How the Back Pain Industry is Taking Patients for a Dangerous Ride

For the majority of us, it's not a question of whether we'll someday experience back pain; it's a question of when.

But searching for solutions can lead sufferers into an expensive and sometimes dangerous maze of ineffectual treatments, procedures and pills, as journalist and investigative reporter Cathryn Jakobson Ramin found. For years, she searched for ways to alleviate her own intractable back pain. Then she began to  investigate the entire back pain ecosystem: doctors, chiropractors, surgery centers, pharmaceutical companies, "posture mavens," collusion between personal injury attorneys and doctors ... you name it.

Her new book, "Crooked: Outwitting the Back Pain Industry and Getting On the Road to Recovery," explores what she found, while also telling the story of how she overcame her chronic suffering. When it comes to people making money on -- literally -- the backs of other people,  "A lot of things didn't add up," she says. "That generally means something is wrong."

Ramin recently spoke about her investigation with Eric Westervelt on KQED's Forum program. Here is some of what she said.

Beware the One Surgeon Who Says Yes

Ramin, who had ineffective minor surgery for her back pain, said the post-surgical woes of Tiger Woods and Golden State Warriors' coach Steve Kerr serve as prime examples of what can go wrong with back surgery.

She said some athletes do have successful surgery for back pain, but that it's unlikely their example would apply to the rest of us. "Those athletes are highly, highly trained and in excellent condition," she says.

Ramin says the fee-for-service payment system in the U.S. incentivizes unnecessary and potentially damaging spine surgery, where in other countries, spine surgery is rare.

And beware the surgeon who agrees to operate on you after other reputable doctors have turned you down. She gave the example of author, physician and marathon runner Jerome Groopman, who, after five surgeons had told him there was nothing they could do for his back injury, found a sixth who claimed he could operate and get him up and running in six weeks.

"He spent the next 19 years in extraordinary pain," Ramin says.

Ramin also warns against taking the description "minimally invasive spine surgery" literally, calling it a marketing term.

"These are sexy buzzwords," she says. "Perhaps the incision is small -- and it isn't always. If in fact you do have a small incision, good for you, you might look better in a bathing suit. The damage beneath the skin will be exactly the same as it would be in regular, traditional, conventional spine surgery."

These procedures are often done in outpatient surgery centers , she says. "If anything goes wrong afterward, you're not in a hospital environment."

Chiropractors: A Very Mixed Bag

Ramin says some chiropractors are completely ineffectual while some are treating patients the right way. Of the latter, "They have stopped seeking vertebral subluxations [partial dislocations] which don't actually exist on any X-ray or any type of scan, and have moved onto the very excellent practice of rehabilitation. They may ultimately be a back patient's best hope because they have studied exercise science and they have worked hard on it."

However, "If you see a chiropractor more than one or two sessions, you are wasting your time if you are being cracked, adjusted or walked over. Study after study after study has shown that long-term visits to chiropractors don't help patients. They don't prevent back pain; they don't solve back pain."

She said the World Health Organization has come up with a long list of all the diagnoses for which chiropractic is contra-indicated.( See page 20 here.) "And it's probably anything that would take you to a chiropractor."

Neck adjustments, she said, "are to be avoided at all costs. There is no reason to let a chiropractor anywhere near your neck."

Pharmaceutical Companies: Painkilling Pill Pushers

In the 1990s, Ramin says, pharmaecutical companies embarked on a  well-funded campaign to get primary care doctors to ask all their patients if they were experiencing any pain.

Oftentimes they were experiencing some back pain, "because it is a human condition," she says. "The answer to that from the primary care doctor's perspective, because of the active marketing from pharmaceutical companies, was to say 'Well, we can take care of that pain.' "

Doctors often started out with short-acting pain killers, such as Vicodin, a potent and addictive narcotic. This was often followed by longer-acting, extended-release painkillers, such as the opioid-based Oxycodone -- which has led thousands into heroin addiction.

But, Ramin says, opioid painkillers don't work well for people with back pain.

"They cause those patients to become very unmotivated and very sleepy," she says.

Plus, a condition called opioid-induced hyperalgesia can arise, in which the brain generates pain independent of the original injury.

Expensive Chairs and Standing Desks

Ergonomic "experts" rely on what Ramin calls "smoke and mirrors."

For instance, many back sufferers will try new office chairs.

"I had a stable of office chairs," she says. "One after another, expensive office chairs parading through my office, and I found most of them to be not very good."

These chairs are "often built for 250-pound men," she says.

"I realized you could have a chair from Costco for $25 that could keep you in the right position."

The standard, erect typing position, she says, is actually a relic from when you had to press hard on typewriter keys to get them to work.

Regarding the use of standing desks, Ramin says those come with their own problems. "It's a nice variation from sitting. But remember, if you are standing, you are putting tremendous pressure on possibly a different set of ligaments," she says. "But still you're asking your ligaments to hold you up for a really extended period of time. We're seeing all kinds of problems related to standing desks, now. They tend to be knee and hip problems, but those will lead to back problems."

If you have a standing desk, you still need to move around every so often, she counsels.

The Yoga Trap

Some tremendous benefits can be gained from doing yoga, Ramin says, but there is potential harm, as well.

"One of the  risk factors is finding yourself in a very competitive Northern California yoga class where you are pushed to do what you really cannot do. Most of us who are even remotely competitive will experience that."

She says if you have back pain, there are limitations to what you should do in class, and you need an instructor who can give you variations on postures to suit your condition.

"Be very careful about finding yourself in a flow yoga class where things are moving very fast and there's no way the teacher can keep a close eye on you."

Two type of yoga she recommends for back sufferers: Iyengar yoga and Viniyoga.

"Both of them have a very powerful orthopedic focus," Ramin says.

So What Does Work? 

Two things: Exercise and changing the way you think about back pain.

"Understanding that hurt does not mean harm," Ramin says. "You can continue to live an active life. The most dangerous thing you can do for yourself is take to the couch or take to your bed or take to pain management. But of course that is what most people do.“

Ramin recommends finding a "back whisperer"--someone who understands the musculoskeletal system and is able to help people build strength, balance their gaits and move effectively.

Moving is the key. Our bodies are not built to sit or stand in one place for hours at a time, she says. "The best posture is your next posture."

For more info: Ramin's website features an extensive resources section directing people to information, videos and medical professionals who may be able to help alleviate back pain.