Book Reviews: Crooked / Back Mechanic / Complete Guide to Low Back Pain

This is a review of three books about low back pain: Crooked, by Cathryn Ramin; Back Mechanic, by Stuart McGill, and the Complete Guide to Low Back Pain, an book-length article by Paul Ingraham from (paywalled.)

These are three very different books, written by three very different authors:

  • Cathryn Ramin is an investigative journalist who suffers from severe low back pain.
  • Stuart McGill is a Ph.D. kinesiologist at the University of Waterloo.
  • Paul Ingraham is a science writer and massage therapist, but more importantly for our purposes, he’s a empiricist nerd obsessed with evidence-based medicine.

My personal interest in the subject comes from several places:

  • I work in public health, and low back pain is one of the most expensive and least tractable public health problems in the modern world.
  • Several people close to me either have experienced or currently experience severe low back pain.
  • I have personally experienced a few, short-lived episodes of severe low back pain.

Crooked‘s tagline is Outwitting the Back Pain Industry and Getting on the Road to Recovery.  I’m going to try to not be too hard on it; it’s definitely not the book I was hoping it to be, but it did put me on the right track to find what I was looking for.

It’s organized into two sections.  The first (and better) section of the book explains that many popular back pain treatments are horrible, expensive scams that rarely work and have awful side effects.  In separate chapters, she calls out:

  • Chiropractors.
  • MRIs.
  • Steroid injections.
  • Spinal fusion surgery.
  • Alternative spinal surgeries.
  • Artificial disc replacements.
  • Opioid pain killers.

Each chapter describes the history of the treatment, the ways it is reimbursed, evidence of its ineffectiveness, and its side effects.  Supposedly she’s done a fairly thorough literature review, although the citation style is bizarre – in an apparent effort not to break the flow of the text, there are no superscripts in the chapters themselves; rather, the endnotes are flagged with page numbers and reprinted sentences.

This makes it extremely difficult to check the references as you go along, and to me, suggests that evidence-based persuasion is not this book’s priority.  Along these same lines, the book dwells on each treatment’s horror stories, gruesome tales of rare, worst-case scenario side effects, sometimes at the expense of clearly describing the more likely risks and benefits.  I noticed some other sloppiness here and there – for example, the chapter on opioids describes an epidemic of addiction among low back pain patients, when have reason to believe that the more common problem is diversion to friends and family.

The “Solutions” section is even sketchier; she endorses a grab-bag of cognitive-functional therapy, rolfing; Feldenkrais, Alexander, and other posture therapies; Tai Chi and Qi Gong; and some weird machine called the MedX; it’s quite difficult to tell whether these are simply things that worked best for her or whether she found research backing their effectiveness, nor whether there’s any unifying theory tying these things together.

For these reasons, I decided to check other sources.  Stuart McGill seems to be one of the most widely respected academics studying back pain; he is mentioned favorably in Ramin’s book and has a fairly extensive website as well as three books: Low Back Disorders: Evidence-Based Prevention and Rehabilition, a (very expensive) textbook aimed at clinical and academic professionals; Ultimate Back Fitness and Performance, an applied book aimed at practitioners, and Back Mechanic, a much-cheaper guide aimed at individuals suffering from back pain.  I chose the last for reasons of money and time, though with some misgivings – I’m curious as to what the textbook has to say about the theoretical and clinical issues behind back pain.

McGill claims that “there is no such thing as non-specific low back pain” – he argues for highly personalized diagnosis and treatment; he believes people suffering from low back pain need to thoroughly assess the causes and triggers of their own pain and re-train their movements to avoid these triggers.  Back Mechanic offers a series of steps for self-diagnosis and self-therapy along these lines.  There are, apparently, such things as non-specific low back exercises – McGill suggests a set called The Big Three that he suggests work well for almost anyone.

The other source I checked was the Complete Guide to Low Back Pain, which describes itself as taking a “Mythbusters approach” to medical research and boasts that it has been called “one of the Internet’s saner sources of information on low back pain” by the National Institutes of Health; sadly, it’s also one of the Internet’s most depressing sources of information on low back pain.  It not quite so grim as “nothing works”, but Paul Ingraham is very careful not to overpromise, and he’s ruthlessly critical, not only the treatments Ramin warns against, but also of several of the treatments Ramin thinks are promising – specifically the Alexander Technique and core strengthening exercises.

Unlike McGill, Ingraham thinks most back pain is basically “non-specific”; he believes it’s usually not worth worrying too much about the original cause of back pain, because no matter what the original cause, it’s almost always complicated and prolonged by something called myofascial pain syndrome, which is a fancy term for tight muscles.

This makes some intuitive sense to me.  I once had a back spasm that left me in pain for several weeks; I visited the doctor and was diagnosed, implausibly quickly, with a slipped disc.  Now, it’s not impossible that the triggering event was, in fact, a slipped disc, but the nature of the pain seemed muscular – for example, the muscles in my back were sore to the touch, and the pain eased in response to massage, heat, stretching, and other things that affect muscles, not discs.  Likewise, I know several other people who have been diagnosed with disc disorders, but whose pain “acts like” muscle pain; the argument that slipped discs are overdiagnosed in cases of muscular pain seems very plausible to me.

Unfortunately, as Ingraham notes, the science of muscle pain is a shambles, in part because muscles don’t fit neatly into any existing medical specialty (what’s the name of a “muscle doctor”?  Google tries to tell me it’s an “orthopedic surgeon”, which suggests not much attention is being paid to problems that can’t be solved by cutting people open.

That may seem like a whole lot of disagreement, but Ramin, McGill, and Ingraham all more or less agree on the following:

  • The existing back pain industry is full of scammers and bad advice.
  • MRIs are almost never helpful for diagnosing back pain.
  • Steroid injections are rarely worth the risks.
  • Spinal fusion surgery is essentially never worth the risk.
  • Opioid pain killers are almost never an appropriate long-term treatment for back pain,
  • Neither chiropractics nor acupuncture performs better than placebo.
  • There is a link between anxiety and back pain, and one of the most effective treatments is “cognitive functional therapy”, which focuses on reducing anxiety and sensitivity to pain.
  • Regular, moderate exercise can help reduce back pain, although the three authors differ slightly on exactly what kind of exercise is best.

Sadly, there is more mainstream consensus on what doesn’t work than on what does.  My impression is that Stuart McGill’s work represents the more mainstream approach, whereas Paul Ingraham’s is a tentative exploration of an understudied area of medicine.  Cathryn Ramin’s book is definitely not the place to go for the best evaluation of evidence, but it might be the most persuasive thing to hand to someone whom you need to quickly talk out of getting spinal fusion surgery.

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