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Cathryn Jakobson Ramin shatters assumptions about surgery, chiropractic methods, physical therapy, spinal injections, and painkillers and addresses evidence-based rehabilitation options describing in great detail, how to avoid therapeutic dead ends while saving money, time, and considerable anguish.
Now listened to in 100 countries, The InForm Fitness Podcast with Adam Zickerman is a presentation of InForm Fitness Studios, specializing in safe, efficient, High Intensity strength training.
Adam discusses the latest findings in the areas of exercise, nutrition and recovery with leading experts and scientists. We aim to debunk the popular misconceptions and urban myths that are so prevalent in the fields of health and fitness and to replace those sacred cows with scientific-based, up-to-the-minute information on a variety of subjects. The topics covered include exercise protocols and techniques, nutrition, sleep, recovery, the role of genetics in the response to exercise, and much more.
50 Outwitting Back Pain with Cathryn Jakobson Ramin
Wed, 3/23 12:09PM 1:00:19
SUMMARY KEYWORDS
pain, people, book, exercise, patients, problem, surgeon, opioid, hurts, chronic pain, surgery, spine, prescription, injections, mri, called, long, program, drugs, absolutely
SPEAKERS
Cathryn Jakobson Ramin, Mike, Adam, Tim Edwards
Cathryn Jakobson Ramin 00:05
The reason that exercise is successful with back pain patients is that it ends what really is the plague the back pain patient which is fear avoidance behavior, and catastrophizing and guarding. Those are three factors that we know of from basically they all come from behavioral psychology, but they are very, very prevalent in back pain patients and people who tend in that direction are the ones who frequently end up in chronic pain.
Tim Edwards 00:44
We are halfway to 100 Hello inform nation and welcome to episode number 50 of the inform fitness podcast with New York Times bestselling author and founder of inform fitness. Adam Zickerman. I'm Tim Edwards with the inbound podcasting network and a client of inform fitness. Adam Zickerman and Mike Rogers will be joined today by Cathryn Jakobson Ramin, who is an investigative journalist, a lecturer, and author of the book, crooked, Outwitting the back pain industry and getting on the road to recovery, which is a brilliant and comprehensive book that is essential to millions of back pain sufferers and healthcare professionals in Katherine's book, and in this episode, Catherine shatters assumptions about surgery, chiropractic methods, physical therapy, spinal injections and painkillers and addresses evidence based rehabilitation options. Describing in great detail how to avoid therapeutic dead ends while saving money, time, and most importantly, considerable anguish. Now if after listening to this episode, you decide to pick up Katherine's book, we will have a link in the show notes to audible trial.com forward slash inbound That's audible trial.com, forward slash inbound. And if you are not yet an audible member, you can sign up for a free 30 day trial membership and download the audio book crooked for free. If you decide to cancel your membership for any reason, you keep the book if you are already an audible member, and have cashed in your Free Audiobook download, then you'll receive a considerable discount on any of audibles 180,000 titles to choose from. Again, that's Audible trial.com forward slash inbound to get your free book just scroll on down to the show notes and you're one click away.
Adam 02:35
Hello everybody. Welcome to the show. This is gonna be a very good discussion, because it's about a subject that I am very personally involved with, which is of course back pain. me talk about my back issues on several of our episodes and we're just going to keep the ball rolling now so let's let's give them some some stats. Over 77 million people in United States experience back pain each year. For some the pain is present day and night for others. Well it shows up the moment the suitcase comes out of the closet or whenever the relatives come to stay stress. In other words, all in back trouble will cost the United States about 100 billion with a B dollars a year more than the cost of treating cancer, heart disease and aids combined. This prevalent woe exists in political, psychological, social and economic context that greatly influences how patients will be treated and if they'll ever recover. Today, we have with us journalist and author, Catherine Jacobson Raman, whose New York Times bestseller carved in sand. When attention fails and memory fades and midlife was published in 2007 spent years and a small fortune in her effort to resolve her own low back pain somebody similar to me. When nothing works, she decided to take an investigative look at the reality of the spine medicine arena. Expensive, ineffective, sometimes illegal, and often harmful. She found that the back pain industry exemplified the worst aspects of the US healthcare system. Today we welcome Catherine to our show, and to talk about her new groundbreaking book, crooked, Outwitting the back pain industry and getting on the road to recovery. Catherine, welcome to the show.
Cathryn Jakobson Ramin 04:19
Thank you so much. I'm delighted to be here with you today.
Adam 04:23
When I found out about your book, I had to get it immediately. I heard through the grapevine that you talked about some of the MedX machines that we use here and I needed to know what you felt about that. Little did I know I didn't realize you got this this book was thick. How many pages is it about?
Cathryn Jakobson Ramin 04:41
I think it's 340 pages or so.
Adam 04:43
And it's broken up into two parts. The first part basically, is discussing all the issues with our healthcare industry and all the problems and misleading information in all how and how all the scientific evidence points at all these modalities that our doctors are trying to push on. US aren't working, and why. And then she goes into the second part of her book where she talks about, well guess what there is hope there are things you can do. So, without further ado, let's talk about the first half. And let's talk about this dismal situation that the healthcare industry is in, why are there so many ways to treat back pain, yet, so few of them are effective?
Cathryn Jakobson Ramin 05:24
Well, back pain has largely been medicalized over the past 60 or 70 years. Up until the 1930s, nobody was having spine surgery unless you had been hit by a bus or had some other major kind of traumatic accident, because the chances of recovery or actually being able to walk again, were extremely poor. But in the 1940s, a couple of surgeons at Massachusetts General Hospital, discovered almost by accident that you could remove the intervertebral disc from the spine, and the person would survive. And in certain cases, the person's leg pain might relent. So having discovered that, that this, this disc could be removed safely enough, they said about doing a lot of that, what they realized was that they didn't fuse the two vertebrae together after they removed the disc, people had a lot of pain subsequently. So someone else came along and found a way to attach vertebrae of one vertebra to another vertebra. And that was the beginning of spinal fusion. And that really occurred in the 1960s and 70s. And it built from there. And Spine Care became medicalized, because it also became commercialized, there was now a way to make a bundle of money off of it. And that is really how it worked
Adam 07:03
to make money
Cathryn Jakobson Ramin 07:03
to make money, you know, when we many, many listeners have probably heard of John Sarno. And when Dr. John Sarno was at the Rusk Institute and after that at New York Hospital, New York University Hospital, he he very much understood that what surgeons were doing and what interventional pain management doctors were doing giving injections that these were, in general, not benefiting typical low back pain patients. And when I say typical low back pain, I mean patients who have what's described as axial or mechanical, low back pain. There are instances of course, where spine surgery is a benefit, but it's extremely rare. And in fact, I think the most telling statistic is that about 2% of patients who walk into surgeon's offices are actually candidates for surgery. Nevermind can't nevermind exclusively candidates for surgery, we don't even have a number for that. But so when John Sarno, what went around saying that he inspired massive hostility in the back pain treatment community, his book would eventually sell over a million copies, so plenty of people were listening to him. If patients listened, then they would not have surgery and they would not have injections and a lot of money would not be captured by the what I refer to as the back pain industry cartel.
Adam 08:43
It also didn't sound believable. I remember when somebody brought to me, Sarno's book many years ago now knowing that I was a back pain sufferer. And I remember being very skeptical, because it's mind, but come on the mind body connection between back pain. You talk about in your book, the discovery that that doesn't have to be an organic problem to have pain,
Cathryn Jakobson Ramin 09:04
Right. There usually isn't an organic problem.
Adam 09:08
Can you tell us a little about that? That research that you did
Cathryn Jakobson Ramin 09:10
as you said, the mind body, the mind body connection, you had trouble with that idea. And a lot of people have have trouble and this is just really beginning to change. Now. A lot of because of the Cartesian understanding of the mind and the body is that they are separate and that dates back to the 1600s. But we've known for a very, very long time certainly since the early 1970s. That obviously the mind is not separate. The brain controls absolutely everything you will be doing feeling sensing with your body there. There is no separation. There's also no such thing as a psychological problem because the last time I looked there is No psyche that anybody can track down. It is a neurological issue. So changing, it's very counterintuitive for people to think that the problem is not in the tissue, not in your back, not in your hip. When you're dealing with chronic pain, the problem has really migrated to the brain. And now this message is circulating around and around and around in your system. And because of the way the brain works, and how what because circuits in the brain become stronger when they are used, the more times the circulates, the more likely it is that the pain is going to continue. So largely what we look at is how do you break the circuit? What do you do? Can you help we can't just get a pair of wire clippers and go in there and break the circuit we have to find another way. And Adam, that's something that you work very hard to do in your gym. And so to many other people. That's the second book
Adam 11:06
that's the second Yeah, I just pointed I just pulled out of my bookshelf I found did want to just saw another book that I was handed it's called the mind body. That's what I had in mind, body in my brain
Cathryn Jakobson Ramin 11:14
there. They're about three or four of his books, but they all more or less say exactly the same thing.
Adam 11:19
Yeah. So I have the mind body prescription, which you're telling me is the second book that he wrote.
Cathryn Jakobson Ramin 11:23
Yeah, yeah.
Adam 11:24
Yeah. Yeah. So breaking that circuit would you said that we take we do partly some of that stuff
Cathryn Jakobson Ramin 11:30
that's the reason that exercise is successful with back pain patients is that it ends what really is the plague of the back pain patient which is fear avoidance behavior, and catastrophizing, and guarding. Those are three factors that we know of, from basically, they all come from behavioral psychology, but they are very, very prevalent in back pain patients and people who tend in that direction are the ones who frequently end up in chronic pain. So what are those? What does that mean? Fear avoidant behavior. That means thinking, because likely, you've been told by your chiropractor, possibly by your surgeon, probably by a half a dozen other people, be careful how you lift, don't pick that up. If you don't know if it hurts, don't do it. Rest, take it easy. Watch your backs, spare your back. All of that language makes people feel that it is in fact very dangerous to pursue normal activity or even strenuous activity. And, and it's easy to see why because it hurts. So we understand pain, we understand pain to be an indication of damage, but when chronic pain hits, pain is no longer an indication of damage, it is now an indication that your brain has is not really functioning right. It is getting it is getting a message in it's sending a message, but it is wires are crossed. It is not understanding that you have healed and as a good example, which I I wasn't happy to have this happen to me, but it did happen. I burned my wrist while cooking for dinner party few couple of weeks ago. And it's really quite a sudden significant burn to the point where people who see it sort of gasp and when it happened, I thought okay, burn my wrist. Um, let's see, what do you do with a burn? Okay, they say no, look it up. Okay, don't put any ointment on it. Just put gauze on it gauze on done cook the rest of the dinner party. And I watched with great interest as it healed miraculously over the next week and a half. And at no point did I think I would die from it. Or did I think that my life would be changed and I would not be able to work or go on vacation. I didn't think I wouldn't be able to take care of my family. And I certainly didn't think that I couldn't cook the rest of that dinner party. Now, if that had been my back, all those thoughts would have prevailed, I would have thought I probably have to cancel the dinner because I really cannot move here. So it's a very different feeling we have about our spines, we feel that they are fragile. And if we can get past that with exercise, that is often step one to recovery. When I left you I had the good luck to work out here earlier in the week, which I enjoyed very much. And when I left I thought I picked up my backpack which at that point had not only my laptop, which is especially light but a couple of more or less textbooks in it, plus a pile of paper and I said to myself as I walked down 56th Street I said I should not be carrying this. I know should not be carrying this. And I thought, wait a minute, what is the matter with you? You just pumped iron for an hour.
Adam 15:06
He just wrote a whole book about the fact that you shouldn't have those thoughts.
Cathryn Jakobson Ramin 15:10
And I thought to myself, I'm perfectly fine carrying this thing. This is not a problem for me. And as it turned out, it really wasn't
Mike 15:19
these instincts, though I think it's they are normal for people their first impulse because it is sometimes picking up a suitcase, it's doing sometimes activities of daily living that triggers a back pain for a lot of people or something lifting something. And I think they just their instinct is I have to do less in order to not feel that pain
Cathryn Jakobson Ramin 15:39
but that is wrong
Mike 15:40
Right? Exactly
Cathryn Jakobson Ramin 15:41
And very frequently, what we consider everyone can always give you the inciting incident, you know, what was your injury? And, and physicians ask that question. And physical therapists too. How did you injure yourself? Well, I've had people tell me that they injured themselves picking up the newspaper off the front walk. And I said, really? I said, Have you ever done that before? Yes, I have done that every day for 26 years. But it was that one time? Well, clearly, it wasn't it is the straw that broke the camel's back. And I know as well as anyone that when back pain strikes, you do not want to not want to do anything you want to crawl into your so under your sofa with a heating pad. But you know that that isn't ever going to be the solution to your problem,
Adam 16:29
not just a heating pad, which does kind of bring me to the question I've been wanting to ask you also, I found very interesting in your research. When we deal with pain, not only do we reach for the heating pad, but we like to have a little bit of help by a little bit of medicine, possibly. So the opioid healthcare crisis is in full swing right now is getting a lot of press recently. And you discovered that a large part of this crisis has been caused really by the back pain industry.
Cathryn Jakobson Ramin 16:57
That is certainly true. And I wouldn't say that I discovered this necessarily, because obviously, there's been some tremendous journalism done in this area for the last 10 years. And I happened to walk into this story, just as it blew wide open, which is one of the better things that can happen to an investigative reporter. But a lot of the reporting is definitely not done by me. It was done by others. And I have, you know, brought it into the book. And, and added to it, I hope. When I began this work, in 2009, I interviewed a couple of people who happen to tell me that they told me this astounding thing they told me, you know, the opioid epidemic? And I said, Yes, you know, yeah, I know about, you know, street corner, drug sales and addicts, and, you know, teenagers and young people doing these, you know, picking prescription pharmaceuticals, out of candy bowls at parties, and, and this one scientist and physician, Andrew Kolodny, whose name is been in the media a great deal, said to me, uh ahh, he said, that's, that is part of it, but it's not most of it. Most of it is happening because physicians are writing those prescriptions. The reason they're writing those prescriptions is that they have been massively encouraged, sometimes financially, to prescribe by pharmaceutical companies. And as you can see, I mean, even today, there was something in the paper that every every state in the union is suing Purdue pharmaceuticals, and which is the manufacturer of Oxycontin, and there's no way a Purdue will be bankrupt long before they can satisfy those suits. There's absolutely no way that restitution could be made for all of those states. But the point is, is well taken that more than one company jammed this idea down primary care physicians throats and primary care physicians see tons of back pain patients and they have, they do not know what to do for them. They do not really have a good concept of physical rehab. There's almost no training on pain in a medical school education, except to become an anesthesiologist and, and drag it away.
Adam 19:27
And again, drugs again.
Cathryn Jakobson Ramin 19:29
Right. So I was fortunate in that I never used opioids in treating my own back pain. I had just written a book about memory and attention and what happens to it in midlife and I knew for sure that, you know, even an Aleve, affected my ability to think to a certain extent I just wasn't as sharp so and now even though those they were offered to me repeatedly and you know from 2006 to 2009, I never went there, but most people honestly do. And I remember spending some time going to see, I guess the second or the third surgeon I saw on my hunt for a solution to my own problem. And he said to me, so what kind of medicines do you take? And I said, Well, I have a thyroid condition. So I take, you know, and I started to name the drugs, the two drugs I take for my thyroid condition. I said, I also have allergies. He said, No, no, no. What kind of painkillers do you take? I said, I don't take painkillers. And he said, but how can you manage? And I said, I don't think I could manage if I took them. So that's why I don't take them. He was very surprised.
Adam 20:51
Yeah, I've always resisted it myself. I always felt was muscular there. I brought I'd ride it out, I wasn't going to start taking these these high powered drugs.
Cathryn Jakobson Ramin 20:59
the evidence is absolutely clear that they are not effective in the treatment of chronic back pain. They're not effective. So why bother. And people develop after they get on a high enough dose, which sort of inevitably they do, they develop what is known as opioid based hyperalgesia. And or I'm sorry, opioid induced hyperalgesia, which means now, the opioid that you are taking is actually generating your pain. And I've seen quite a few people, lower their doses is not easy for them. And they lower their doses and a great deal of their pain goes away, which comes as a great shock to them, because they thought that they needed the drugs so badly. Getting off of them is not a simple matter. Because people are afflicted, they feel like they have the flu, and they are very, very anxious, and they are nauseous. And a lot of things happen that are very disturbing. And we need a lot more programs that can treat opioid addicted chronic pain patients, because you cannot just taper them. Because if you do just taper them, they will be over, possibly overwhelmed with pain, at least for a period of time, because it is just generally painful to taper opioids. So it may have nothing to do with their actual back pain condition. But you can be assured that they will be in pain while they are tapering.
Mike 22:27
I was as I was going to comment, the health crisis part of the book, it was surprising to think about how big this event really is. But I look back on a couple of times. I had two hand surgeries back in 2007 and 2009. And I did not ask for any the painkillers nor did I need any of the painkillers. And remember, I was just looking back. They actually did they gave me a bottle of 30. They didn't ask, they just said here. They just said here's a prescription for 30 Percocet if you need them. And then I got another one a month later. And I remember I got them again from the same doctor. And I just I didn't even I wasn't asked if I was in pain or if I even needed them.
Cathryn Jakobson Ramin 23:02
And did you take them?
Mike 23:04
I think I took one like one day because I did I did.
Cathryn Jakobson Ramin 23:08
and they kept giving you the prescription
Mike 23:10
like the day the day after the surgery the day after the surgery. I took one that day. And that was it.
Cathryn Jakobson Ramin 23:17
But they continue to give you prescriptions even though you were not taking them
Mike 23:20
a month after on a follow up visit. I was like here's another prescription. I didn't even ask for it. I look back and I'm like thinking why did they do that? I just
Cathryn Jakobson Ramin 23:28
Well, you know, this happens now very still is happening. Incredibly, it's still happening with kids who are having their wisdom teeth out. And they are you know, they sending them off with prescriptions for narcotics. And I got a call. I remember so well because it was thanks the night before Thanksgiving, at 10 o'clock at night I was here in New York. And the phone rang and it was a woman who I don't know well, but whose son went to school with mine and to high school and she said I am I read your book I'm standing in in the drugstore. I have a prescription in my hand that the local community spine surgeon just wrote for my son for 70 Vikatan. And I'm having a crisis of faith. And I said do not fill that prescription. I said there if your son is walking around which he was he definitely does not need that. And she said you know he would never ever I said if you knew how many mothers and fathers I have heard from whose kid would never ever but who isn't the child is no longer with us, then you would understand that never ever means absolutely nothing in this context. And particularly if you're dealing with a person of that age, it seems to be especially risky.
Adam 24:51
It's unbelievable to even know that's happening. It's tragic.
Cathryn Jakobson Ramin 24:54
It's this is a spine surgeon in my community and I was you It was all I could do not to get back to California where I live and march into his office and say, throw my book at him and say, What the hell are you thinking? And do you know that that boy did not have surgery, and he is perfectly fine. And that surgeon was giving him the Vikatan to tide him over until he had surgery two or three weeks later, which he never had.
Adam 25:25
Well, I had spine surgery in the 70s. They it wasn't like that back then. They didn't do that. For me it this is a recent This is a relatively recent thing
Cathryn Jakobson Ramin 25:32
it happened in the 80s Primarily because at that time, up until up until the mid 80s, the understanding was that you did not use you did not use narcotics to treat chronic pain. You use them to treat cancer pain. And typically in hospital not, you know, not an outpatient,
Adam 25:55
You are not going home and 50 oxycontin.
Cathryn Jakobson Ramin 25:57
But there was such an enormous push and if read my book in the chapter called The opioid wars. I mean, it is a saga that you just cannot believe in terms of how Purdue pharma recruited a physician named Russell Portnoy to sell these drugs to primary care physicians. And it wasn't one of the most probably the most successful drug marketing effort in the history of pharmaceuticals, but look where it has.
Adam 26:27
Now, moving on to what we can do about it, which is the stuff that really excites me is, you know, we mentioned John Sarno and how he understood there was a mind body connection to this back pain. And he, let's face it, he didn't get a lot of cred from from his peers. He was basically ignored by his peers. And they were skeptical, because, again, what we talked about earlier, you know, they didn't believe the mind body connection, not to mention the fact that they felt that their their jobs might be in jeopardy if he was right. But anyway, people coming around, and now there exists these facilities called chronic pain rehabilitation programs, otherwise known as CP RPS. And you talk a great deal about these CPRPs.Tell tell us about these because that's seems to be the answer for this back pain industry.
Cathryn Jakobson Ramin 27:20
Well, those these types of programs are typically three weeks or four weeks, and you might be going eight hours a day, five days a week. And they are multidisciplinary or interdisciplinary programs, which means that there's a physician, often a physiatrist, sometimes surgeon on staff and psychologists and physical therapists and exercise specialists. And other sometimes there's a biofeedback specialist, there may be a Feldenkrais instructor, but it is a combined effort of all of those parties, and especially the patient who will be working her butt off during this period. And these programs are they do not make money for their facilities. So RIC, the Rehabilitation Institute of Chicago has a program and you know, the rest of Ric has to support this program because it does not pay the bills. And that is a sad, very sad comment. And I do believe that given for instance, the three papers that were just published in The Lancet, all of which you can locate on my website, which is at CJ Raman ra M I.com these three LANSA papers really substantiate the benefits of multidisciplinary care. And of course, they also rule out the benefits of surgery shots, etc.
Adam 28:54
And even they deal with the opioid addictions if somebody
Cathryn Jakobson Ramin 28:58
while they yes, they some programs do some programs don't some feel that they're the real thing is to get their patients strong enough and fit enough and psychologically functional enough and then deal with the opioid problem and then others take it the other direction entirely. But I go through these programs in the book and you know, I spent time in sub with several of them and met people who had gone through them. And this is an appropriate intervention for people who have tried pretty much everything else and are not surgical candidates or do not want to be surgical candidates. And just as an aside, I hear from so many people you know, I had no other options surgery was my only option. You know, that is a problem that phrase because for surgery is the only option. Possibly if you have been hit by a bus but it is not the only option. If you are dealing with axial or mechanical back pain,
Adam 30:06
which is a called unspecified
Cathryn Jakobson Ramin 30:07
unspecified, which means that you can take a you know, you can have your MRI and they can take a look at and they go, you see that that's a disc herniation. Well, you know what they're perfectly normal people with no back pain at all whose spines look just like that. In fact, pretty much everyone spine looks just like that. And and this is something that people don't recognize because they're sent for the MRI or sometimes very frequently, they demand to have an MRI their neighbors have had MRIs their colleagues have, everyone has and they want theirs too and they paid good money for that insurance coverage. And they're getting it. And when they get it, they take a look at that MRI. I've never seen one before and they flip out. Because MRIs are very unattractive. They look like bones that have been left too long in the oven. I mean, they're, they're crumbly, and they just look sick. And then with that comes the note from the radiologist, and those notes, say things like herniated disc, degenerative disc disease, protruding disc, long list, black discs, white discs, there are so many things that show up on those reports. And at one point, in the course of my research, I was contacted by a radiologist who was no longer practicing. And he said to me, do you realize that if you if, as a radiologist, you frequently work for a spine surgeon. And if you send back the report that says, Nope, we got no trouble here, they send it back to you and say find some. So they're many of the things that are noted on a radiology report are absolutely meaningless, because they are found in the general population.
Adam 32:00
So here we go again. So there's like this, there's this conflict of interest here, because that's what they're doing, you get this report back, and they're saying you need some fusion, you need some you need injections, or you need some type of surgery to relieve the pressure on the disk, they hardly ever work. But that's the automatic response to these MRIs.
Cathryn Jakobson Ramin 32:20
And we play into that because as patients we are really committed at from a very early age, possibly from the time you, your mommy takes you to the pediatrician, when you're two days old, we are committed to the idea that whatever is not working properly, can be fixed, it will be fixed for us, we will not have to fix it. And this this kind of commitment is so powerful for people who are struggling with back pain. And that's why they go through serial interventions, they go from one to the next to the next to the next. It's extremely common for people to tell me they've seen eight surgeons or they've seen 40 different practitioners and they keep moving and paying. Because none of this is free. Even if you have insurance, you're still paying co pays now. And
Adam 33:10
speaking of cost, what is the cost? Check into a chronic pain rehabilitation program.
Cathryn Jakobson Ramin 33:16
It depends a lot on what what your coverage is. If you are workers compensation patient, it may be completely paid for. If you are a person who's like me an independent contractor with basically a PPO, you're going to pay a lot more, it could be $30,000. And it could be $15,000. Insurance coverage varies dramatically from insurer to insurer. Now, do I think this is about to change? Yes, I think it already is changing because believe me, knowing what insurers knowing what they know now about how ineffective surgery and injections are and about how risky MRI is in terms of driving surgery and injections, they're not going to want to pay for that. And just spent a bunch of time with physiatrist who effectively earn their keep by giving injections. And they are mighty darn nervous because what they do for a living is now publicly recognized to not be effective. So something is going to have to give and it is always physicians who drive what insurance covers. Most people don't realize that but you know, if your Blue Cross and you're talking about back pain coverage in the greater metropolitan area, you will have a panel of surgeons and maybe you'll have some physiatrist or maybe you'll have some some rheumatologist who will say yes, this will be covered and that will be covered and this will be covered at a higher rate than that. So
Adam 35:04
therefore, let's do that.
Cathryn Jakobson Ramin 35:05
So let's do that. Let's do this thing. And, and yeah, I did also hear from a physiatrist, that now that spinal fusions are, they're harder to get approved. What is happening and this is just horrifying is that when one is approved, they do more levels, and they do put in more instrumentation. So they price they, they drive the price upward on a single patient, because they know the next patient might be hard to find, which is just I made me I could barely eat my lunch.
Adam 35:41
Yeah, well, you know, what I've found to be astonishing was, when given the choice, when the insurance companies given the choice to either pay out for $150,000 spine surgery, I think you used $150,000 as the average cost.
Cathryn Jakobson Ramin 35:57
Thats common for spinal fusion yeah
Adam 35:58
as opposed, they'll do that in a second. But they'll give you a lot of pushback, if you say I want to check into a chronic pain rehabilitation program for $45,000.
Cathryn Jakobson Ramin 36:10
Right, but they'll say at the moment, and as I said, is changing
Adam 36:14
something that works a lot better than spine surgery by the way
Cathryn Jakobson Ramin 36:16
and is much safer, it has no long term downsides, what they'll say usually is we'll just bill that by the individual modality. So you know, for exercise, we don't actually pay for that. But physical therapy will pay $38. And for, you know, a biofeedback, we don't pay for that. So it becomes very counter to the concept of multidisciplinary training, because they don't pay for this, and they don't pay for that, and they don't pay for this. And you know, it's been a huge problem. And I'm ready to go to Washington on this. So insurance companies used to listen to the doctors when they were doing this. And now they're, they're actually putting their own brains out on they're starting to because you know, it's going to cost them more to pay out, I guess exactly. And the long term pay out is much higher, because if you do a multi level spinal fusion on a patient who's 50, and that patient never recovers, and is in has, is addicted to opioids, and has a car accident. And you know, this goes on and on. And you know, and potentially no longer works. And now he's on total disability, and therefore is receiving social security disability payments. I mean, the cost to society is enormous, and it's avoidable. But try to get somebody who hasn't been off a sofa in three years to enter a multidisciplinary program of which is going to be three weeks, eight hours a day, five days a week, and you're going to be exercising really many, many of those hours when you're not in a cognitive behavioral psychology group. It's pretty hard to get people to do it. They just have some drugs or another operation.
Adam 38:11
But as you reported, studying and visiting a lot of these programs, you've discovered that their success rate for the ones that make it through are very high,
Cathryn Jakobson Ramin 38:21
very high. I mean, in the book, I've got multiple stories from the programs. But the story is from a rebuild patient Institute of Chicago, the surely what is now called the Shirley Ryan ability lab is the name of their chronic pain program. And I spent a lot of time with two women who had come out of it. And both had felt that their functional lives were over, they were going nowhere. And they were really obsessing over their pain and their lack of function. And one of them was massively distressed. If her husband went to work she she would just fall into a hole over this and the other was raising to two young adopted children in a from an from another country very challenging adoption situation. And you know, these people couldn't afford to give up. And they went through this programs and they came out very functional. One of them was so functional, she was back to skiing, black diamonds and that was so awesome. Except for on the last run of the day. She was on the you know, the little trail between the lodge and the parking lot and something went wrong and she slipped and broke her leg on the catwalk and she broke her leg and I would I would when I called her I said so how are you doing? Because I keep up with these people someone she said I was doing. I was doing mama never broken legs. Not good.
Mike 39:56
I think if I recall from all of your stories whenever you're bad has acted up. It's never been like after during a ski trip or a snowboarding trip. I mean, usually it's some some bullshit.
Adam 40:08
Like, nothing. A sneeze.
Mike 40:09
Yeah, but it's never you never come back from, you know being like really athletic and doing.
Adam 40:14
No, it actually feels better after that right? My back also feels better when I've spent the weekend skiing and stuff like that.
Cathryn Jakobson Ramin 40:20
Well, probably it hasn't been all that stressful unless you have a couple of kids with you, in which case, it can be very stressful
Adam 40:26
Yeah, well, you know, the thing is, I've, I didn't fall into that I am a back patient kind of mentality. I feel lucky in that respect. I just didn't maybe I'm just somebody who denies everything anyway, in my life. But but this is, this is maybe one of those cases where denial is a good thing, because I never accepted it. And there are so many people with my back pain, and I have some bad back pain at times, I don't let it ever stop me from doing things because I feel the best way to overcome it is just to do do do do not to mention the fact that I also have done my research. And for the last 20 years I've been using using and you have a whole chapter about it in your book about the MedEx machines, and, and these spinal extension machines that do such a wonderful job of isolating spine a really strengthening the spine, much better than the typical conventional method methodology out there. And you did a lot of research on that. And you spent a lot of time with Brian Nelson out in Minnesota and runs a whole practice using these medics medical machines
Cathryn Jakobson Ramin 41:31
He's now retired, but he did and the practice has been purchased by an insurance provider.
Adam 41:38
That's good news,
Cathryn Jakobson Ramin 41:38
it seems but I also have heard that they're not quite running the program
Adam 41:43
they're gonna they're gonna, they're gonna dilute it
Cathryn Jakobson Ramin 41:45
they're gonna they've diluted it and see the key for a program like this. The very best thing you can have is a orthopedic surgeon on board. Because that person can quickly remarkably quickly separate people who are appropriate format acts are appropriate for serious weight training for that matter from those people who need to do something else first. And not everyone is ready, even when they begin to hop on a MEDEX. And those who aren't
Adam 42:21
Michael and I were just talking about this morning because there's other things that you looked at that work also not just these expensive MedEx machines that we have, but But you talked about Felton Krauss, you've talked about Stuart McGill and his program, which is very, they're they're a series of exercises that that go a long way to really relieving back pain. Right?
Cathryn Jakobson Ramin 42:43
And sometimes if someone has is very deconditioned, I'm starting with the Feldenkrais program and certainly can read about that in the book, but it's basically affecting the way that the brain is understanding movements.
Adam 43:00
repatterning
Cathryn Jakobson Ramin 43:01
Yes
Adam 43:01
it was my breaking that sort of that bad circuit
Cathryn Jakobson Ramin 43:04
Yeah
Adam 43:04
kind of reminds me of the heart procedure like an Appalachian which also breaks a bad circuit in the heart and, you know, it's called an ablation, just kind of, you're reminding me of that, because it's a neurological connection. They didn't, that that that create a pattern that keeps circling in that bad pattern and you have to break that pattern. Right and some of these movements, the Feldon crass, the Stuart McGill, play in other words, planks, certain types of proper abdominal work. bird dogs, things like that go a long way. And then of course, doing spinal extension on a MedEx machine which really fixes the hips in place and a lot of expense goes into these machines really have you extend the spine the proper way and strengthen lumbar muscles that are otherwise ignored pretty much any other way
Cathryn Jakobson Ramin 43:52
you can't strengthen them. I mean, I do think that the McGill exercises done properly do do affect those muscles Absolutely but the McGill exercises very often are not done properly. And I did them with you the other day and I've been doing those exercises for at least six years. And I would say that my trainer will find something wrong with the way I do them at least every two weeks. There's always something you know you're now dropping your right shoulder dropping your left shoulder or tilting that way
Mike 44:25
there's always a little correction that can be made and or something that could be improved upon or something that you're doing that cheated a little bit but from my experience doing those types of exercises with it's unbelievable the results you have almost immediately with some people within like the first session or within the week, two weeks I've seen 50% Almost 100% recovery
Cathryn Jakobson Ramin 44:47
it's amazing and I so many people ask me about them and I've actually put on my website which is again at CJ Raman ra m i n.com. I have an right at the top of the of the homepage, I have a button that takes you straight to a video showing you those exercises because I got really tired of having to send it. Gosh, you know, guys, it makes me want to go do them right now can we go do those exercises? Man, I need to do this.
Mike 45:17
I have a text, a text message about five clients a day, like I just I did your exercise today. I'm not kidding. Because they just they need me to sort of push them into doing so even though they know they might get they work so great. But I just forget to do them. And I'm like, Why do you forget to do that they give me that much life.
Cathryn Jakobson Ramin 45:37
I like to complain.
Mike 45:41
We have all the time though.
Adam 45:42
But I just see, you know, you're saying this. And obviously the physical aspect of these exercises are doing something from a physiological point of view. But I can't help but think that as soon as you tell somebody, let's do this, we're going to have a solution, you have this confidence about yourself, and they trust you. And you do these things. And they're saying, Wow, I can do this. And then you get them on the MedEx machine and they can extend their back. And maybe it hurts a little bit. But they feel so much better two weeks later, always gonna have this confidence like, hey, there is hope.
Cathryn Jakobson Ramin 46:08
Yes
Adam 46:08
you know, and that in itself
Cathryn Jakobson Ramin 46:10
I 100% agree. And I talk about that in the book that the chapter is called The back whisperer.
Adam 46:16
Right. I love that chapter
Cathryn Jakobson Ramin 46:18
Everybody, the thing is, everyone has a different idea of the coach that will provide that kind of confidence. And for me, I have a trainer who's a wonderful woman I adore about five years younger.
Adam 46:35
I think I say I was
Cathryn Jakobson Ramin 46:36
well you were you're really not you're kind of adorable you are kind of way that Diana, Diana is referred to in the book as the goddess of exercise
Adam 46:48
That's right
Cathryn Jakobson Ramin 46:49
And she's about five years younger than I am, which is good. So she'll be around a while. And basically, she's an athlete, and tough as nails. And she can really push me without me feeling like I am endangered. I really don't feel endangered anymore. Now I don't really care what people give me. But when I was beginning and I would have a twinge here and a twinge there, when you're just beginning you need someone who's going to give you that kind of confidence. I also really like and you know, some some men don't do well working with men because they feel very competitive with men, other men can only work with men. I happen to like coaches like Brian Nelson, who was this big giant Air Force guy. And you would not say no, to Brian Nelson, nor would you ever say no to Joseph Barrett, who was also extensively interviewed in the book. And you can't be going around saying no, and you can't back out of things because they hurt. There is a world of difference between this is really hard and it hurts. And I have been stricken with nerve pain. And I think I'm going to pass out. And very few people are able to tell the difference when they're doing the exercises. So you do have to have some faith and one thing I can absolutely guarantee it is going to hurt because it hurts to sit and it hurts to walk and it hurts to sleep. So why would you think it wasn't going to hurt to do these exercises? And you know, the thing that is drilled home over and over again that is that once you've had a good evaluation and you know cancer and progressive neurological issues have been ruled out don't have an infection. You know what hurt does not mean harm. And I just spent hours and hours with my brother who is struggling currently with back pain. And I yesterday I did an hour on the topic of none of this is going to harm you. And this morning he said you know what? I realized none of this is going to harm me and I'm feeling a lot better and really crossed my palm with silver right now. $147 But he he was afraid he was really afraid and catastrophizing not to me but in his own mind about what this meant and and how it applied to aging at 55.
Adam 49:23
Well, you can understand and you this pain is bad
Cathryn Jakobson Ramin 49:26
and this pain is real.
Adam 49:28
It's real and it's bad.
Cathryn Jakobson Ramin 49:29
And it makes it hard to think and it makes it hard to do anything. But it's to break the circuit is your goal and you may need some help in terms of cognitive behavioral therapy, which I talk about in the book in order to dispel some of your issues with fear avoidance behavior. Many people with back pain take toe walking in odd ways because they are guarding the part that hurts but Actually, they're doing nothing for the part that hurts. I mean, I've seen people put down, you know, pick up things and put them down in in ways that are far more deleterious to their spines than if they did it normally. And you do read all this about, you know, lift with the knees and not with the back wall, trying making a bed with your knees bent, you cannot do that, because you can't get close enough to the bed to do it. So many, many things that are drilled into patients about how they should lift you know, all of this is kind of nonsense. Once you are sufficiently conditioned, you know, you can I throw my bag into the overhead compartment. I not worrying about that on an aeroplane anymore. And it used to be, I would worry about it for three days, you know, how am I going to get that back up there? And being that I am five foot 10. And I look like I'm perfectly fit? No one I have yet to encounter a man of any age who wants to put my bag up there for me. And so it's a good thing that I can do it myself.
Adam 51:05
I would do it for you
Cathryn Jakobson Ramin 51:06
know, you wouldn't you'd say she's super fit
Adam 51:09
She's taller than me for crying out loud.
Mike 51:11
My, my older clients were like in their 70s I don't help them off the floor. I help everybody else. You need practices. Yeah, yeah. So and we there are people actually who I work on how to do that, you know, more efficiently, where to put their arm where to turn how to do everything. So they can actually do it and hopefully develop the strength in the skill of doing
Cathryn Jakobson Ramin 51:34
Which is, might be in their 70s, the most important thing you'll teach them. Sooner or later, they're going to fall on the floor, and they need to be able to get up.
Mike 51:42
Yeah, there are times when you're doing rehabilitation for your body or even exercise where it's not comfortable. And it could actually hurt a little bit. And there are times where I think those are signals that are like, Wait, you're doing something that's wrong, and maybe you're guided in the wrong way. And maybe you're guided in the right way. Like how do you know when to say that hurts, and that that hurt is bad. And that hurt is good?
Cathryn Jakobson Ramin 52:04
Well, when I was working out with you, earlier in the week, I asked you a number of times, where am I supposed to feel this? What muscle groups are engaged. And I know because I've been at this, you know, working on pretty seriously for five years or seven years, maybe I'm you know, if I'm feeling this, like in some tiny muscle in my shoulder, that is probably not what we had in mind. You know, I think that I think that once people become, start slow, start really slow, start light and build up. Don't start heavy build up slowly start with what you can safely easily do. And that doesn't mean that I won't hurt, but start light and then add. And I think the place where people you know get in trouble they I think CrossFit is a place that a lot of people overdo it completely. Especially well, people go to CrossFit are typically very competitive. So it is very easy.
Adam 53:10
It's a sport. Not an exercise program.
Cathryn Jakobson Ramin 53:11
And they get very, very competitive and overdo it. And I did one half of one CrossFit class and I said,
Adam 53:19
Nope
Cathryn Jakobson Ramin 53:19
you've got to be joking.
Mike 53:23
that's the thing. I think that's I wanted to hear you say I mean, it started right. Yeah, progressions where you start at level one, and then you go to level two, and do you feel a little bit that should be normal that you're feeling like you're working but not straining? Um, yeah, so it's, uh,
Cathryn Jakobson Ramin 53:38
well, we hit one exercise towards the end of our session where I was to have moved some pulleys and nothing was happening, I was not moving them, you know, and nothing hurt, but I was not moving them. And that meant to me that I was misunderstanding what I was supposed to be doing. Because, clearly, if I can move everything else in the room, there's no reason I couldn't move that weight. I just simply didn't know what to do how to do it. So having someone to explain Oh, no, it is not supposed to be coming from that tiny joint behind your elbow. It's supposed to be coming from somewhere. And this is one reason why it's very important for people who are trying to climb out of this abyss to work with talented trainers. And how do you find that? Well, that's what everyone wants to know. And in the book, I detail what you should be looking for what kind of qualifications, what kind of personality? Because if you're working with someone who says, does it is that bothering you? Well, then stop. We'll stop lie down. Let me stretch you. Well, that is not going to work out for you. But there are definitely questions that you should be asking. And I go through these in the book and you know you cannot as a middle aged person who's not very fit. You do not want a 22 year old cowboy for a trainer who is going to treat you as if you're 22 years old and fit. And that happens a lot. It happens to people all the time I had somebody throw a medicine ball at me. There was absolutely no possibility I could catch that thing. Yeah. But, you know, I guess he thought that would be fun.
Mike 55:22
Yeah, there's it's definitely the answer is not to stop. But it's to find the right progression at the right level for the person. In your blog, I loved when you commented on acute pain, the first thing to do is take a walk, be mobile. And the thing is, I'm I've always been a believer that like mobility is what you know, you know, I think that's one of our big problems is over. So many people, we don't as trainers, but a lot of people are just find themselves in their life and in their job just to immobile.
Cathryn Jakobson Ramin 55:50
That's right, anybody can strike anywhere. Because, you know, my brother is very athletic. And he lives to exercise he truly does. I mean, everything else he does, he does between between periods of exercise. And yet he is really dealing with serious back pain right now. Because for all his exercise and all his sports, he never really built the right musculature for life. And so you know, he can hit the hell out of a tennis ball, but his spine is really not operating properly currently. And we have to do something, you know, some things about that. And it's very hard for someone who has been really serious athlete for his entire life to get that into his mind.
Adam 56:38
Well, he's lucky he has you as a sister that did all this work
Cathryn Jakobson Ramin 56:40
you better check with him. How lucky he is feeling
Mike 56:44
I got to hear about this back pain
Adam 56:47
from my younger sister for crying out loud. No older, I'm older maybe will listen to you. Alright, so we have to we have to read we're running out of time we have to write Are there any concluding comments you'd like to make before we sign off?
Cathryn Jakobson Ramin 57:00
Well, I think that we have to really think about and talk to patients about changing the chip and converting from a, okay, I'll do this exercise, but I'm still looking for someone who's going to fix me. And I am undergoing numerous interventions while I'm exercising, I'm not going to really be very serious about exercising, because I really still believe that there is someone out there who can fix me to considering that the only person who is going to make a difference here will be you yourself. And you're probably wasting time and money running from intervention to intervention.
Mike 57:45
The efficacy of exercise
Cathryn Jakobson Ramin 57:47
has been now clearly shown, clearly shown you may need some psychological help because a lot of things spiral when you suffer from chronic back pain. I mean, there are plenty of people whose marriages are a wreck. Now whether they are wreck because of the back pain or the back pain the or the marriages have caused the that's another question. But there's sometimes other help is needed and you shouldn't be afraid to get it. Because sometimes that is the key to resolving the problem.
Adam 58:20
Well, the book is crooked Outwitting the back pain industry and getting on the road to recovery by Catherine Jacobsen Raman,
Cathryn Jakobson Ramin 58:28
and it's now out in paperback. You can also download the Kindle version. And if you really want to listen to me for 13 hours, you can get the audiobook from Audible or from Amazon.
Adam 58:43
Well, thank you so much for joining us. It was a real pleasure.
Cathryn Jakobson Ramin 58:46
Thank you.
Tim Edwards 58:49
Special thanks to Katherine Jacobson, Raman, author of crooked Outwitting the back pain industry and getting on the road to recovery. Now, as I mentioned at the top of the show, and as you just heard, Catherine mentioned herself, her audio book is available in audible, and you can download it for free just by clicking the link in the show notes to audible trial.com forward slash inbound, sign up for a free 30 day membership trial and download Katherine's book, crooked Outwitting the back pain industry and getting on the road to recovery. If you decide to cancel your membership for any reason, you get to keep her book Simple as that. And while you're in there, you can pick up additional audio books from other guests that we've had on the show, and you'll enjoy discounts of up to 30% Just by being an audible member. Now getting back to the workout if you haven't tried the power of 10 workout for yourself, What in the world are you waiting for? Click on over to the inform fitness website that's informfitness.com. There you'll find a free slow motion high intensity strength training workout waiting for you click the Try us Free button right there at the top of the homepage, fill out the form that pops up and pick your location. then you can experience free full body workout that you will complete in just 20 to 30 minutes. Thanks again for listening. And until next time for Adam Zickerman and Mike Rogers of inform fitness. I'm Tim Edwards with the inbound podcasting Network.
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