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Crooked: Is the back-pain industry doing more harm than good?

Jules Older talks to the author of a spine medicine exposé.

In 1906, Upton Sinclair upended the American meatpacking industry with his book, The Jungle. In 1963, Jessica Mitford exposed the American funeral industry with The American Way of Death. This year, Cathryn Jakobson Ramin is disrupting the back-pain industry with her book, Crooked.

The difference between Crooked and the others? Crooked’s target extends well beyond American shores. And, unlike Sinclair and Mitford, Ramin doesn’t expose only what’s not working, she explores effective solutions. They worked for her chronic back pain; in Crooked, she says they’re likely to work for yours, too.

The book’s premise is as short as it is startling: most surgery for back pain is unnecessary and much of it leads to more pain, not less. Ditto, opioids; ditto, injections. The “back-pain industry” is a mega-billion-dollar business promoting cures that don’t cure, relievers that bring no relief.

But if shots and surgery and addictive pills don’t relieve back pain, what does? Ramin makes a strong case that activity is the cure. Building muscles, extending flexibility and improving posture are paths to a pain-free back.

Two things worth noting. First, when denouncing most medical interventions, she is speaking of backs and only backs. She’s not against knee surgery or hip replacements. And second, she draws a clear distinction between the pain that seems to stem from vague roots – axial, functional, non-specific, unknown – and that caused by trauma, birth defect, tumour.

Crooked author Cathryn Jakobson Ramin.


She’s more specific on her website: “If the ‘inciting injury’ involved an ass-over-tea-kettle spill off your bike, or a tumble down the stairs or you were involved in a car crash – it’s time to visit your primary care doctor or head to the emergency department of your local hospital. If you are running a fever that arrived with the back pain… or have numbness along the inside of your thighs, or have lost control of your bladder or bowels… ditto. If you’re a cancer survivor, don’t even think of waiting out back-pain symptoms or visiting a chiropractor – call your oncologist.”

As Crooked notes, most of the roughly $US100 million Americans spend each year on backs is not caused by trauma, defect or tumour. Most is spent on painful reactions to lifting timber, picking up a two-year-old, laughing at a joke, or sneezing.

Among Ramin’s villains: most chiropractors and many physiotherapists, physicians who rely too heavily on MRI, epidural-steroid injectors, plenty of back surgeons, almost all bionic-spine manufacturers, and the myriad of opioid prescribers. But the main target of her sharp scalpel is spinal fusion surgery.

In this procedure, spinal discs are removed, then the adjacent vertebrae are fused with cages and screws. American back surgeons love this operation, as well they might: the average price is $US80,000. The problem, according to Ramin’s research, is that it rarely works. And when it does work, the relief is often short-lived.

The chief non-surgical medical response – heavy doses of opioids – is held responsible for the opioid/heroin epidemic killing teenagers and ruining lives across North America and beyond. Last year, 53,000 Americans died from opioid and heroin overdoses, more than from car crashes, gunshots and Aids combined.

And, Ramin maintains, interventional pain physicians – those who perform epidermal spinal injections – have to face the fact that most of their shots don’t work, either.

One practitioner who sails through with high marks is the late Robin McKenzie, the internationally respected New Zealand physiotherapist. Ramin describes McKenzie’s flexion method as “one of the few therapeutic approaches with well-quantified results”.

But even Ramin’s good news demands a hefty dose of sweat equity: “Successful rehabilitation is never passive,” she writes. “It requires sweat, persistence and a lifetime of hard work. No matter what you’ve heard, back pain is not the unsolvable enigma of modern medicine.”

In other words, you can get better, but it’s going to be through serious physical activity, not surgery, drugs or injections.

So, how does this stack up with patients’ experiences, and what do spine physicians and physiotherapists have to say about Ramin’s assertions?

One former back-pain sufferer whose experience supports her conclusions is Todd Pitock, a leading American travel journalist. “I had back pain in my 30s when I stopped running and put on weight,” he says. “Then, at some point, I recognised my back was where I put all my mental stress, and just recognising that gave me relief. I remain vigilant about stretching and deep tissue work. I’m also a marathoner and a devoted runner, which most back-pain experts would argue against, though I believe that running has made my back stronger. The body loves physical stress.”

At 32, when he first started having bad back pain, Pitock was told he had two herniated disks. “I’m sure I did,” he says. “But I’m also sure, now, that at a certain age, everyone does and that it probably doesn’t matter.”

Another sufferer, however, had pretty much the opposite experience. James Stafford, an Auckland sales manager, slipped on a wet floor in 2015 and spent a year with severe, chronic back pain. After surgery, Stafford went from downing painkillers and being barely able to walk to being pain-free and mobile.

“I herniated the disc between my L5/S1 joints. I couldn’t stand, walk, sit… anything. The back pain was intolerable. I just laid on the floor, unable to move. And the pain intensified as the herniation kept hitting the nerve. For days that turned into weeks, I struggled to walk, stand, sleep, sit, and I had lost nearly all the feeling in my left leg. I took more and stronger painkillers, but relief was only temporary.”

Physiotherapy-osteopathy treatment didn’t work and was very painful. Doctors prescribed pain-relief and anti-inflammatory tablets and injections. After an MRI, surgery was recommended. In January 2016, Stafford had L5/S1 spine fusion surgery. “It was an almost immediate success. The pain in my lower back had gone. I felt strong and mobile.”

However, intense post-surgery pain lasted for several weeks and took months to finally dissipate. “Now, I experience no restriction of movement in my back, and no lasting back pain. I feel 100 per cent fixed. It’s like I never had a back issue or an operation. I can do anything, lift anything and play with the kids. I no longer take painkillers.”

Note that although Stafford’s experience includes back surgery, it’s the kind of surgery the author of Crooked approves of. Remember: “[If] the ‘inciting injury’ involved an ass-over-tea-kettle spill… it’s time to visit your doctor.”

Most people I contacted avoided back pain by exercise, stretching and temporary reliance on over-the-counter pills. New Zealand playwright Roger Hall, who’s 78, has suffered from lower-back pain since the early 1980s. “At times it was incapacitating, but not often. I always remained active, mainly walking and tennis. Treatment included years of physiotherapy, back exercises and four Paracetamol a day. No surgery. The pain reduced as I got older; I still get aches, especially getting out of bed, and after golf, but it’s much better than it used to be.”

Playwright Roger Hall: "At times the pain was incapacitating."

And in San Francisco, 85-year-old retired software professional Janet Bensu has had major relief from epidural shots, supplemented by a lot of exercise (she’s a competitive swimmer) and daily stretches. Plus, one other ingredient: “I believe and trust marijuana in small doses.” Bensu takes three puffs before bed each night. And sleeps well.

How about practitioners? Although they have very different approaches, two Auckland specialists start with the same premise.

Musculoskeletal medicine practitioner Dr John Malloy says of Crooked, “I’m nervous about lay people making very generalised claims about the medical and paramedical field.”

Physiotherapist Damian Taylor puts it more bluntly: “I find it very difficult to listen to somebody discuss medical and health topics who has obviously had no medical training.”

That said, both basically agree with most of Ramin’s conclusions.

Malloy: “A great many treatments do not work or work for some people, some of the time. Part of our job is to advise people when these treatments are not likely to work. However, occasionally, the patients prove us completely wrong by having a treatment that is not expected to work, but does.”

Taylor concurs: “I do agree there is over-medicalisation of back pain. People with low-back pain are definitely over-medicating and far too often have surgery that is not indicated. I also agree that relying on passive intervention treatments is not the answer and patients need to play a large role in their recovery.”

He believes imaging for lower-back pain (LBP) is far too prevalent, resulting in poorer health outcomes and making patients more likely to have surgery. “Annular tears, disc degeneration, facet joint arthrosis do not predict LBP. In fact, disc bulges may be associated with a lower risk for LBP. There is also far too much emphasis on trying to achieve a specific diagnosis, which is not possible in about 90 per cent of cases.”

Malloy also notes the situation may be different in the US, where medical issues are more driven by commerce than in other English-speaking countries. “There is, for example, five times the rate of back surgery in the US compared with the UK. This would indicate the decisions are driven by consumer demand rather than medical indications. What we want is not always what is good for us.”

As someone who’s suffered from lower-back pain myself, I believe Ramin’s main conclusions in Crooked are sound. For back-pain practitioners, it should be a required text. However, she doesn’t give sufficient voice to those who have benefited from surgery, injections and the judicious use of opioids. And I think she falls too hard for the no-gain-without-pain approach. In my experience, simple, painless stretches are just as effective.

I used to have a classic bad lower back, complete with aches, twinges and zaps powerful enough to knock me down. Nearly every piece of advice I got from physicians and physiotherapists was wrong; most of it was harmful. The highest-status physio I saw told me to “get rid of the curve in your spine”. The highest-priced medical specialist sold me a corset. Note: The human spine is supposed to be curved. And a corset will make weak back muscles weaker.

What cured my back was doing five minutes of stretches every morning before I get out of bed. Sure, not smoking and not weighing more than a Captain Cooker help, but those five minutes a day have made me a pain-free man.

Finally, on the “over-utilisation of surgery”, here’s a quote from an American surgeon who no long performs spinal fusion: “Many hospitals are tightening up the criteria for spinal fusion operations. Sometimes, they’re absolutely needed – for instance, people born with severe spinal stenosis. But sometimes, they’re being performed by surgeons who needed to cover the next payment on their Porsche.”

This article first appeared in the November 2017 issue of North & South.
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