From the Introduction
A TERRIBLE AFFLICTION: When I Went Looking for a Solution, I Found a Much Bigger Problem
My goal with Crooked is to set the back pain industry’s offerings in their proper context, so that patients have the information they need to make good decisions; to know what works sometimes, what works rarely, and what can cause harm. With luck, I will spare you the side effects of “optimism bias”: the very human proclivity to seek out information that supports your own views, while ignoring that which does not. Patients have a tendency to overestimate the benefits of treatments, while underestimating the downside, especially when in the presence of a health care provider who would prefer not to admit that he doesn’t know. Whether he or she wears a white coat, hospital scrubs, or workout gear; cracks your back; cossets you with heating pads; sticks you with needles; or hands you a set of free weights (and then ignores you in favor of his Twitter feed); remember that every stakeholder wants and needs your business.
From Chapter 1
BACK PAIN NATION: How We Got into This Mess
The Back Pain Channel never stopped broadcasting news. Many victims were young. Ethan, a literary agent in his early twenties, gave up a bookstore job for a much more promising one that chained him to his desk chair. He’d gone through two jumbo-size bottles of Advil in a few months. A friend requested that her daughter’s buff thirty- year-old fiancé sit next to me at dinner, so he could fill me in on the details of his condition.
In midlife, people had just as many problems. Richard, an ad agency creative director, had taught his team to bring pillows to staff meetings, so that they could join him as he stretched out at on the floor. Melanie, a writer, had bought and sold three used cars, but still had not found one she could bear to sit in for more than an hour. Roxie, an administrative assistant, had concluded that she and her partner “could stay home and eat ice cream, or have sex and go to the hospital.” Jeannette, a middle school principal, admitted that she could not carry her own briefcase from the parking lot to her office. Simon reported that his back spasms had nearly caused him to skip his eldest son’s bar mitzvah, while Pam said that on her long- awaited trip to the Vatican, she’d had to sit and wait in St. Peter’s Basilica, while everyone else took the entire tour of the holy city. People in their seventies, eighties, and nineties cornered me with similar frequency, desperate to know what to do about the spinal stenosis that made it difficult to walk a block. “You start to design your life to fit your pain,” said Barbara, who was extremely active until chronic back and leg pain made for agonizing days and nights. “It’s a hellish way to live, and you can’t put it out of your mind. It always wins.”
From Chapter 2
A TALE OF TWO TABLES: Why Back Patients “Fail” Chiropractic Treatment and Physical Therapy
In Trick or Treatment, a must-read book about fallacies in alternative medicine, science reporter Simon Singh and his coauthor, scientist Edzard Ernst, describe an experiment conducted by psychiatrist Stephen Barrett, one of the most fervent naysayers regarding chiropractic. To see what they might advise, Barrett arranged for a twenty-nine-year-old woman to make four visits to different chiropractors. The first chiropractor “diagnosed ‘atlas subluxation’ [an improperly situated vertebra at the top of the spine] and predicted ‘paralysis in 15 years’ if the problem was not treated. The second practitioner found not just one, but many vertebrae ‘out of alignment’ and one hip ‘higher’ than the other. The third said that the woman’s neck was ‘tight.’ The fourth said that misaligned vertebrae indicated the presence of ‘stomach problems.’” Despite the disparity in diagnosis, all four recommended long-term regular adjustments.
Physiatrist Heidi Prather, chief of the Physical Medicine and Rehabilitation Department at Washington University School of Medicine in Saint Louis, blamed many of physical therapy’s failures on the confusion of physicians, who, in their referrals, were supposed to specifically describe the nature, extent, and duration of the problem and how they wanted the PT to treat it. That was rare, because in medical school, physicians underwent just three or four hours of training in how to handle musculoskeletal disorders. Typically, said Prather, physicians just scrawl “diagnose and treat” on their prescription pads and leave it at that. They rarely follow up, said Prather.
The term for this nonchalant approach is “rocket launching,” Prather said. “It’s hoping the PT knows what he’s doing, and sending the patient into space with no tether and no supervision.” When she sends patients to PT, she observed, “I say, ‘This is what I saw in my evaluation, and this is what I think should be done.’ If there’s something I missed, I expect the PT to tell me about it.” The follow-up is just as important, notes Prather: “When the patient returns to see me, if what she’s been doing with the therapist in terms of exercise has nothing to do with the prescription I wrote—if she’s telling me she’s mostly had hot packs and muscle stimulation, and she’s seen five different people in that office, and no one has taken ownership of the case and developed a relationship with her—then she’s out of there, and I won’t send anyone else to that facility.”
From Chapter 3
HAZARDOUS IMAGES: Why You Do Not Need—Or Want—To Have an MRI
Anywhere that people fancy high technology—South Korea is a good example—MRI units were humming and spine surgery was booming. In 2014 at the Mayo Clinic, researchers found, yet again, that disc degeneration was normal at all ages; it was present in more than a third of asymptomatic twenty-year-old subjects, and in 96 percent of eighty-year-olds. “Black” discs, often employed as one of the indications for a diagnosis of degenerative disc disease, were found in more than half of these normal subjects over forty—and in nearly 90 percent of those over sixty. Those bone spurs I’d picked out on my scan were common in pain-free subjects as well. Mayo Clinic scientists concluded that such changes were not “part of a pathologic process requiring intervention.”
The most recent data available, published in JAMA Internal Medicine in 2013, assessed how often advanced imaging was ordered in nearly twenty-five thousand physician visits. The proportion of patients who left their doctors’ appointments with orders for MRIs increased from 7.2 percent in 1999 to 11.3 percent in 2010. As a result of this increase in imaging, the percentage of patients who were directed to spine specialists for interventional procedures and surgery more than doubled, rising from 6.9 percent to 14 percent in the same period. In 2015, orders were still creeping upward. A significant number of practitioners acknowledged that they ordered all those scans defensively, in an effort to avoid malpractice liability.
From Chapter 4
NEEDLE JOCKEYS: How Epidural Steroid Injections Can Go Wrong
A few months earlier, in a 2015 review of the medical literature, the Agency for Healthcare Research and Quality had found no evidence that epidural steroid injections were effective in treating symptoms of spinal stenosis or typical low back pain. Even in the presence of a recent disc herniation and ensuing sciatica, the benefits of injections were small and not sustained over time. That news followed on the heels of an FDA statement warning that injection of the active medication in these shots, glucocorticoids—a class of corticosteroids—into the epidural space of the spine could result in rare but serious neurological problems, including loss of vision, stroke, paralysis, and death. Based on those and other findings, the Journal of the American Medical Association (JAMA) advised physicians to refrain from recommending injection therapy to patients with any kind of chronic back pain.
From Chapter 5
THE GOLD STANDARD: Why Lumbar Spinal Fusion Is Never Your Only Remaining Option
Spine surgeons, who are typically trained as orthopedic surgeons or neurosurgeons, do essential things. They repair traumatic injuries; they excise spinal tumors; they fix congenital abnormalities. But except for top-tier physicians, who usually work at academic medical centers, such procedures are not their main-stay. About 60 percent of patients who walk into a spine surgeon’s clinic have back pain that will be diagnosed as “ordinary,” “axial,” “mechanical,” “degenerative,” “functional,” or “nonspecific.” Those terms describe flattened discs, black discs, bulging discs, herniated discs (described as “prolapsed discs” in the United Kingdom), and the bony outgrowths known as osteophytes. Too often, surgeons point to these commonplace artifacts on an MRI and diagnose “degenerative disc disease,” recommending lumbar spinal fusion surgery as the best option.
But there’s a problem with this very common procedure, in which the intervertebral disc is excised and adjacent vertebrae are connected with cages, screws, plates, rods, and other medical devices. Studies show that lumbar fusion succeeds in barely 40 percent of patients. And in this context, the word “success” does not mean much. In one study, two years after spinal fusion, in “successful” procedures, pain had barely been reduced by half and most patients continued to use painkillers. In another study, two years after surgery, about one-third of the patients reported that their pain was as bad as it had been before they’d had the operation, and 14 percent believed that after spinal fusion they were in worse shape than before it.
From Chapter 6
GOOGLE YOUR SPINE SURGERY: The Truth about “Cutting-edge” Procedures, as Advertised Online and on TV
As my plane took off for Philly, an ad featuring a bikini-clad woman on a beach, a Band-Aid stuck to the small of her back, grabbed my attention. The copy read: “Just two weeks ago I had back surgery. Thank you, Laser Spine Institute.” Reading further down the page, I learned that 97 percent of patients recommended this safe, fast, and apparently bloodless minimally invasive procedure, which took less than an hour. Apparently, you could expect to “get your life back” immediately.
As soon as I was on the ground, I found a wireless connection and went directly to the Laser Spine Institute’s website. Happy patients at LSI’s facility in Tampa, Florida, waxed euphoric, including their full names and hometowns in their endorsements. Patients had to be incredibly impressed to be willing to do that, I reasoned, feeling my journalist’s customary skepticism ebb away.
Laser Spine Institute described itself as “the premier health care provider in spinal surgery.” Physicians there employed “a wide variety of laser-assisted techniques,” performed while the patient was “under local anesthetic.” The Band-Aid on the woman on the beach covered “only one three-millimeter incision at the surface.” Naively, I reasoned that an incision that small meant that the disruption of the bones and soft tissue beneath the skin was also minimal. Desperate for a solution, and just as LSI’s direct-to-consumer marketers hoped that I would, I picked up the phone.
For the frustrated patient, direct-to-consumer medicine, such as exists at LSI, North American Spine, and countless other entities crawling the Web, appears to be the best way to skirt the relentless red tape of the medical-industrial complex. But it’s essential to realize that health care companies that market their services this way on the Internet exist in a regulatory netherworld. The institutions that patients expect to safeguard them—among others, the FDA, the American Medical Association, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, or the Joint Commission, for short)—exercise little or no authority over how such entities conduct their businesses. Although ads that drugmakers pay for typically carry disclaimers, there are far fewer such requirements for outfits that sell surgical procedures, so they can tout convenience, speed, and the size of the incision without ever discussing risks.
From Chapter 7
REPLACEMENT PARTS: Why a Bionic Lumbar Spine Is Not in the Cards
After we’d gotten to know each other pretty well, Rosen entrusted me with a stack of letters from patients with identifying information redacted. Most were in their thirties and forties. They’d opted for the device specifically because they’d been told that a disc replacement would preserve motion and function better in the long term than spinal fusion.
Those letters broke my heart, as they had broken Rosen’s. The words “unbearable” and “desperate” appeared repeatedly. Patients wrote that they planned to kill themselves unless Rosen could intervene. They described themselves as “completely disabled,” with maddening neurological symptoms—burning feet, numb toes, and electrical shocks that shot through their limbs. Some could not find comfort even while lying in bed; for them, sleep was a thing of the past. In their correspondence, they noted that they had lost jobs, spouses, and homes as a result of their failed procedures.
When they returned to their surgeons, in desperate need of help, they were told that their disc replacements were perfectly positioned in the X-ray, which meant that the surgeon had done his job. With no options remaining, they were sent to pain management, where they required increasing doses of extended-release opioids and faced a lifetime of disability.
From Chapter 8
THE OPIOID WARS: How Chronic Opioid Therapy Keeps You in Pain
For a long while, it was understood that opioid addiction was the outcome of misuse or abuse, and was unrelated to doctors’ prescribing habits. “The reality is that the vast majority of people who are given these medications by doctors will not become addicted,” Russell Portenoy told those assembled for a media gathering at a D.C. press conference. Repeatedly, Purdue described a “bright line” between the state of addiction and that of physical dependence in the treatment of chronic pain. For patients who needed pain control, Purdue said, access to chronic opioid therapy was really no different from providing insulin to a diabetic.
Some regarded that comparison as outrageous. Andrew Kolodny, at the time an addiction psychiatrist at Maimonides Medical Center in New York City, had founded a group called Physicians for Responsible Opioid Prescribing (PROP). (Subsequently, he would be chief medical officer at Phoenix House, before accepting the position of co-director of opioid policy research at Brandeis University.) In 2011, in the first of many conversations I’d have with him, Kolodny explained that physicians who overprescribed to patients with non-cancer chronic pain were largely responsible for having created the epidemic of addiction, not only to prescribed opioids but also to heroin. “The reason we have a severe epidemic of opioid addiction,” Kolodny said, “is that we have overexposed the U.S. population to opioid pain medicine. The people who are using heroin are out there using heroin because they were first addicted to opioid pain medicines.” In 2010, enough painkiller prescriptions were written and filled to medicate every American adult around the clock for a month.
From Chapter 9
HEAD CASE: What Your Brain Has to Do with Your Back
Sarno published his first book in 1982, but it was not until Healing Back Pain: The Mind-Body Connection came out in 1991, eventually selling over a million copies, that he became a household name. In 1998, when Sarno published The Mindbody Prescription: Healing the Body, Healing the Pain, 20/20 coanchor John Stossel was in the midst of his own struggle. After Stossel sat down with Sarno for a chat, he realized that his back felt better for the first time in months. As he planned a TV special on Sarno, Stossel requested permission to call twenty of his patients, randomly chosen from the doctor’s medical charts. The patients that Stossel’s team interviewed all reported being “better,” or even “much better.” Roughly fifteen million people watched that segment, and Sarno became “America’s back doctor.”
But there was a problem. Sarno was unmistakably bad for business. He did not endear himself to the medical community when he announced that physicians were “chiefly responsible for the pain epidemic that now exists in this country.”
Once patients became Sarnoites, they lost their appetite for serial interventions. They canceled long-scheduled surgical procedures, usually at the eleventh hour, citing a new perception that their problems were emotional, rather than orthopedic. They stopped getting MRIs and spinal injections, and didn’t show up for physical therapy appointments.
After lunch, when everyone felt drowsy, it was time for a high-energy game of beach ball volleyball. Earlier that morning, most had questioned the safety of bending over to tie their shoelaces. By afternoon, the same crowd was whooping and leaping and ducking and stretching, determined to keep the ball aloft for as long as possible. In less than six hours, fear-avoidant behavior and guarding had vanished. Physical therapists Carlson and Hartmann joined in the game, advertising the fact that the best-ever score was 708 sequential taps—achieved without letting the ball touch the ground. When the game ended—after a respectable 312 taps—Clifford proclaimed, grinning: “So, this is how you start doing things without thinking about whether or not it’s going to hurt you. You find out you’re still alive and kicking. You had a little pain—and that’s all.” Carlson and Hartmann nodded approvingly. The activity was so fast that the players reacted without thinking; they were unguarded and unguided. They reached, they jumped, they bent and stepped without thinking. Instead of getting hurt, they found themselves having fun in a social environment.
From Chapter 10
THE BACK WHISPERERS:How to Find a Rehabilitation Partner
Back whisperers are not profession-specific: In their ranks, you will find physiatrists, orthopedic surgeons, physical therapists, personal trainers, disenchanted chiropractors, and exercise scientists. Here’s what they have in common: They are able to observe how you walk and sit and stand, and grasp what your posture and gait say about your muscles, tendons, and ligaments. Generally, they focus on functional training, prescribing exercise regimens that are “non-pain-contingent” (whining will get you nowhere), “quantitative” (you will not be allowed to quit until you hit your “number”), and “high-dose” (you will do this routine on a schedule rather than when the spirit moves you). Although they agree on the basics—for instance, the value of non-pain-contingent, quantitative exercise—back whisperers often diverge on the specifics.
As you search the Internet, look for candidates with backgrounds in “orthopedic sports medicine,” “corrective exercise,” “non-pain- contingent exercise,” “functional rehabilitation,” and “strength training.” It’s a plus to have undertaken coursework with rehab’s big guns, among them Stuart McGill, Craig Liebenson, Gray Cook, Joseph Heller, and Karel Lewit, but ask questions: Did your prospective trainer read a book, or study with the expert for a weekend, a month, or several years? Avoid personal trainers who prioritize vague, “holistic” terms in their bios, like “fitness,” “weight loss,” “nutrition,” “toning,” and “wellness,” because that expertise does not require specific coursework or certification, and is unlikely to help you resolve your back pain.
From Chapter 11
THE RIGHT KIND OF HURT: How a Much-maligned Machine Might Still Change Everything
Over the quarter century that Brian Nelson ran PNBC’s program, practitioners treated 120,000 patients. Although many said it could not be done, Nelson figured out how to deliver consistently excellent and cost-effective back pain treatment to 115 new patients each week. Patients spent $2,500 for twenty-four individual sessions of forty-five minutes each. In 2009, HealthPartners, the largest consumer-governed, nonprofit health care delivery organization in the United States, with $3 billion in revenues, acquired PNBC, dropped “Clinic” in favor of “Center,” and made Nelson’s program available to its 1.5 million members. Six years later, Nelson retired, confident that PNBC was in good hands.
From the beginning, PNBC’s approach to rehab was quantitative and non-pain-contingent, terms that meant, essentially, “You’re going to do more reps today than you did last week,” and “Whining will get you nowhere.” Nelson’s many research papers backed up his theories. A Journal of Orthopaedics study of 895 patients, nearly all of whom had failed six other treatments before starting at PNBC, showed that 76 percent reported their outcomes as good or excellent after going through rehab at Nelson’s clinic.
Within months, it was evident that MedX was effective. Anywhere that a MedX lumbar extensor machine was up and running, spine surgeons complained bitterly that their surgery volume was declining. Physical therapists thought that chiropractors who bought or leased the MedX were walking off with their patients. Both physicians and PTs requested that Medicare make a special effort to scrutinize MedX billings and reimbursement requests.
Designed to serve as a stand-alone therapy, the machine was never meant to be a profit-generating “add-on” to other protocols. But chiropractors were double- and triple-billing, tacking MedX training onto bills for adjustments, ultrasound, and electrical stimulation. In 1996, Carpenter and the other researchers were worried. “More and more third-party payers were denying payment,” said Dave Carpenter, “and we knew that if we couldn’t stop it, it would be the end of MedX. Third-party payers had no way of knowing which providers were legitimate and which were gouging.” They assembled a utilization steering committee, and issued guidelines that set out rules for billing.
Unfortunately, it was already too late. Although MedX served a completely different purpose, it was still a back therapy machine intended for spine care, and as such, Medicare lumped it into the same category as the spinal decompression unit I discussed in chapter 2, and called it experimental, declining to pay for treatments. Large private health insurance providers and self-insuring entities like Washington State’s Department of Labor and Industries followed suit. From that moment, in many states, MedX therapy would be reimbursed at the same rate as a session of exercise on a $25 inflated plastic Swiss ball. Over the next several years, many MedX machines were relegated to dusty, dark corners, with sheets thrown over them. In 1996, because Medicare was not going to pay, and therefore it was unlikely that MedX would ever fulfill its inventor’s dream of “printing money,” Arthur Jones announced that he would put MedX on the auction block.
After Werner Kieser took me on a brief tour of the company’s unpretentious headquarters—there’s a sign out front with the company motto on it: “Man grows only through resistance”—we entered the gym. It had a bright, loft-like feel, with hardwood floors and big windows, and lots of brushed aluminum and glass. The machines were lined up in rows, like so many armor-clad knights awaiting their marching orders. At eleven a.m., the place was silent—no crashing of steel plates or thumping of barbells, no clients groaning with effort, no sound except for the gentle whir of the machines’ cams, gears that alter the resistance of the weight stack. A lot of things that are standard in U.S. gyms were missing: This gym had no posters encouraging you to “Just do it,” no smoothie bar, no music, no flat-screen TVs, no mirrors.
This was not by accident. “It’s thirty minutes of training twice a week, followed by a shower,” Werner Kieser announced. “We tell people they will accomplish three things, in order of importance. First, they will get rid of pain. Second, they will become stronger. And third, they will become more attractive. The fitness industry seems to offer what is requested, but not what is actually needed. The point is to provide the correct amount and type of exercise to produce optimal results.”
From Chapter 12
THE POSTURE MAVENS:How to Make Gravity Your Friend
Although I had my doubts about ever being able to tolerate a standing desk, I thought that a walking workstation had promise. In the New Yorker, I read that one of my literary heroes, the author Susan Orlean, managed most of her work on a treadmill desk. She’d been a runner for years, and maybe that explained her higher-level motor skills, and her ability to mesh cognitive and motor demands. For me, simple tasks were no problem; in fact, it was a blast to chat on the phone with a friend while walking at one mile an hour and feeling virtuous about it. I could even fake-type, running my fingers nimbly over the keys. But when I set to work in earnest, the stumbling blocks were evident: My brain freaked out. Through my progressive eyeglass lenses, the words swam, making it impossible for me to read, take notes, or write a coherent sentence. I felt dizzy, and a little car-sick, and, even more than usual, my back hurt. It was back to the chair—and the slouch—for me.
Research revealed that I wasn’t the only one who tortured her spine while working. “The erect posture looks very nice, but it is impossible to sit this way for very long and there is no scientific basis for it,” wrote A. C. Mandal, a leading Danish surgeon who dedicated most of his career to studying better options for sitting, particularly for children. “It is entirely based on wishful thinking, morals, and discipline from the days of Queen Victoria. This erect sitting posture cannot be maintained for more than one or two minutes, and usually results in fatigue, discomfort, and poor posture.”
One day, while thumbing through physical therapist Deane Juhan’s handbook for bodywork, I found something that rearranged my thinking. Everything in our lives, Juhan observed—“our habits, our jobs, our social situations, our general dispositions”—encouraged us to “prefer certain fixed positions over others.” We developed “particular fixations” and clung to them, until the possibility that “we might in fact stand up in a different way passes out of our conscious consideration.” Those ingrained postures, he explained, create patterns of tension in our muscles, and, in time, that constant tension “alters the thickness of our fascia and the shape of our bones in order to more efficiently accommodate a limited number of positions.”
We find familiar postures comforting, wrote Juhan, because they provide “sensory and psychological stability, a constant norm which we return to as to a favorite jacket or old friend.” Escaping was tough: “Person, posture, and point of view become firmly welded together, unfortunately limiting all three. And what was a familiar friend can become an increasingly tormenting millstone around the neck.”
To liberate myself from those millstones, I’d have to become aware of my “old friends”—postures and positions that did not help me but which I habitually assumed, such as the classic “knee-over-knee,” with my body angled to the right for balance. That position, a favorite since I took it up in the classroom as a young teenager, had shortened all the muscles on the right side of my torso.
Since there were more approaches to correcting posture than I could reasonably hope to study, I stuck with six fairly accessible interventions. (Although not all are available in all parts of the country, in most regions you will find at least one of them.) On the list were methods that are basically European—the Feldenkrais method; Rolfing structural integration; the Alexander Technique; and Pilates and its close relative, Gyrotonic—and from the East, the practices of Iyengar yoga and the Asian martial arts Tai Chi and Qigong. Although several of these approaches had been properly studied in randomized controlled trials, others had not undergone evidence-based scrutiny. In such cases, I relied on my own experience, and on word of mouth.
Stretched out on the low, padded therapy table, fully dressed, I listened to her soothing voice. My body tends to tense up in the presence of an unknown massage therapist, but Bowes was so gentle that readily, I granted her admission to a very primitive part of my central nervous system. “This is about finding out where the ‘noise’ is,” she murmured, as she ran gentle fingers over my rigid trapezius muscles. “We want to find out where the blinders are. You may have been crooked for years without noticing . . . until you do. Pain is like a garment you don’t know you’re wearing until you take it off.” As she continued to manipulate my head and spine, I spent ninety minutes in a semiconscious state. This was not any kind of massage: It was visceral communication. It took considerable sweet-talking, but I felt the taut muscles of my low back and hip finally give up their fight.
A month later, I was less nervous. As Salveson probed the taut piano wires at the base of my neck, some kind of emotional dam crumbled. Sniffling and apologizing for the waterworks, I reached for the tissues. I was not to worry about it, he said. Rolfing almost always provoked emotional arousal. If it didn’t, something was wrong. If I’d been looking for a way to debunk Cartesian theory, I’d found it.
Because the holidays were over, Salveson’s appointment book was full—for the next year. So that I might complete the remaining eight sessions, he referred me to an advanced certified Rolfer, who worked closer to home.
His referral, James Schwartz, was tall and thin, and very well read. While I was on the table, he was inclined to produce on-target metaphors that I couldn’t write down and had to try to remember. In one of the eight sessions, he compared the situation in my right hip and low back to a brawl: “It’s a lot like trying to calm down a mob,” he said, pensively. “It’s tempting to intervene with riot police and mace and clubs, but it’s usually more efficient to look for the ringleaders—the ones that are spearheading all this trouble—and to try to negotiate with them.”
Clinical trials of expensive drugs and devices are common, while investigations of protocols or products that won’t make hundreds of millions of dollars are rare. Still, there are exceptions, and the Alexander Technique, which has received considerable attention in peer-reviewed medical journals, is among them. Thirty-three years after F. M. Alexander left Tasmania for the West End of London, a group of nineteen doctors composed and signed a letter to the British Medical Journal, endorsing his approach. Noting that they had seen “beneficial changes in use and function with the technique in their patients and themselves,” they urged that such training should be incorporated into medical school curricula, to be taught by F. M. Alexander himself. Poor “use” of the body, they wrote, predisposed a patient to disorder and disease, including back pain, and they thought that the Alexander Technique might be the antidote.
From what I could see, that advice was ignored. But seventy-one years later, the BMJ published the outcomes of a large randomized controlled trial, funded by the United Kingdom’s Medical Research Council, which is in turn funded by the government. University researchers had recruited about five hundred patients from sixty-four general medicine practices. Prior to starting the trial, the patients, all of whom had experienced at least five years of back pain, made lists of tasks they could no longer perform. When the study ended, the plan was to evaluate whether anything had changed. One group of participants received “normal” care, that is, physiotherapy (as physical therapy is referred to in Britain) or an educational booklet. Another got massage therapy. The third group engaged in six lessons in the Alexander Technique, and the fourth group had twenty-four AT lessons, in combination with a walking program.
Those who were massaged were the first to experience relief, but when the massages ran out, so did the benefits. The physiotherapy patients and those who had six AT sessions saw less improvement than those who took twenty-four Alexander lessons and joined the walking program. In that group, the number of “things I can no longer do” decreased by more than 40 percent.
Instead of inspiring admiration, the study upset both allopathic physicians (who practice conventional Western medicine) and holistic practitioners, who feared that the British National Health Service (NHS) would bail on standard conservative treatments for back pain, ruining their practices. Normally, after a paper appears in an eminent scientific journal, a few comments, phrased with great deference to the authors, are published or posted online. But after the paper describing the Alexander Technique study appeared in BMJ, it generated sixty-seven such comments within days, mostly from physicians. Few of them were even marginally polite.
I learned that two styles of yoga, Viniyoga and Iyengar, were the most suitable options for people with orthopedic and musculoskeletal problems. (Some people refer to Iyengar yoga as “furniture yoga,” because the class incorporates blocks, belts, blankets, and sandbags, as well as folding chairs, stools, wall ropes, benches, and “tresslers” of various sizes, all of which are used to facilitate various poses.) In the past, these practices were studied in clinical trials that focused on posture, pelvic and spinal alignment, and training muscle groups to work properly together. The outcomes, published in the Archives of Internal Medicine and the journal Pain, showed that a well-designed yoga program not only decreased the perceived intensity of back pain, but also improved people’s ability to accomplish their daily tasks, and reduced their reliance on pain medication, the last by a very impressive 88 percent. More studies were needed, but those were not statistics you could ignore.
When Lisa Miller suggested that I might like to come with her to class, I quickly agreed. A couple of weeks later, after a hour-long drive in heavy commuter traffic, Miller and I were standing outside the Abode of Iyengar Yoga, in Glen Park, a residential neighborhood in the southern part of San Francisco.
We walked through a very ordinary front door and found ourselves in a gorgeous yoga studio, illuminated by a skylight. The place was jammed; later Manouso Manos would tell me he usually had about sixty students. “Some people call it ‘hope for the hopeless,’” Miller said softly, steering me toward a line that had formed in front of Manos, who sat on the floor at the front of the room. “There are countless numbers of us,” she added, “with surgeries gone wrong, and really significant pain issues—and somehow, he manages to address all our needs while running the class.”
Manos wore an old T-shirt and a pair of bloomer-like yoga shorts. When I finally reached the front of the line, I squatted down next to him, prepared to give a full account of my condition. He asked me to point to the problem, so I did. My right hip ached as usual. “What about the other one?” he asked. That was fine, I said. “Okay,” he said. “We can fix it.” Just as he had with Lisa Miller, he sent me to the back of the room.
Both Tai Chi and Qigong have been studied extensively in clinical trials. The research that really piqued my interest came from the Australian George Institute for Global Health, where, in 2009, investigators addressed the effect of Tai Chi on arthritis and chronic back pain. Their first study, a placebo-controlled trial, demonstrated that Tai Chi improved pain and disability among arthritis sufferers and also showed its potential to improve overall health. The follow-up randomized controlled trial, which incorporated eighteen sessions over ten weeks, focused on the therapeutic effect of Tai Chi on chronic low back pain, addressing postural and body awareness, arm and leg strengthening, balance, and gentle upper back stretching. Participants in the Tai Chi group were encouraged to find ongoing practice in their neighborhoods, while those in the control group pursued their usual health care routine. When investigators examined the outcomes, they found that those in the Tai Chi group reported a 23 percent improvement in back pain and a 32 percent reduction of disability. The control group showed no such improvement.
From the Conclusion
SIX YEARS LATER
The atmosphere in the auditorium felt more melancholic than enthusiastic. The go-go years were over. Many seats were vacant. Surgeons were no longer in charge. The 2015 NASS president, physiatrist Heidi Prather (who you met in chapter 2), now vice-chair of the Department of Orthopaedic Surgery at the Washington University School of Medicine, is a doctor of osteopathy, rather than an MD. Outspoken, female, and barely in her fifties, Prather’s comments revealed a great deal about the future of the back pain industry.
“We need to look from the outside in and look at how we, as specialists, contribute to the crazy road trip patients are placed on, in hopes of eventually finding what they need,” she told the audience. “I refer to it as ‘the specialty fishing pond.’ The patient is fished out of the pond [by] one specialty. If they don’t fit . . . they are thrown back into the pond, only to be fished out again. This costs a lot of time and money and promotes the evolution of a chronic problem. Chronic problems . . . are costly; lost time from home and work activities, increased anxiety and depression [and] increased health-care spending.”
Prather advocated a change in the way that back pain patients were treated. Physicians and health care plans had to give up their allegiance to fee-for-service billing, she said, or “we are going to lose the ball game.” They had to start sending patients to interdisciplinary rehab programs. “We don’t get reimbursed for educating and communicating,” she said. “Being paid only by what we do limits us to being mere technicians.”
It was essential to remember, Prather said, that “people are complex organisms . . . they don’t always fit in a box.” While she spoke—her expressive face looming huge on a couple of video screens—I checked out the reactions of the people sitting around me. Younger people—many of them might have been physical therapists or physiatrists, engaged in rehab—nodded in agreement; Prather was their hero. But all around me, spine surgeons sat there slack-jawed, pale, and probably feeling a little ill.