Book Review: CROOKED: Outwitting the Back Pain Industry and Getting On the Road to Recovery by Cathryn Jakobson Ramin

First: Crooked was sufficiently useful that I listened to the audiobook twice, and then bought a hardcopy so I could page through it more carefully. In many ways, it changed my thinking about back pain and treatment, and made me realize that my failure to respond to the treatments prescribed to me has less to do with my own unique situation and more to do with the failures of the system. Although I questioned some of Ramin’s conclusions, I was ultimately grateful for the work she put in to navigating the perplexing and labyrinthine back pain treatment system.

Writing the book was no small feat. When Cathryn Jakobson Ramin first began working on her book, she already had three decades of reporting experience behind her. She spent six years working on the manuscript, and during the course of her research, she interviewed over six hundred people. It was a major undertaking, one that most patients will never have the resources or inclination to pursue. She dug up many stories and unsettling conclusions that most patients, left to their own devices, would never find out about.

Maybe Read This Before Being Treated

Crooked made me question every danged procedure my doctors put me through to fix my back — up to, and including surgery. Back when I had my first appointment with a spine surgeon, I remember leaving the office in tears after he explained there was nothing operable in my MRI and I wasn’t a candidate for surgery. In my mind, surgery was my best chance – possibly my only chance to return to full capacity. If surgery was off the table, what was I supposed to do instead?

After reading Crooked, I realized that surgeon had done me a great service. I didn’t realize how poor back surgery outcomes often are, and how depressingly common it is for people to end up in worse shape than they started with. Had I known, I would have thanked that surgeon for saving me from a costly and probably ineffective procedure.

I did eventually have surgery (performed by another surgeon). When that failed, I went through a phase where I wanted to try anything that might make me better, even if it meant being a guinea pig. I used to keep my eye on clinicaltrials.gov, to see if there was some experimental procedure I could sign up for. Doing nothing was unthinkable. I figured that joining a clinical trial might at least give me hope.

I never did find a trial I was eligible for, and looking back, I am so glad I never got the chance. Experimental spine surgeries — and routine ones, for that matter — have not gone particularly well historically. Spinal fusion surgery seemed light years ahead of the haphazard approaches tried before. And yet, as it became more widely available, the surgery left a trail of ruined lives behind it. Kyphoplasty seemed promising, until it wasn’t. The outcomes of “minimally invasive” spine surgeries are actually worse than more invasive surgeries. And artificial discs have a turbulent history, to put it charitably.

Once hardware has been installed in your spine, as is the case with several surgical procedures, your spine health is out of your control. Finicky as they are, spinal discs are uniquely well-designed to bear the stresses placed on your spine, and so far, there simply haven’t been any man-made replacements that compete.

Ramin is at her best when diving into some of the corporate and government scandals that have plagued the back-pain industry, and when giving the backstory as to why certain treatments exist. Why do chiropractors take X-rays? Or for that matter, insurance? How did physical therapy come to be a front-line treatment, and why does it require a prescription? How did painkillers come to be so widely available? When answering these questions, Ramin shines.

So…Science.

Now that I’ve got all that pesky praise out of the way, I can move on to the fun part – whining,

Ramin seems out of her depth when it comes to scientific research. Although she cites several academic studies, my confidence in her ability to interpret them is shaky. I found this gem of a quote near the end of her book, when she describes a study (conducted by orthopedic surgeon Vert Mooney) evaluating the effectiveness of a particular exercise machine:

“To be taken seriously, a study must receive peer review. That means that a group of Mooney’s colleagues would have to critique it, and find it substantial. Mooney’s study was eventually published in the Journal of Occupational Rehabilitation, but it never received peer review, probably because the results the paper described were so good that they would have damaged the prospects of those occupational medicine practitioners who would have had to sign off on it.”

Ramin appears to be serious. Even in the audiobook, which she narrates, there is no trace of irony in her voice (unless her sense of humor is Atacama-Desert-dry). But…really? Yes, reviewers can be difficult, and good results can well be questioned by the establishment. (And unfortunately, there are rare instances in which papers are retracted, or rejected after peer review, out of fear of political backlash.) But in any normal situation, that is just not how peer review works.

I don’t have the backstory for this particular manuscript. And true, it was published in 1995, well before my time in the industry. But generally speaking, any reasonably well-designed study with noteworthy results will be able to pass peer review. It’s not at all unusual for the first journal to reject a paper, but a good paper will find a home eventually. Ramin’s offhand comment seems completely blind to professional publishing practices and ethics.

Anyway, I took that as my cue to double-check any points that might directly affect my own health.

On a related note, Ramin shies away from delving too deeply into the medical basis or efficacy of each treatment. For example, in the “Needle Jockeys” chapter (about epidural injections), Ramin did an excellent job detailing the horrors that result from rare complications. Medications contaminated with fungal mold, and botched approaches that pierced the dura matter have led to unimaginable suffering on the patients’ part.

But what about the patients who don’t experience catastrophic injections? How likely are they to actually see any benefit? And what exactly counts as a “successful” procedure? I got the feeling that the doctors use different criteria than I do, but I’m still fuzzy on the distinctions. These sorts of questions are given short shrift.

When the Solutions Are the Problem

Ramin divides her book neatly into two sections. Part I: Problems, and Part II: Solutions. The overall message is that everything you know about standard back pain treatment is wrong, but there are some intrepid souls out there willing to take on the system and get you fixed. It’s a compelling storyline, certainly, and I can imagine some editor at HarperCollins salivating over the sales projections. (The World Health Organization notes that 60-70% of people in industrialized countries will suffer from low back pain at some point, and the treatment market is measured in billions. The Powerpoint pitch practically writes itself.)

Unfortunately, the subject matter doesn’t always fit neatly into this dual structure, leading to some awkward reading. Ramin wanted an underdog to root for, and she put her skepticism on hold in order to find some. Had Ramin approached her “back whisperers” (her term for the back pain gurus she interviews in Part II) with the same cynicism she did the establishment, it would have been a different book.

In Part I, Ramin pointed out repeatedly that there was a strong profit motive driving established physiatrists and surgeons, and this ensured that ineffective procedures continue to be pushed on patients. That her selected back whisperers (with the possible exception of some tai chi instructors) also make their living by treating back pain, was not addressed.

The cognitive dissonance was especially striking when Ramin was discussing Kieser Training, a European therapeutic exercise company headed by Werner Kieser. Ramin said:

“For $1,050 a year, Kieser Training members are entitled to a medical evaluation and two thirty-minute workouts each week. Each gym is equipped with exactly twenty-nine exercise machines, many of them of Kieser’s own invention. They are laid out in precisely the same order, no matter where in the world they stand.”

A short while later, she quotes Werner Kieser himself, who said:

“Back patients guarantee repeat business, and a budgetable source of income…That’s money these physicians can rely on, year after year.” 

That Kieser’s own business relies precisely on that budgetable income goes unmentioned. Instead, Ramin is content to frame Kieser Training as a feisty upstart sticking it to the man.

In the Part I section on physical therapy, Ramin denounces “shake and bake,” programs, in which each patient receives the same treatment plan with little regard for individual differences. The advantage to the physical therapy practice is that these programs can be cheaply administered by poorly-trained or inexperienced staff. The rates billed to insurance companies, needless to say, is not discounted.

Maybe there’s a reason why Kieser’s one-size-fits-all approach is superior to standard PT programs, but if so, it’s not given in this book.

In the physical therapy section, Ramin also dismisses passive treatments (ultrasound, heat and ice, etc.) as ineffective but popular among patients. I’m still not clear on why Rolfing, which sounds like an intensive form of massage, is much better.

Ramin is content to lay out the alternative treatment options and let the reader decide which, if any, to pursue. She does not make recommendations, nor does she offer any particularly compelling personal testimony about which worked best for her.

By the way, Ramin still suffered from back pain by the time her book was published, though she was coping with it better. I emailed her while I was working on this piece, and she responded to say that she still works out with a trainer twice a week, walks daily, and (pre-coronavirus) swam regularly. She also switched to a sit/stand desk with a stool, which she credits with further reducing her pain.

Ramin seemed aware that looking into alternative treatments could turn into a never-ending project, so she wisely decided to pick a cutoff point. However, she still maintains a list of back resources on her website. (I reached out to Ramin to ask about the selection criteria for the practitioners she lists. She responded to say that there are no formal criteria; resources are listed at her discretion. She also pointed out that there are no payments involved – she trusts her experience to sort out the snake-oil salesmen from the real deal.)

I got the distinct impression that, through the course of her reporting, Ramin grew fond of her sources and wanted to believe all of them. It’s a tendency I understand, being prone to it myself. Does it serve her readers well? That, I cannot say.

Are We All Just Lazy?

This is my own pet peeve, and I am going to pick on Ramin, although this trait pervades much of the back-treatment industry, and isn’t unique to her.

Some of Ramin’s assumptions about back pain patients require some magical hand-waving to make inconvenient counterexamples disappear. She seems sold on the general idea that exercise will improve back pain, and also implies that the main impediment to recovery is either fear or laziness. People are afraid to aggravate their backs, and so they shy away from activities which they could realistically handle. They may intend to exercise, but then life gets in the way, and people flake.

Fun as it is to get on a soapbox and harangue the couch- or office chair-potatoes (and Ramin counts herself among them), this leaves out exceptionally fit individuals who also suffer from debilitating back pain. What about the dedicated athletes she describes, who are desperate to return to practice? And what about those whose jobs involve heavy manual labor? I have a hard time believing that their main obstacles to wellness are psychological.

One notable story involved an out-of-work ballerina who couldn’t perform because of her back pain. She had to borrow the money for expensive chiropractic treatments from her father, but the sessions didn’t help. Was fear really her main impediment? I don’t know this woman personally, but I found the idea tough to swallow.

I admit that I find this irritating on a personal level. When my problems started, I was committed to the tough-it-out school of thought. I was (and still am) an exercise junkie. For a while, I kept up my gym routine, continued pole dancing, and tried to keep running. I figured that if I kept pushing myselt, I would eventually push past the pain. (Either that, or I’d damage myself properly, in which case I hoped the doctors would finally figure out what to do with me.) All I accomplished was to set myself on a steady downhill trajectory, until eventually I stopped sleeping and developed one health complication after another. I came to my senses slowly and begrudgingly, and eventually cut out or modified all the activities I linked to pain.

The Bottom Line

Crooked is useful enough to be worth its flaws, and I’ve recommended it to several people who either have back pain themselves, or are close to someone with back pain. Even at full price (around US $28 for the hardcover), it costs about as much a single doctor’s visit with a good health plan. (If you don’t have to worry about the cost of an appointment because you live in a country with government-sponsored health care, it’s still a worthwhile purchase. You can finish reading it before you actually get in to see your doctor.) I, for one, certainly got my money’s worth.