RESOURCES | Back Pain
Many people—most of them in pain—have asked me when Crooked will be published. When I tell them that it’s likely a year out, they ask me what they might read or watch in the meantime. Below, I’ve assembled a list of helpful links accompanied by brief comments. Consider this list a preliminary exploration of what’s out there. These resources are discussed in much more detail in the book. I suggest you visit this section often, because it is constantly changing and expanding as I discover new and useful material.
A General overview of what's out there
NIAMS is the National Institute of Arthritis and Musculoskeletal and Skin Diseases. It’s one of the research institutes of the National Institutes of Health. Click here to get a decent overview of options and issues. It’s not perfect—I can smell the influence of the FDA, an agency that is very much under the thumb of pharmaceutical companies and device manufacturers—but it’s decent.
It may be hard to believe, but in 1998, Richard Deyo, MD one of the most clear-thinking back pain experts in the U.S. published an article in Scientific American explaining what was wrong with back pain treatment. See, particularly, his list of myths, complete with matching cartoons, on page 52.
Physical Medicine & Rehab Specialists
They aren’t all great—in fact, some of them keep the office lights on by giving spinal injections—but if you find the right PM&R doc (they are also called “physiatrists”), your back will be in excellent hands. Look for a physiatrist who has done a fellowship in spine medicine. This site lists programs that offer PM&R fellowships, so that’s a first step toward finding a good resource. Physiatrists are MDs and DOs (doctors of osteopathic medicine) who specialize in working with patients with nerve, muscle, bone, and neurological conditions. They are talented diagnosticians, far more talented than your average spine surgeon in discerning the source of your problem. Typically, they’re well schooled in physical therapy and exercise physiology. If someone claims to be an “interventional physiatrist,” it means that he or she focuses on giving injections. That’s a signal that you are in the wrong place, so look some more. Click here for the American Academy of Physical Medicine and Rehabilitation’s patient page.
It can be quite difficult to find a PM&R doc who really focuses on the rehabilitation part, rather than the “let’s give some shots and make some money” part. Docs who work for university hospital systems are not quite as compelled to perform income-producing procedures as their self-employed brethren. A phone call or email to The Association of Academic Physiatrists on this list should yield someone good.
Physiatrists I Love
I met Dr. Heidi Prather, D.O., Associate Professor of Orthopaedic Surgery and Neurology and Co-Director Director of Orthopaedic Spine Center at Washington University School of Medicine, at a spine surgery conference where many of the other doctors (most surgeons) did everything they could to avoid me. Dr. Prather and I chatted for a couple of hours about her interests – women’s health; in particular, low back pain, radiculopathy, sacroiliac joint pain and pelvic dysfunction. A few weeks later, I had a woman call her who had been scheduled to undergo a two-level spinal fusion…but who turned out not to need any type of surgery. It can be tough to get a hold of Dr. Prather – her office tends to put people off, telling them she only sees dancers and athletes. Not true. If you’re in the St. Louis area, keep trying, because it’s worth it.
HELP FOR CHRONIC PAIN PATIENTS
Penney Cowan, the founder and director of the American Chronic Pain Association, provides a constructive, non-opioid painkiller perspective for patients here.
If, like so many people, you have been prescribed opioid painkillers—from Vicodin to Oxycodone—as treatment for your back pain, you’re likely aware of the problem of physical dependence. You may be wondering how on earth you wound up in this situation and how you might taper the drugs, a process that your “pain management expert” may not be very interested in facilitating. The Washington State Agency Medical Directors website harbors some progressive thinking on this matter. It’s kind of technical, but worth inspecting. While you’re on the site, click on the PDF called Cautious, Evidence-Based Opioid Prescribing.
And have a look at the website of Physicians for Responsible Opioid Prescribing. Believe me, you’re going to get an eyeful.
MULTIDISCIPLINARY PAIN PROGRAMS
Each year, the American Pain Society gives a Clinical Center of Excellence in Pain Management Award to five or so pain management facilities around the country. Here you’ll find the index, all the way back to 2007. Not all of them offer multidisciplinary chronic pain programs—some are tiny, community-based programs—but it is a good place to start. Be sure to click on the detailed descriptions of each year’s winners.
CHECKING UP ON YOUR SPINE SURGEON
If you believe that anyone who survived his or her medical training and hangs out a shingle is deserving of your trust, think again. And then go here to see whether the American Board of Medical Specialties has certified your physician.
A spine surgeon with a high-volume practice speaks frankly, giving you the low-down on when it is time to say “thank you—and good-bye” to your spine surgeon.
Crooked will show you why it is highly unlikely that you need spine surgery. But if you do find yourself in the surgeon's office, here are Twelve Questions You Must Ask before you even dream of setting up a date in the OR.
FUNCTIONAL RESTORATION PROGRAMS
Here’s a link to James Rainville, MD’s program at New England Baptist Hospital’s Spine Center, on the outskirts of Boston, regarded as one of the best in the world. Here is an article published by the center on the benefits of innovative back programs.
The RealHealth Institute, with facilities in London, Coventry, and Nottingham, is where Jeremy Fairbank, one of the United Kingdom’s foremost spine consultants, sends his patients to get them in shape. Charles Pither is the medical director.
The Dartmouth-Hitchcock Functional Restoration Program in Lebanon, New Hampshire, is directed by Roland Hazard, MD. After spending a few days at the facility, I was extremely impressed. There are videos on this site that will give you an excellent idea of what functional restoration is and how it can work for you.
Rehabilitation Institute of Washington PRIDE Dallas was one of the first functional restoration facilities in the United States. Run by Thomas Mayer, MD, and his wife, Holly, it combines an excellent physical rehabilitation program with superb psychological support, making it a top choice for people who really want to get back to work.
Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence. (Source: Wikipedia) For information about the Chiropractic’s Subluxation Theory, click here.
Rolf Structural integration If you are interested in learning more about structural integration, a practice I describe in detail in Crooked, or in finding a practitioner, have a look at the Rolf Institute’s site.
The Feldenkrais Method of Somatic Education Feldenkrais Awareness In Movement is a very gentle, inexpensive—and extremely effective—method of neuromuscular re-education. Anyone, at any age, and in any physical condition can do it. It is particularly useful for people in chronic pain. There are nearly three thousand guild-certified Feldenkrais practitioners and teachers worldwide. For help finding one near you, click here.
The Alexander Technique Here’s the online home of the American Society for the Alexander Technique with a “Find a Teacher” search function. Alexander Technique International provides access to a thousand teachers around the world.
The British Medical Journal published the outcomes of a large study of the Alexander Technique. These two BMJ-produced videos will give you a good idea of how it works.
Iyengar and Viniyoga Practice There are many forms of yoga, and some of them are much better for people with back pain than others. (In fact, people frequently hurt their backs practicing yoga, usually while under the supervision of a "certified" yoga teacher, who took a short course.) As a back pain patient, you're looking for a teacher with many years of training, and a strong focus on orthopedic problems. There are also trained yoga therapists, but certification requirements are— ahem— flexible. A certified viniyoga therapist has been through 500 hours of training.
Becoming an Iyengar Yoga teacher begins with long term, thorough and dedicated practice. One is a student of Iyengar Yoga for many years before becoming a teacher. Only after three years' study, and after developing a relationship with a Certified Iyengar Yoga Teacher who agrees to become a mentoring teacher, may the candidate begin the application process. Then comes two years' teaching, exclusively in the Iyengar Method -- all before the actual testing begins. In the assessment process itself, candidates are carefully observed and evaluated as they demonstrate asanas and Pranayamas and as they teach a class of students. If you find the right Inyengar or viniyoga teacher, you'll get remarkable results, quite quickly.
Here's a link to the Iyengar Yoga National Association of the United States. Certification as an Iyengar yoga teacher takes many years of training, and Iyengar yoga inherently has a strong orthopedic focus. You will find interesting information about how Inyengar views the spine here.
If anybody doubts the structural strength of the spine, have a look at this performance... nothing fragile about it:
In recent years, there have been several important scientific studies addressing yoga's efficacy in the treatment of low back pain. It is evident that the proper kind of yoga practice can be strongly beneficial. Here is a video describing one of those studies, published in the Annals of Internal Medicine.
Here is another video describing the work of Yoga for Backs, a large U.K. clinical research trial.
Roger Cole, based near San Diego, conducts workshops around the world. He is an internationally recognized specialist in Iyengar yoga for people with bad backs. You can find his website here and more information about his philosophy and practice here. He is a scientist who studies sleep psychology.
Mary Pulling Schatz, M.D., who has been called the "barefoot back doctor," graduated from Vanderbilt University School of Medicine, where she also completed specialty training in pathology. She has used yoga successfully to heal her own lower back and neck problems.
TAI CHI CHU'AN
Tai Chi Chu'an, which is a type of Quigong (pronounced chee kung) practice, is quickly gaining ground as an excellent approach to treating back pain. It is a practice that works for almost everybody – age and fitness level are not important. There's at least one DVD dedicated to helping back pain patients. Dr. Jwing-Ming Yang demonstrates exercises that help you relieve pain and rebuild the strength and flexibility of your back. These movements can gradually recondition your entire torso, including the spine, tendons and muscles. You can find the DVD here.
A lovely overview of Quigong can be seen below:
EXERCISE AND REHAB SPECIALISTS
One of the smartest guys I’ve run into on this journey is Stuart McGill, a professor of spine biomechanics at the University of Waterloo in Ontario, Canada, and I recommend that you go to his website.
Joe Zarett, whose large facility, Zarett Rehab, is in Philadelphia, is one of my very top picks for getting your body back in order. He’s incredibly demanding—and so is his staff. But he changed things for me, big time.
View more news videos at: http://www.nbcphiladelphia.com/video.
Physicians Neck & Back Clinic is Brian Nelson, MD’s brainchild, with a base in Minneapolis and numerous satellite clinics. Dr. Nelson put down his scalpel when he realized he wasn’t getting good results from spine surgery and substituted a rigorous, multi-week, spine-focused exercise program.
To learn more about PNBC's Core Spinal Fitness Program - this is a gym you can join to maintain the gains from their rehab program - click here.
If you're in Michigan, count yourself lucky -- you've got four of the top rehab facilities scattered around the state. Pure Healthy Back (formerly Dynamic Rehab) uses MedX medical therapy machines, exercise machines and the McKenzie Method to treat spine patients. And spine patients are the only patients they treat. (In Crooked, I describe Pure Healthy Back's approach in more detail.)
Craig Liebenson has been instrumental in developing the International Society of Clinical Rehabilitation Specialists, many of whom were trained as chiropractors, but have chosen to retrain in spine rehab and sports medicine. For information on providers in your area, search here. Have a look at some of Craig Liebeson’s work, here. Trained as a chiropractor, he’s one of the great spine rehab specialists, located in West Los Angeles.
Here are a couple of Craig Liebenson’s articles in the Journal of Bodywork and Movement Therapies, describing exercises that you can do – though I strongly suggest that you do them under supervision. See The Missing Link in Protecting Against Back Pain in Protecting Against Back Pain and How to Stabilize My Back. Note that the exercises described here are variations of exercises that Dr. Stuart McGill has made famous, but there’s no such thing as intellectual property when you’re talking about exercises.
If you’d like to find a top-notch rehab specialist near you, check out clinicalrehabspecialists.com. Many of the therapists who are listed were once traditional chiropractors. But they’ve seen the light…
If you speak Spanish and would like to join an functional rehab program in the Balearic Islands, have a look at the program offered by the Fundación Kovacs at S'AiguaBlava. The program is called Escuela de Balear de la Espalda. There are three facilities, each with a fantastic back-oriented gym program, and an amazing "high vitality" spa - which in much of Europe means hydrotherapy in a large pool with may stations equipped with jets at different heights. The facility I visited, on Majorca, combined physical therapy with supervised, high intensity exercise. Here (again, in Spanish) is video with director Dr. Mario Gestoso, explaining what goes on in the Back School.
New ACE research that shows older adults can expect quick benefits from functional fitness programs. Read more about it here.
PILATES AND GYROTONIC™
Not all Pilates classes - be they tower or mat - are good for your back. In fact, under-supervised Pilates often results in back pain. Look for a teacher with specialized therapeutic training. For an example of what you should be looking for, visit Amanda Tennant's site.
FINDING A PHYSICAL THERAPIST WITH AN ORTHOPEDIC CERTIFICATION
The American Physical Therapy Association has a helpful website. After you review the material there, click here to search at a very specific level. Look for therapists who have OCS and DPT after their names. This means that they have specific orthopedic training and doctoral degrees.
FINDING A HIGHLY QUALIFIED, BACK PAIN-FOCUSED PERSONAL TRAINER OR EXERCISE SPECIALIST
Anyone can call himself or herself a personal trainer. To find the person you need, the American College of Sports Medicine is an excellent resource. Its ProFinder allows you to search by level of certification, city, and ZIP code.
The NSCA is the National Strength and Conditioning Association, based in Colorado Springs, CO, which – probably not a coincidence – is also the location of the flagship training center for the U.S. Olympic Committee. Several people who definitely know told me that NSCA turns out the most qualified personal trainers, most of who have degrees in exercise science. If you look for a trainer with an NSCA-CPT (certified personal trainer) certification, you’re off to a good start. Here is a not-too-great index of NSCA trainers. You can search by state, but when you do, the results are not alphabetical.
It can be hard to track down some of these items, especially if you’re not sure what a Roman chair is, click here.
Low-tech and inexpensive giant exercise balls, known as physioballs, Swiss balls and posture balls, can play an important part in your rehab – and they’re fun to have around! Working out on a ball requires balance, which means that you must recruit the deeper back muscles, rather than the large, superficial ones. Typical exercises include push-ups with the legs suspected on the ball, crunches with the back resting on the ball, and leg lifts (on your back) with the ball squeezed between the ankles. Some people use these balls as office chairs, with good results. To remain upright, you need to exercise good posture. You can order exercise balls here
Wish you could use a standing desk occasionally, but don’t want to be bothered with dealing with one all the time? (Studies show that in most cases, people spend a lot of money for a desk that goes up and down – and alter its position twice before giving up.)
has a nifty (and decently-priced) addition for the office that could be the answer to your prayers.
See the best standing model, with keyboard and mouse trays,
The Internet is rife with back pain forums—essentially chat rooms where people talk about their conditions and no one ever seems to get better. (If they do improve, they don’t come back to the forum, I suppose.) These are scary places, and I recommend you stay away from them, unless you’re looking for a pity party. (Forum members post an ever-lengthening list of surgical interventions and pharmaceutical cocktails after their names.) There is a great deal of misinformation out there, not to mention desperation. If you visit the forums, do so with a skeptical eye. Given the incredible proliferation of unproven procedures on these forums, I am reasonably sure that money changes hands between the people who run these forums and device manufacturers and pharmaceutical companies, but I’ve never been able to prove it. One of the better ones is run by the Spine Patient Society.
IMPLICATIONS FOR HEALTH CARE REFORM
The Dartmouth Atlas provides shocking data about the prevalence of spine surgery here.
If you’re interested in how surgeons and device manufacturers wound up in bed together, you’ll want to have a look at the website for the Association of Medical Ethics. Take some time to study the section called AME Star Rating System, which rates the value of the medical evidence produced in clinical trials. As you will discover, much of the data is practically useless. The AME Star Rating System provides an easy-to-use report card on products, procedures, and devices. It also tells you how much surgeons have been paid to consult on a specific product.
The investigative reporting organization called ProPublica is creating an increasingly robust and truly eye-opening source of information regarding the payments that drug and device companies make to doctors in return for promoting their drugs. This database—broken down by state, which is more convenient—has been assembled by the superb investigative reporters at ProPublica. Start with this article that explains how patients can use the database. The database is here.
JOHN F. KENNEDY'S BACK PAIN
For an eye-opening read about JFK's back pain and Hans Kraus, the exercise doctor who banished it, see JFK'S Secret Doctor: The Remarkable Life of Medical Pioneer and Legendary Rock Climber Hans Kraus.
In this video, Jacqueline Kennedy sheds new light on the depth of JFK's back pain (for the external link, click here):