Posted on 06/26/2017 1:56:20 PM PDT by nikos1121
Anyone who has endured back pain knows it is an erratic dictator. It takes hold of your psyche, demanding your attention and devotion before all else—before you can plan a hike, return to a work routine, pick up your child for a hug. So when someone offers to make that dictator disappear, it’s hard to resist—no matter what the price.
“People in pain are poor decision-makers,” says the investigative journalist Cathryn Jakobson Ramin, author of a new book, Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery.
Millions such bad decisions, she argues, have fueled a $100-billion-per-year back pain industry in the US—one that’s largely selling Americans wrong and even dangerous responses to back discomfort. These include unnecessary painkillers, injections, surgeries, and chiropractic “adjustments.”
About 80% of Americans are expected to suffer from at least one episode of lower back pain in their lifetime, and millions with chronic pain are already lost in the industry, subjected to pseudo-interventions, or taking unnecessary and addictive opioids like Vicodin or Oxycontin, then doubling down on the drugs as their tolerance and the pain escalates. (In some cases, the increased pain is actually caused by the opioids.)
The truth is, as Ramin’s extensive research indicates, all that most people need to do is keep moving.
From diagnosis to treatment, a dearth of evidence
It’s hard to choose one data point from Crooked that lays bare all the misrepresentation and snake oil in the back pain industrial complex, but a few key statistics that Ramin has collected stand out.
Spinal fusion surgery, for instance: Involving the removal of worn-out or injured discs, then the fusing together of the vertebrae above and below that disc with metal screws and cages, this is the form of elective surgery that people spend the most on in the US, costing a total of $40 billion per year. The problem is, it rarely works.
The procedure, with a price tag averaging $80,000, has a success rate of about 35%. Those most likely to benefit are the young, trim, and athletic, not the typical surgery candidates, whose average age was 54 in a 2008 study by the Spine Research Foundation. (Smoking, being overweight, and taking opioids before the surgery each also reduce the likelihood of a positive outcome.) Even its “successful” patients often end up on painkillers two years after the surgery, according to studies, Ramin writes.
Such conclusions should have shut down the market for unnecessary fusion surgeries, she proposes. Instead, the number of operations performed every year increased 600% between 1993 and 2011, jumping from 61,000 annual procedures to more than 465,000.
Also consider this: In a poll at a 2009 conference in Bonita Springs, Florida, 99 out of 100 surgeons who were asked whether they’d elect to have lumbar fusion surgery if it were recommended to them said “absolutely not.”
They were too keenly aware of the odds, and they would have known that after the invasive operation, the spinal sections around the welded-together vertebrae are more likely to weaken, since they’re forced to compensate for the unnatural immobility of their neighbors. Some surgeons recommend a second or third revision operation, with the rates of success dropping each time.
The procedure itself is risky, too. When you go in through the abdomen for any spinal surgery, Ramin tells Quartz, “you have to go through muscle. You detach muscles, you detach ligaments, and ligaments in particular don’t regenerate quickly at all, so you weaken the entire system.” Even when the surgeon enters the patient’s body through his or her back or side, the actual fusing is done perilously close to the spinal cord.
Another common operation, decompression surgery, or a discectomy, has better evidence to support its outcomes, especially to resolve leg pain, Ramin acknowledges. But she says even this cheaper and less invasive procedure, which eases pain by removing bone or tissue that’s putting pressure on a spinal nerve, may not be necessary for many patients.
“The problem is, when you look at the studies, two years out, the outcomes from having that procedure [for a disc herniation] and not having that procedure are the same,” she explains. “Because there is a lot of rehab involved if you do have it, and the natural history of a disc herniation is that it will go away and disintegrate within a month or so, and disappear.”
It also carries similar risks as fusion surgery. Ramin points to Steve Kerr, coach of the Golden State Warriors NBA team, who underwent decompression surgery two years ago: it apparently led to a spinal fluid leak, which caused debilitating headaches and nausea.
Even the diagnosis of back pain can involve some chicanery. Spine surgeons told Ramin that in an estimated 80% to 85% of cases, they can’t point to a person’s source of pain with accuracy, although they can see something abnormal on an X-ray or MRI. That’s because studies have shown that most people are walking around with bulging or worn out discs, but feel nothing, so these indicators on an MRI aren’t always meaningful.
As Ramin writes in Crooked, “The ambiguity inherent in diagnosing back pain makes it possible for surgeons to do practically anything they want.”
Finally, bad news for those who have turned away from modern medicine and toward chiropractors (practitioners of a drug-free approach that has gained mainstream approval): Ramin also spends a chapter debunking traditional chiropractic, that which involves cracking and “adjustments.”
Her summary of the treatment’s roots certainly inspires skepticism:
A self-proclaimed healer born in 1845 near Toronto, Daniel David Palmer was the father of chiropractic. He began as a revival tent mesmerist and entertainer who could make people fall asleep, dance wildly, or tumble into convulsions. Later, he described a “vitalistic force” or “innate intelligence” that existed in the spine; it could organize, maintain, and heal the body. But vertebral subluxations could derail that energy, with dire physiological consequences.
Subluxations are said to be spinal joints that have slipped out of alignment, and some chiropractors will explain that they lead to back pain, digestive issues, mood disorders, and more. Ramin reports that they are impossible to point at on an x-ray, because they don’t exist; a dislocated joint in your spine would be the result of a horrendous injury that sends you to the hospital, she explains, not to a massage table.
Chiropractic manipulation combined with other treatments, such as heat applications and massage, has been found to offer short- to medium-term relief for lower back pain and disability. Critics say, however, that the the forceful thrusts that chiropractors apply to the spine push the vertebral joint beyond its natural range of motion, and the World Health Organization says the modality is counter-indicated for several conditions (PDF).
If someone feels less pain after a chiropractic visit, it’s usually the result of a rush of endorphins, which eventually run out, Ramin said in a Canadian Broadcasting Corporation radio interview. Typically, the pain returns. If it doesn’t, there’s a chance a person would have had the same outcome without care.
Importantly, there are non-conventional chiropractors who have walked away from “adjustments” and other questionable therapies over the past decade or so. “They have restyled themselves as rehabilitation specialists,” which means they’re training patients in effective back-strengthening exercises as a reliable physical therapist would, she tells Quartz, “and are doing a great job with it.”
A back pain folk hero is born
Ramin wasn’t fully aware of spinal surgery’s poor rates of success when she decided to see a back surgeon for her own chronic back and leg pain nearly a decade ago. Then a freelance journalist, having just published a book on memory in middle age, she was frustrated and baffled by her own lack of progress, and her questions led her stumbling into a public health story that would take more than 600 interviews and eight years to write.
Crooked weaves together her compelling personal story and those of compatriots in back pain of all ages. It also follows the money, revealing the hidden motivations of many industry players: workers compensation insurance companies, pain management specialists, the drug companies that make narcotic painkillers, personal injury lawyers, spinal device makers, and spinal surgeons, especially the ones who advertise late at night, often touting their laser surgery. All appear to make a living by exploiting the “fix me” pleadings from people in pain.
This is not to suggest that all spine surgeons or specialists are villains, of course. Sometimes surgery is necessary, though many top spine specialists interviewed for Crooked agreed that surgery is overused. A spinal surgeon at Cedars-Sinai Medical Center in Los Angeles, Hyun Bae, explained why this might be, saying, “It’s not only a financial conflict. It’s an emotional conflict. We get paid to do the work. We want to make the patient better. So we concentrate on the good results and we dismiss the bad results.”
The problems often begin, Ramin tells Quartz, when patients are ill-informed. They might demand MRIs for acute pain, though their primary care doctor discourages it. They might also be influenced by direct-to-consumer advertising from less reputable spine centers. “When they go see his surgeon and the surgeon says, ‘I’m sorry I can’t help you this. There’s nothing I can do for you,’ the tendency is to misunderstand that, and to think ‘You’re not smart enough. You’re not good enough; you don’t have the right high-tech whiz-bang tools,’” she tells Quartz, “and I need to keep looking. I need to find someone who is smart enough to do this.’”
Carol Hartigan, M.D., medical director of the Spine Center and the Spine Rehabilitation Program at New England Baptist Hospital, tells Quartz that she agrees with most of Ramin’s critiques, though she finds the author extreme in her opinions—for example, by saying that a person should never have back surgery. Still, Hartigan says, “She did an outstanding job of researching. She had an eye for looking for flaws in the ‘industry,” and she interviewed the highest level players. She should be commended.”
Most reputable spine surgeons will discourage people from surgery when they don’t think it will be helpful, but “You do see some crazy ways that people are treated by high level clinics,”says Hartigan. They neglect to offer people an option to get better, she asserts, which, in her practice, would involve physical rehabilitation and systemically progressive resistance exercises.
After only a month in bookstores, Crooked began shooting up the Amazon bestseller list, because back pain is so universal and so emotional. “It’s part of the human condition,” Ramin told San Francisco public radio. “Few of us will make it off this mortal coil without it.”
As a person ages, the discs in one’s back naturally dry up, especially when a person isn’t active, and our lifestyles have only become more sedentary and sitting-focused, complicating matters tremendously. A meta-study published in the British Medical Journal found lower back pain to the be the number one cause of disability worldwide, affecting 83 million people globally.
Doctors are now advised not to turn to pain medication for garden variety back pain, but for years, we know too well, powerful painkillers, whose drug companies spent millions on marketing, were over-prescribed for back pain, arthritis and other conditions, creating an environment that made the drugs easy for anyone to access, and led to today’s opioids (and related heroin) crisis.
Dependence comes easy with these drugs: In March 2017, a report from the Centers for Disease Control and Prevention found that when a person takes a narcotic painkiller for one day, there’s a 6% chance that he or she will be still taking that pill a year later. If the prescription is for eight or more days, that probability rate jumps to 13.5%.
The unpopular truth about recovery
The media has raised awareness about the hustlers of the back pain industrial complex before Crooked’s publication. Surgery has been outed as, for many patients, “useless.” When, in early 2017, the American College of Physicians issued new guidelines saying that strong opioids such as Vicodin and Oxycontin should only rarely be prescribed for nonspecific back pain, reporters helped get the word out, while calling out the back pain businesses for their role in the current opioid crisis.
Nonetheless, the prescriptions and surgeries continue, partly because patients want the pain to go away—now. To many it seems counterintuitive that exercise is doable or the right solution when someone is already suffering.
As Ramin also told CBC radio, the psychologists she spoke to for the book talk about a cognitive shift that’s needed to “understand that yes when you start exercising there will be pain. There definitely will be because you are just as out of shape as all get out. But in the right hands, in the hands of a back whisperer, you can get through that and you can get strong and you can get your back muscles and the rest of your body balanced and you can straighten out your gait and you can straighten out your posture.”
The second half of Crooked is a guide to finding those right hands. Ramin shares her tips for tracking down a back whisperer—such as a physiologist or a doctorate-level physical therapist who’s also an orthopedic clinical specialist—to coach you through recovery.
She introduces Stuart McGill, a professor of kinesiology at University of Waterloo, in Ontario, Canada, and a globally recognized “back mechanic,” whose “big three” exercises she does daily:
The author is often asked for her thoughts on certain forms of exercise, such as yoga or pilates, which she also covers on her website. What she tells people, repeatedly, is that “movement is essential.”
“We’re sitting for 50 to 60 hours per week,” she says. We sit at our desks, in our cars, at the dinner table, and we sit to write email messages from bed at night. “We think three hours of exercise on the weekend will undo the problems that creates,” she laments. Even standing desks aren’t the easy out, as standing the wrong way all day can lead to different issues. Her mantra: “The best posture for sitting is always the next posture.”
Unfortunately, even as pro-exercise messages gain more traction here, some of the shadier players of the back pain industrial complex are taking their very different mantra into new markets. Ramin found that in China and Japan, spinal surgeries “are expected to nearly triple in number between 2014 and 2020, and almost double in revenues, with more than a little encouragement from US spinal device manufacturers.”
Correction: An earlier version of this story said that Steve Kerr had spinal fusion surgery. He had decompression surgery.
My wife is an LMT and has successfully treated back pain, often with one treatment, sometimes two. They don’t need to come back for further treatment, but refer others.
I have dissolved pure aspirin in a 60% DMSO/water solution and it works topically on areas of pain. This is a safe treatment. No opioids, no gastric distress from the aspirin.
Yeah:( we are not very good at marketing but you basically just use the lanyard or para-cord to maneuver the bakkball between the knots in your back and a convenient wall or hard back chair, works especially great in the car too. Our daughter Emily discovered that it’s much easier to control using two lanyards. When you’re not using it you can wear it like a necklace until you are ready to use it again just swing it around back and you’re good to go. I have endured many years of low level pain that was just not bad enough to take a pain killer let alone go see a doctor. NO MORE! If we don’t sell another one of them, at least my family and FRiends are pain free and it was worth the small amount we have invested in the effort.
Same here. Cronicles lower back pain for years. I asked a chiropractor why and he had me lock my knees and try to touch my toes. Could not get within a foot of my toes. He said upper hamstring was to short and rotating pelvis back. Told me to stretch them out. 6 months later, no back pain and I can touch my toes.
Also as others have said downthread I have an inversion table and if I am hurting I go hang for a few minutes before bed and it allows me to (sometimes) sleep and if I’m in pain in the morning it allows me the few minutes of warmup so the morning is manageable as well.
I am not a Dr and I didn’t stay in an Express last night .. . just stuff that works for me.
Please tell me, does the VA provide Chiropractic? Or, reimburse it?
If so, I’m going to hit ‘em up.
Heart health? Vitamin E. 400 units of d alpha tocopherol a day will reduce the chance of cardiac problems by 50 %.
NOT L or DL, strictly D Alpha tocopherol. Read the vitimin e label.
Artery plaque buildup? Blood infection... rotor rooter your heart with 6000 units vitamin c and the same L lysene. Once a day for a week. Drink lots of water. Then do anti fungal foods to clear up infection.
Or get a bypass a few times and supressed your immune system with statin drugs for as long as you last...
That would be so good for the elderly who can’t reach their back. They could even do it in their wheelchair! Contact your local community college with graphics design students and web design students who can do the work for your site. Then find out how to advertise online. Actually, the college profs could help getting students to do a youtube video, too.
Yes, my Mom turned 90 in March and loves it. Thank you for the suggestions. We have a nearby community college I can visit. We are demoing our Software to an important affiliate tomorrow so I’ve been otherwise occupied.
Prayers for good success welcome.
I’m 57, 6’1”, 180 lbs. and walk 2-3 miles per day.
Have degenerative disc disease in L4,L5 & S1
The only thing that helps is Inversion therapy but the pain relief is temporary.there
*** “The only thing that helps is Inversion therapy but the pain relief is temporary” ***
Long enough to fall asleep and what I need it provides, then in the morning long enough to warm up / loosen up and get busy enough to not worry about discomfort ... and then there is Beer. It is a routine now and I can go back to doing almost anything I did before with only minor discomfort. (Fishing on a Windy Day still kicks my butt, I just sit more and drink more beer, but hey it’s fishing and I’m old and don’t give a rip)
We have all these posts that vary, and; I do not see a one where anyone has at least a Grade II-III spondylolisthesis with every lumbar disc herniated plus foraminal stenosis SEVERE on each disc and on both sides, add facet joint hypertrophy L2/3 nerves on left trapped coming out of the left side of spine and add arachnoiditis caused by an idiot pain MD who is not an Anesthesiologist. Do not let idiots give you caudal ESI’s. When you start losing control of bladder and bowel you might be serious.
a neurologist told a friend that most all herniated discs stabilize after a few weeks...
I've never had surgery and so far, so good...
really, Naprosyn is a miraculous drug...it doesn’t make for immediate relief, but its very helpful...with all drugs, you can’t use it all the time...its hard on the kidneys...
Prinzmetal I’d had perhaps 300 episodes over 30 years. Always on cold damp nights. Easy to recognize the real thing. Got a stent (LAD), and now only hints of nighttime Prinzmetal. Interesting that most doctors didn’t know what it was!
Neighbor had an awful back break while boating...suffered for years. Got an electronic “pacemaker”-type gizmo inserted into his spine. He’s back to normal!
My wife was treated by a physical therapist that started off specializing with pregnant women - for my wife her hip was out of whack. The guy kept learning and growing - now he treats anybody.
He tests the weak spots by pulling down on my out-stretched arm, and then presses very gently on the various places that hurt. Ankle, hip, rib, neck - wherever. It is so goofy - but it works. He realized that a lot of the problems are related to poor foot support, so he got into making custom orthodics.
Most people don’t believe us. But the ones that give him a try are astounded. One gal was at her wit’s end after a car wreck years ago. Numerous doctors, chiropractors, etc. and the pain would never really go away. She went to our guy and after the first visit she was much better. After a few more she was pain free.
My wife just took an older friend (83) to see if there was anything he could do. Although he warned her ahead of time that the bones are brittle and he might not be able to do too much. He was able to adjust some things, and she was finally able to sleep without her right shoulder hurting her so much. Numerous doctors had tried over the years. Most just said “Well - at 83 you’ll have some aches and pains.”
My daughter was having terrible headaches after bumping into a door. X-rays, several doctors, etc. A couple of months and the headaches were no better. For some reason it didn’t click right away - but finally we thought - “Hey - maybe ‘Bob’ can help!?”
Turns out her jaw was out of whack and causing the headaches. So he sent her to a dental guy that made a mouth guard for her to keep her jaw in place. Slowly getting it refitted to bring the jaw back into alignment. The headaches are now gone (and no need for the guard anymore after months of using it).
He warned us to never tell a regular doctor about it. He had discovered this and researched it with the dental guy and they got a paper published on their results. The American Dental Association or some-such poo-pooed the published paper and filed a lawsuit against him or something - basically told him to never try any of it again - mainly because he wasn’t a dentist I think.
I recently had a head injury. My first call was to him. “Thanks - but you need to go to the ER right away After they check you out and if you’re still sore you can come visit.” He isn’t the type to not recognize the importance of medical doctors in some situations.
He’s pretty young, but years ago he was talking about retiring early and going overseas to live. Then he and his wife had a child. Thank goodness for us - as he decided he better keep his practice until his son is grown!
This is true. Most herniations will recede in 6 weeks. So, waiting is not a bad idea.
Also, I use McKenzie certified therapists for neck and low back pain. I’ve had success in well over 99% of the cases I see using their exercise protocols. No one is on chronic pain meds. Those that end up needing surgery, do very well.
Sounds like you were suffering from a classic lumbar derangement that responds to extension. This is the most common cause of low back pain in adults. The majority of these respond to lying on your stomach, and doing press ups, ie lifting your upper body. Some people call these “girl push ups,” and I apologize to the ladies for saying that. The same exercise can be done standing also, by simply extending backwards from the waist up. Doing this 4 to 5 times per hour for 24 hours usually does the trick, along with maintaining good posture.
Epidurals along with other pain meds, might make you “feel” better, but won’t make you “get” better. Spinal stenosis that is severe to the point that you have to sleep in a chair should be assessed by a back surgeon.
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