Watch your back: Outwitting the back-pain industry with Cathryn Jakobson Ramin

Dan: In 2008, Cathryn Jakobson Ramin was an investigative journalist whose back was KILLING her. She started trying to book herself for surgery.

But then she started learning more. She put her training to work — and spent six years investigating. She found the treatments that get prescribed for back pain — surgery, drugs, you name it — mostly do not work. Hugely expensive. Often leave people worse off. A LOT worse off.

Ramin: As the story evolved, the journalist in me relished each appalling revelation. As a patient, however I felt as if I barely avoided stepping off the curb in front of a bus.

That’s from page 2 of her book, Crooked: Outwitting the back pain industry and getting on the road to recovery. Whenever somebody I know posts to Facebook, like OY, my back is killing me?

Who knows a good doctor— or a chiropractor, or whatever?

I immediately send them a link to this book.

And I’ve wanted to do this story since I first started planning this podcast. I kept putting it off because— well, it was so big. I was like, “this could be a whole season.”

But look. I cannot hold out anymore. This season of An Arm and a Leg is about self-defense from the cost of health care— watching your back. And this story is so big, and so important, and so crazy, and ultimately so helpful. I could not end this season without it.

Because not only does Cathryn Jakobson Ramin show us the horror stories— she also points to what actually works.

So we’re gonna hit the highlights here. It’s going to make you mad. It could freak you out a little bit. And if you, or somebody you care about has a bad back, it could help save you from a WORLD of hurt. Financially and otherwise.

I mean, just to state the obvious: I’m not a doctor. Nothing here is medical advice. I am passing along what I’ve picked up from another person who is NOT a doctor, but seems to have really done her homework.

Ok, let’s go.

This is An Arm and a Leg— a show about the cost of health care. I’m Dan Weissmann.

Catheryn Ramin’s back bugged her since she was a teenager. She dealt with it for decades. Exercise. Stoicism. Like you do.

Then, after she published her first book in 2007, she hit the road for about 18 months to do speaking gigs. And she discovered new levels of pain. This was murder.

She saw her primary-care doc, and his first two ideas were total duds.

First he was like: How about physical therapy? And she reminded him, she had tried it. Twice.

So he’s like: OK, then: how about some pain meds?

Ramin: And I was like, expletive, no, I don’t want any pain medicine.

Her first book had been about how our memories and our brains go downhill as we age.

Ramin: And I’m doing everything I can to have a brain that can, you know, carry me through and allow me to work. And I am not about to take your pain medicine.

He was like, OK, cool. Ah there’s an orthopedic surgeon’s office right over there— you just walk across the parking lot. She went.

The first conversation she had there did NOT inspire confidence. The person she talked to whipped out a notepad with a big Oxycontin logo splashed across the top of the pages— it was a handout from the good folks at Purdue Pharma.

RAMIN: And wrote down a list, which I still have of five choices of ways to proceed and told me to go home and study them on the Internet.

And that seemed to her like a BAD sign.

Ramin: Whenever there are a great many options for treating any kind of a pathology, um, there’s something wrong.

Huh. Yeah, It DOES kind of suggest that none of those options is a sure thing.

Next, Ramin says she got sent for x-rays, even though she’d just had an MRI. She was like: Huh. More radiation for me, money for you. None of it smelled good. Smelled like trouble.

So she started sniffing around.

Ramin: And I realized at that point that, you know, not only was I in trouble, but so many other people were in trouble.

She could see it. That orthopedic surgeon’s office was BUZZING. And there were people with back pain lining up at similar offices all over the country.

And she found, most of them would NOT benefit from spinal-fusion surgery: In a lot of cases, it’s just not the right tool for the job.

So, people have surgeries all the time that do. Not. Work.

Ramin: And many, many people go for second surgeries, third surgeries, fourth surgeries, and these are almost never successful. It’s the, the, the success rate, which is low to begin with, really, really declines fast on second surgeries and onward.

Horrifying, right? Her book is full of statistics that make you go “Holy crap!” Here’s one. It’s from a study on people who got spinal-fusion surgery as part of workers-comp claims. The most common cause of death after surgery? Overdosing on painkillers.

Ramin: Now as you’re probably aware, people OD all the time and they don’t die, right? To say that they actually die from an overdose, that is really saying something.

Ramin does think most doctors— most surgeons— do their best to be responsible. They don’t offer surgery to people who wouldn’t benefit.

She just doesn’t think they lay out the WHY NOT clearly enough.

She quotes one doctor who thinks surgeons should probably tell most people: “Yeah, we can do this very expensive surgery, but there is still more than a 50% chance you’ll have a lot of pain and you still won’t be able to work and you’re going to need pain medicine and you’ll have complications related to surgery.”

He thinks that might scare more people away. And it might.

But Ramin says most doctors take a gentler approach.

Ramin: They use this phrase — and I think it’s a mistake: They say, “Well, I don’t see that there’s anything I can do for you.” And patients hear that, and instead of reading it as, “I don’t need this surgery,” they read it as, “I need a smarter doctor.”

This totally makes sense. If we’re talking with a surgeon, we are already in the market for drastic measures. We’re in a ton of pain. And nobody has shown us a better alternative.

We are desperate to find somebody who says Yes, I can fix you.

We look for that somebody, we’re gonna find that somebody.

There are interventions short of surgery. Like steroid injections. Which don’t affect your underlying problem at all, they just could make you feel a little better for a little while.

Meanwhile, hello? You’re getting shot up with a steroid…

Ramin: Which is hard on your heart, on your brain, on your bone. Um, you know, you name it, it’s not good for you. There’s nothing about it that is good for you.

You noticed she said it’s hard on your bones, right? Yeah, that’s well established. And in the book she cites a study that found that for each injection— and they are often administered in series of three— for each individual shot, the risk of suffering a vertebral compression fracture goes up by 21%.

Ramin: Isn’t that crazy?

Super crazy. To be fair, there have been other studies since then with less alarming findings. But still. The latest round-ups don’t really give the all-clear.

And of course a dozen years ago, when Ramin was in her desperate phase, lots of doctors thought opiates were A-OK. Ramin’s primary care doc offered them to her right off. The orthopedic surgeon’s office she visited used notepads with the Oxycontin logo.

There are “conservative” treatments— no surgery, no shots, no drugs.

Physical therapy is a special case.

And later, when we talk about real solutions, we will hear about it again. There are great physical therapists out there.

But Kathryn Ramin tried PT early on, and it didn’t work for her, and now she’s done the research to help her understand why.

Cause it turns out, the problem is GENERIC physical therapy. Which there’s a lot of. And which Ramin says has its uses.

Ramin: If you have a new hip or a new knee or you’ve had a stroke

You might be able to walk into LOTS of places and get what you need.

But those are different kinds of problems. To get effective help with chronic back pain, you need somebody who has a LOT of training and experience

And that is not what you necessarily get when you just pick the first place your doctor or insurance company might send you. That place could easily belong to a big chain.

Ramin: Where you go for four sessions that are paid for by insurance and you’re being dealt with by a fairly inexperienced assistant.

There are a lot of big chains out there these days— private equity likes to invest in them — and Ramin says this is part of their model: One highly-trained person supervises a number of lower-paid assistants.

It’s all engineered to make the corporate owner a good dollar at rates that insurance will be happy to reimburse.

One expert in Ramin’s book says “Cookie cutter PT is a pseudo-intervention.” He calls it “A holding tank for patients on the gravy train of scans and tests and injections and surgery and pain management” meaning drugs.

That expert is a physical therapist.

Oh, there’s alternative treatments too, like getting adjusted by a chiropractor. Non-invasive, no drugs…

Ramin: The only issue is, and it’s enormous, is that there is no scientific evidence whatsoever for what we understand as traditional chiropractic treatment.

She has got a whole section about the institutional history of TRADITIONAL chiropractic. Adjustments. The old-school stuff.

And it’s harsh: her portrait is, an army of quacks got organized and fought like hell — against the American Medical Association — to get a place on the gravy train of Stuff That Gets Reimbursed By Insurance.

As you might imagine, a website called Chiropractors for Fair Journalism vehemently disagrees with Ramin. But her read on the evidence amounts to this:

A couple of treatments MIGHT help with a short-term episode— although, short-term episodes often resolve by themselves.

For chronic conditions… You might feel better for like an hour after somebody cracks your back. But that’s it. That’s all you’re going to get from it.

Ramin: You know I wouldn’t pay ninety, a hundred, a hundred-and-fifty bucks for relief that lasts under an hour, at this point. Although I certainly did when I was struggling. It wasn’t unusual for me to drop two to $3,000 a year on things like massage, physical therapy, acupuncture. If I could pay for it. I think I did.

And there was always someone to take the money.

In the book there’s a quote from a doctor— a bigwig at Harvard named James Rathmell— that kind of sums things up. He says the back pain industry is “just a microcosm of what’s happened in all of medicine. As a rule of thumb,” he says. “If you pay practitioners to do more stuff, they will do more stuff.”

Ramin: I hear, you know, almost daily from people who have read Crooked, and they list the numbers of practitioners they’ve seen and the numbers of, different treatments they’ve received. And it’s extraordinary. And the money involved is extraordinary.

So, to really watch your back— to make yourself less likely to fall into this cycle of paying lots of people to do lots of questionable stuff— you have to go back to the very first stage of Cathryn Ramin’s journey — before she even got suspicious.

Before she went to that orthopedic surgeon’s office, she had already done something that she NOW says — if your back is killing you — you should NOT be in any rush to do.

She had gotten an MRI to check for “degenerative disk disease.”

These days, she’s like, yeah, maybe don’t do that.

Ramin: because you will receive your radiological report. And it will point out all of these artifacts and what it will not point out is that they are actually normal. That what you’re seeing there — that quote unquote disc bulge or herniated disc — may very well not be the cause of your pain.

Because that kind of thing is normal — like gray hair or wrinkles. Just something that happens to people’s bodies as they get older.

In fact, those kinds of things are SO normal… they frequently show up in people who have no symptoms at all.

In her book, Ramin cites several studies— including one of people WITHOUT any back pain: And scans showed that more than 90 percent of them had degenerated or bulging disks, and a third had herniated disks.

So, a lot of primary-care docs are much more reluctant to send folks to get MRIs these days.

Ramin: One physician described it as launching a Scud missile. She said, “You know, I send the person out with the prescription for the MRI — and that is going to explode. And I’m going to be just responsible for the care of that patient who may get that MRI and then may have surgery and then may become addicted to opioids and not recover from the surgery…”

She says this doc sees patients go on to become obese, develop diabetes… all of it. But just because docs are reluctant to prescribe MRIs, that does not mean patients won’t get them anyway.

Ramin: People are extremely eager if they suffer from back pain for more than say a week to have an MRI and they get rather upset if their physicians tell them that they don’t need an MRI, they shouldn’t have one

That totally makes sense. It’s related to a dynamic that this show documents— that this show is a part of, honestly: a breakdown in trust: Trust in doctors, insurance companies, whoever.

We think we have to fight— fight to get doctors to listen to us. To get insurance companies to pay for the help we need.

And a lot of the time— we’re 100 percent right.

I mean, I can think of two people RIGHT off the top of my head who had to fight for tests that ended up showing they had ADVANCED CANCER.

And those fights took time, and the delays hurt their chances of recovering— of surviving.

And Cathryn Ramin says, if you or your doc thinks that something like cancer could be a concern, DEFINITELY you want a test like an MRI.

And if you have to fight for it, then fight that fight.

just maybe not for back pain by itself.

And if you think an MRI can’t hurt, think again. Because Cathryn Ramin says an MRI will have one big effect.

Ramin: it will make you feel worse.

She says this has been studied

Ramin: People after they have their MRIs, they feel worse. They go down hill,

they have been thoroughly medicalized

Wait, what? Medicalized? Yeah, here’s where we’re about to turn the corner.

To the good news part. And it’s a big turn. Here check this out.

Ramin: For the gross majority of us, back pain — chronic low back pain — it is not a medical condition. It has been medicalized because it’s extraordinarily profitable, but it is not a medical condition.

OK, so what the hell IS it? And how do we deal with it? That’s right after this.

[Midroll break: This season of An Arm and a Leg is a co-production of Public Road Productions and Kaiser Health News. That’s a non-profit newsroom that covers health care in America. Kaiser Health News is not affiliated with the giant health care provider Kaiser Permanente. I’ll have a little more on Kaiser Health News at the end of this episode.

OK, Cathryn Jakobson Ramin says chronic low back pain is NOT a medical condition.

So what the hell is it?

RAMIN It is a condition of being deconditioned.

De-conditioned. Out of shape.

Ramin: We need to be moving. We are as humans, as primates, we are designed to move.

Instead, we spend an alarming amount of time sitting or standing still. At our desks, in cars, at the dinner table, watching Netflix. It adds up.

So that’s the first big thing to know. And the other big thing is this: Back pain and the WAY WE DEAL WITH IT? The way we perceive it? It’s a mind-body issue, all the way.

That is, super-bad back pain that sticks around: It is partly about our bodies— they are out of shape. And it’s partly about what our minds are up to.

This idea we’ve been given— if your back hurts, that means it’s like a stained-glass window with a million little capillary fractures and you better not move it or allow it to experience any kind of stress— or it could shatter into a million pieces? And you’ll be in a wheelchair the rest of your life?

It’s a hundred percent wrong.

I mean, granted: It doe not FEEL wrong. Not at all.

Ramin: Well the thing that people want to do when they have back pain and I totally get it is you want to take to the floor or the sofa or your bed and you want to just lie there. And that is THE single worst thing that you can do.

So, if somebody Cathryn Ramin knows is having a back-pain episode, and she’s right there, Cathryn Ramin gets them down on the floor and she gets down there with them and has them do some simple, little exercises with her.

Ramin: And they go through them and they go, Oh my God, I feel a lot better. I’m okay. I’m now, why are they okay? A very interesting question to explore. They’re not okay because they did these exercises. They’re okay because they gave their brains new information. When you twist or you pick up something and you get that twinge and then a muscle spasm comes on right after that usually can be very, very painful.

The TWINGE is the information your brain gets: Hey, something could be really wrong here. And the SPASM— the big pain— is your brain’s immediate response.

Ramin: And the brain does not have enough information to ask questions such as, Oh, you picked up a newspaper, you’re probably fine. You’re hit by a bus, you’re probably not fine.

So your brain is going, “NOBODY MOVE. THIS COULD BE SERIOUS.” And you are locked up in pain.

Ramin: The brain needs a new piece of information to let go. Exercise is that information and I cannot state that more strongly.

Ramin: And if you never provide the new information, and in fact the information you provide is actually I’m lying on the floor now, I’m making my wife do everything. Um, that information provided to the brain says, Oh God, we must have been right in the first place and let’s just keep this up.

In her book, Ramin profiles some examples of what DOES work. And it’s wild.

She visits a couple of places where the patients get told: See these milk crates over here filled with steel bricks? Grab one, haul it over to the other side of the gym over here, then come back and grab another one, till they’re all over here.

And they do. And they’re fine. And these are places that treat HARD CORE cases, people who have been in serious pain for a long time.

And I mean, there’s crying. And there’s coaching. And there’s careful staging of the whole experience.

The people who run these places are very mindful of the psychology of the whole thing.

Because over time, there’s a big second layer of how your brain gets involved in back pain.

Being in a lot of pain clouds your judgment — and it’s depressing and anxiety-provoking. Like clinically depressing. Clinically anxiety-provoking.

And guess what? Anxiety causes us to clench up and our back muscles spasm, and BANG.

Ramin: So it’s a two way street. It’s almost a circular problem. People who suffer from anxiety frequently suffer from back pain, which causes them anxiety and it’s a hard loop to get out of.

Ramin says what works is targeted functional exercise and often cognitive-behavioral therapy.

She says it’s worked for her.

Ramin: And I’ve built a, a very different body than I had before. And I consider myself to be very strong. I’m about to be 63 years old, but when I’m in an airplane, you know kinds of people hand me their luggage to put up into the overhead compartment. And I find that very amusing because I was the person who couldn’t do that eight years ago.

But what got her there was NOT a generic workout.

Ramin: Going to the gym and working on your abs or working on your biceps, or whatever you want to work on — that’s not adequate to resolve chronic back pain.

Cathryn Ramin has had expert guidance. People who examine her closely, and tell her exactly what exercises she SHOULD be doing. And watch her like a hawk to make sure she’s doing them right.

Ramin: You have to learn to recruit the proper muscles. Back pain patients, um, in particular are experts in cheating.

Yeah, using the right muscles HURTS.

In her book, Ramin profiles some people who do effective work: She calls them “back whisperers” and “posture mavens” — and here’s the thing. They DO NOT all have a credential in common.

James Rainville is an MD. Joe Zarett is a physical therapist who runs a gym— you go to his website, you see pictures of people working out and you choose whether you want “rehab” or “fitness.” Stuart McGill has a Ph.D. in something called kinesiology— but Ramin calls him a bio-mechanicist.

There’s a whole chapter in her book about a line of exercise machines designed by an eccentric fitness guru, promoted by a surgeon in the U.S. and a former boxer in Switzerland.

And she says there are a lot of chiropractors out there who are actually worth seeing these days.

Ramin: Many of them and particularly the younger ones have moved to become intensive exercise rehab-focused practitioners. You know what? I admire that. I really do.

Here’s one big tip she offers about physical therapists: Look for somebody with the credential DPT — doctor of physical therapy — AND OCS — orthopedic clinical specialist. Both of those credentials require a bunch of graduate training.

But there’s no one credential or job title that guarantees you’ve found a back whisperer. These people don’t all even agree with each other about a lot of specifics.

What they’ve got in common is a focus on relentless, targeted, functional exercise: It may hurt, a lot, but it won’t injure you.

Ramin built a resource directory into the website for her book Crooked. But there’s no central body certifying what works, or who does it well.

Which is scary, honestly. But the impression I get is: There are a LOT of good people out there. They just may not be the first ones that present themselves. So you’ve gotta do your homework. You probably want to scout out multiple options, and you want to keep your wits about you when you’re evaluating them.

And— this is the kind of awful part— a lot of them, there’s a good chance insurance won’t end up paying for everything you need from them.

Insurance is more likely to pay for the stuff that Ramin chronicles NOT working.

And the things that do work are no fun.

Ramin: The thing that we have to remember is that no one can fix you. You have to fix you. And it takes commitment to do that. And when you’re being offered a host of things that are promised to fix you overnight, there’s a real inclination not to pursue the things that are hard work, but the things that are hard work are the ones that actually work.

Ramin says it’s a lifetime commitment. If she lays off her exercise for a week? She feels it, and it’s not pretty.

There’s a way in which I think this whole story is kind of a match for what this show is all about— what this season, about self-defense against the cost of health care is about.

The bad news is, it is REALLY, REALLY hard. There is a whole system out there, stacking the odds against you including — in the case of back pain — just whole way our lives are organized:

Most of us are in situations where it’s hard to get the exercise we need, to avoid being super-sedentary, all that stuff: We’re trying to earn a living, be with our friends and family a little bit, just get by.

And if we DO run into trouble, the first thing we’re likely to get are a bunch of options that may sound appealing but actually are harmful and expensive. Really harmful, really expensive.

So just finding your way to what works is hard, and then getting the help you need is expensive, and THEN you’ve gotta do the work, which is really hard. Forever.

All of that sucks. It’s a lot to take on. BUT. It is better than no alternative. It’s our fight.

Speaking of the lessons we’ve learned this season of An Arm and a Leg— this is the last regular episode. But it is not quite the end:

We’ll be back later this month, with a look back: What DID we learn in the last bunch of weeks? And what are we going to need to know in the year ahead, as we look at a big election— and at just getting through another 12 months with our bodies and our bank accounts intact?

And this time, I will kind of be getting interviewed. One of my absolute favorite reporters—and favorite people— will be asking the questions. Sally Herships has done a ton of work for shows like Marketplace and Planet Money, and really everywhere else. She’s just one of the smartest and most human human beings I know.

AND I want to hear from you too: What have YOU learned this season? Which of these stories made the biggest impression on you— and why? How are you FEELING after hearing these stories? What are you thinking about what you might do next?

If it fits in a few-hundred characters, you could just tweet at arm-and-a-leg-show

And if you’ve got something longer to say, we’ve got space: Go to arm-and-a-leg-show, dot-com, slash CONTACT. In the subject field, please start with “I learned…” and then take it from there.

You can upload a voice memo there too, or send one to stories at arm and a leg show dot com.

If we get your message— your tweet, your notes, your voice memo— by January 10, 2020, it could become part of the conversation next time.

Which is coming your way a little later in January.

Meanwhile, you’re about to hear me thank a BUNCH of new patrons. I have been asking for your support this season, you’ve been coming through in a major way.

True story: I set a goal of 500 supporters by the end of the season— I wasn’t sure it was realistic. NOW, I’m like: This could totally happen. And that can unlock a LOT of possibilities for this next year.

You can get us there. And we will celebrate with something special for everyone who pitches in.

I don’t know how yet— I had no idea we would get this far! It may involve audio. It may involve something you can print out at home.

I will figure it out, and it’s going to be fun.

And when you get us there, it will make a huge difference for this show— for this community that we’re growing. For the power we’re building, by starting to figure this stuff out.

Thank you so much to the more than 425 people who have come in so far— one of you pitched in while I was writing this little spiel! It’s incredible.

You can join and get us to 500 by going to arm and a leg show dot com, slash support.

I’ll have a report for you — plus details on how we’ll celebrate, and what we’ve got in store for the coming year — when we come back later in January.

Till then, take care of yourself

This episode was produced by me, Dan Weissmann. Our editor is Ann Heppermann, our consulting managing producer is Daisy Rosario. They are rock stars of the audio world, and incredibly smart and incredibly kind, and I cannot believe I get to work with them.

Our music is by Dave Winer and Blue Dot Sessions. Adam Raymonda is our audio wizard. He is unbelievably talented, dedicated, and skilled in the arts of audio magic.

And special BELATED thanks this week to Adam, who composed original music for the closing of LAST week’s episode and really made it shine.

This season of An Arm and a Leg is a co-production with Kaiser Health News— that’s a non-profit news service about health care in America that’s an editorially-independent program of the Kaiser Family Foundation.

Kaiser Health News is NOT affiliated with Kaiser Permanente, the big health care provider— they share an ancestor, that’s it. He’s this guy Henry J. Kaiser— and he had his hands in LOT of different stuff. It’s a fun story— you can check it out at arm and a leg show dot com, slash Kaiser

Diane Webber is National Editor for Broadcast and Taunya English is Senior Editor for Broadcast Innovation at Kaiser Health News— they are editorial liaisons to this show.

Finally, thank you to some of our new backers on Patreon— I could not make this show without you. If you pledge two bucks a month or more, you get a shout-out right here. Thanks this week to:

John Bangsund, Timothy Foster, Andrew Kelsey,

Gary Pritchard, Mae Pennington, Avery Robertson,

Eleni, Darryl Holliday, David Blatt, Amalia Smith,

Mark Skoglund, Matthew Knor, Michelle DuBarry,

Tiger Heise, Ben Sykora,

Laurence J Cass Jr

Ed Buehler, Daniel Li, Larry Kaplan,

Borgna Brunner, Dylan Geraci, Drew Culver,

Andrea Richardson, Sarah Little,

Mariel Courtwright, John Backus,

And Jenn Voss.

THANK YOU so much!

… and Happy New Year.

(SFX: DING!)