we’ve got a complete understanding that opioids should never be prescribed for back pain.
People were typically and standardly receiving injections, now we know that they’ve risks and they are frequently not successful. When I started there was already some thinking that spinal fusion was probably a bust, and now that’s extremely well understood.
So there has been progress, but I do believe that under this current government we are going to see a reversal of that.
MW: We have talked about what to do if you have back pain, but what about if you don’t? Can you do anything to prevent getting it?
CJR: If you don’t have it at all, I don’t think this is time to be worried.
But if you are occasionally having an episode of back pain, this is a really good time to begin dealing with it, before you are decked by it. And certainly before you have decided that you’re in so much pain you can’t move. And then you become very deconditioned, and now you’re starting from a place that’s going to be a long climb.
Should you have pain, don’t take it lying down. Find yourself a physical therapist, according to the specifications in my novel, and if that physical therapist says you’re ready to go into a fitness program–where you will need to remain. You can’t just ignore it.
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