Can a chiropractor really fix my back? (Transcript)

Diane Russo Cheng :
My name is Diane Russo Cheng. I'm in my mid thirties, I am a filmmaker and a photographer.

Dr. Jen Gunter:
When Diane was 12, she learned she had scoliosis…and she started seeing a chiropractor a couple years later.

Diane Russo Cheng:
They would take x-rays and when I was younger and I saw my curved spine, I was like, oh my God, this is horrifying. But they're like, no it's ever so slight. We can fix this, we can fix this.

Dr. Jen Gunter:
Diane doesn’t remember having back pain as a teenager but the promise that a chiropractor could FIX the curve in her spine was alluring… I mean, if something’s off, why not fix it? Diane kept seeing chiropractors and eventually, in college, she did start having back pain.

Diane Russo Cheng:
So excruciating, I couldn't get out of bed.

Dr. Jen Gunter:
It seemed the best way to treat it was to keep up the visits to the chiropractor.

Diane Russo Cheng:
I lay face down and they press on my upper back first until, you know, we hear it crack. And then sometimes they adjust my hips.

Dr. Jen Gunter:
How do you feel after you go to the chiropractor?

Diane Russo Cheng:
Like a little sense of euphoria, right? You go in and your back really hurts and it feels lighter. Taller. By the time I get home I do start to have back pain again.

Dr. Jen Gunter:
By the time Diane was 30, the pain had become worse…

Diane Russo Cheng:
My wife and I would try to go to the farmer's market. And by the time we got to the farmer's market, I would be like, I don't know how I'm going to walk back. And my back hurts so bad. I can't walk.

Dr. Jen Gunter:
The chiropractors Diane saw kept telling her the same thing…it’s this slight curve in your spine.

Diane Russo Cheng:
We can fix you, so slight. And I started being like, well, but I've been seeing a chiropractor, like if it's so slight, why isn't it fixed already?

Dr. Jen Gunter:
She started wondering if the pain was from that little curve they kept showing her??? Or, if the REAL problem was the treatment she had been getting…

Diane Russo Cheng:
Holy shit. I've been seeing a chiropractor for 20 years and my back actually got worse when they were telling me it would get better. So that was when I was like, this is, I dunno, what's going on here, but this isn't working for me anymore.

Dr. Jen Gunter:
Why didn’t the chiropractor help Diane’s pain? How can someone be treated for decades without ever finding relief??? Unfortunately, Diane’s trouble with back pain isn’t unique. Back pain is one of the biggest reasons people go to the doctor. But, one reason many of us suffer with back pain for so long is because people prey on our desperation — and the complexity of back pain — to sell us BAD treatments. I’m Dr. Jen Gunter. And from the TED Audio Collective, this is Body Stuff. In this episode, what to do if your back hurts. We’ll get into it right after this…

[AD BREAK]

Dr. Alexis Tingan is a sports medicine doctor and physiatrist at the University of Pennsylvania. You might not have heard of a physiatrist before. They’re also called physical medicine and rehabilitation physicians.

Dr. Alexis Tingan:
Some of the same principles that I relay to my athletes, as it regards to rest, recovery, rehabilitation, I use those same goals dealing with any patient, be they a teenager or my oldest patient who's 97 years old.

Dr. Jen Gunter:
I love hearing that there's a 97 year old seeing a sports medicine physician.

Dr. Alexis Tingan:
She can beat out a lot of my younger patients.

Dr. Jen Gunter:
Dr. Tingan is also an expert on the back…which is an amazing structure…It’s why we can stand up straight, hold our heads up, bend over to put on our shoes, reach UP to grab an apple from a tree, go swing dancing, or take the dog for a walk. It’s kind of like the homebase for our whole musculoskeletal system.

Dr. Alexis Tingan:
All of our limbs originate from the spine. So the cervical thoracic spine, we have our arms that come from that area and the low back our legs come from the lumbar and sacral area. And so the spine is where it all kind of comes together. And even if you think from a neurologic standpoint, we have the brain, the brainstem, the spinal cord, and from the spinal cord, all our nerves go out to the, to the rest of the body. What that means is that whenever there is a problem in the back it can affect the legs. It can affect higher up in the cervical spine and the arms. It affects everything we do from a functional standpoint.

Dr. Jen Gunter:
Our back is made up of many connected pieces. First, there’s the vertebrae – the bones that run from your neck…to your tailbone. Vertebrae are stacked on top of each other and connected by joints and ligaments. Tendons connect muscles to the vertebrae. All together, the vertebrae make up the spinal column, which protects your spinal cord… that carries signals from your brain to nerves throughout your body. There are also discs between your vertebrae that provide cushion and help absorb and distribute pressure across your spine. So all these pieces — bones, joints, ligaments, tendons, muscles, and nerves — work together to help your back do everything it does for you. But your back isn’t holding you up all on its own. A lot of that work is done by your CORE.

Dr. Alexis Tingan:
The core is composed of our abdominal muscles. It's composed of our low back muscles. It’s composed of our hips and our glutes as well. It is the support system for the lower part of our body. And the reason why it's important is because the muscles in the core take pressure off the rest of the spine.

Dr. Jen Gunter:
Every day, we put all kinds of pressure on our backs…when we walk, stand, carry our groceries, lift furniture…AND …especially, when we SIT…

Dr. Alexis Tingan:
When you sit and you lean forward in bad posture you're putting about 1.8 times the pressure, relative to standing on your back. So that sitting is a hazard and for the great majority of our history as a species we've been standing, walking, running, we've been up on our feet. And so you can make an argument that we've evolved and are designed to be on our feet and be active.

Dr. Jen Gunter:
Bottom line, the back is a complex structure, AND we put pressure on it constantly…. SO a lot can go wrong!

Dr. Alexis Tingan:
We have the musculoskeletal system, we also have the nervous system that's involved. This is opposed to something like the ankle, where if you have pain at one particular part of the ankle, there's only so many things that could be going on there.

Dr. Jen Gunter:
Maybe you pulled a muscle playing basketball or lifting a heavy box — Dr. Dr. Alexis Tingan says muscle strains are a common cause of back pain. Or maybe there’s an issue with your joints, like arthritis. Or your long commute is putting pressure on a nerve, causing inflammation. Or, there’s a problem with one of your discs. Back pain can come from so many different places, and can be exacerbated by many different factors, even stress. So finding the root of back pain is COMPLEX. That complexity — and how frustrating back pain can be — means that it’s easy to be enticed by all the treatments out there…

Cathryn Jakobson Ramin:
Desperation is a bad thing.

Dr. Jen Gunter:
Cathryn Jakobson Cathryn Jakobson Ramin (ray-min) is a journalist and the author of Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery. Her back pain started when she was 16 and fell off a horse…

Cathryn Jakobson Ramin:
And after that, things were a little funky going forward, but it never got too severe until around the time I was pregnant with my first child and then I started to know what back pain really was.

Dr. Jen Gunter:
When Cathryn started looking for help, she ended up going through a pretty common checklist of treatments…Like Diane, one of her first stops was a chiropractor. Around 35 million Americans visit a chiropractor every year. And one survey found that the majority of Americans thinks chiropractors are effective at treating back and neck pain. But chiropractic care is based on a completely bogus premise — that back pain (and ALL diseases) are due to so-called vertebral subluxations — basically misaligned vertebrae. Chiropractors often take X-rays to find these subluxations. And then, they do “adjustments” or manipulations to fix them.

Cathryn Jakobson Ramin:
I had the adjustments at various levels and various people climbing on top of me to adjust me. That does not have any impact long-term. And it can be dangerous. There are people who have suffered vascular strokes after chiropractic treatments.

Dr. Jen Gunter:
There is NO evidence that the “subluxations” chiropractors target cause disease… in fact, there’s not even any evidence that the so-called subluxations are real.. Here’s the deal, it’s hard to research nonsense. And, we also know that being touched and cared for can make you feel better temporarily. But researchers have studied chiropractic manipulation…one review looked at 45 studies and found no evidence to support chiropractic manipulation for treatment of any medical condition. Even the General Chiropractic Council of the United Kingdom says that “subluxations are not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease.” I mean, that’s pretty damning!

Cathryn Jakobson Ramin:
And the problem has been that chiropractors want to see you multiple times a week. They want to adjust you. And that eventually will cause laxity in the ligaments and more instability and you will simply get worse. You will not get better. So yes, it does feel pretty good when you have the adjustment, but once you get home, you're right back to where you started and you will need to go there again.

Dr. Jen Gunter:
Eventually, Cathryn went to a medical doctor for her back pain. She says the doctor offered her some opioids and ordered an MRI.

Cathryn Jakobson Ramin:
My thought and apparently his thought was, there's probably something structurally wrong in there and we should find out what that is. So I went effectively next door. And I walked in and I just saw, it was like planes stacked up over JFK. There were so many people in that office.

Dr. Jen Gunter:
After the MRI results were in, Cathryn didn’t feel like she got good guidance on what they meant and what she should do for her back pain. So when a bit later, she saw an ad for a “minimally invasive” laser spine surgery at a clinic in Florida, it got her attention.

Cathryn Jakobson Ramin:
This particular facility, actually had a website and it would give the patient's name and a town. So it wasn't very difficult to track people down and they had all just come right, come out of there. And they're like, wow you know, at least I feel a lot better. I'm doing very well. I'm out playing golf. I'm like, this is awesome. Okay. So I went down there and there are people from all over the country, from all over the world. We're all going to have spine surgery there.

Dr. Jen Gunter:
There are clinics like this all over the country…they advertise in magazines and on TV…and they promise the kind of quick, easy fix Cathryn was yearning for. And after all the failed “treatments” she had tried, Cathryn was desperate. So she went for it. The surgery removed part of her lumbar vertebrae. And though there are times when surgery might be a good treatment option, this procedure did NOT help Cathryn.

Cathryn Jakobson Ramin:
I am now missing a huge chunk of bone. And I am pretty unstable.

Dr. Jen Gunter:
The more Cathryn learned about back pain…the more she realized every step of her treatment process had been a mistake. And she interviewed a LOT of people who went through similar experiences — chiropractors, opioids, MRIs, surgeries…

Cathryn Jakobson Ramin:
It became more and more obvious to me that people were being sold a bill of goods. They did not understand what they were being offered or the context in which it was being offered.

Dr. Jen Gunter:
Money is part of the problem. We spent around $135 billion treating low back and neck pain in 2016 alone! So this is a big industry! Some doctors and hospitals have a financial incentive to order MRIs...or to do expensive spinal injections…or even to perform surgery. When there is so much opportunity for profit, it can be hard to figure out what is actually good care.

Dr. Alexis Tingan:
We have this kind of backwards approach to medicine in this country. And our current system incentivizes us to do more and more and more , whether or not that particular treatment can, can be beneficial. But even though that is the way it is and we should all work to change it, it doesn't mean that I have to succumb to the pressures that be.
Dr. Jen Gunter:
After the break, when is an MRI or surgery actually called for? And what does GOOD, evidence-based treatment for back pain look like???

[AD BREAK]

Imagine you show up at your doctor’s office with stabbing pain in your lower back. And your doctor says, let’s do an MRI, or anXRay! You might think, “wow, that sounds like a great way to figure out exactly where the problem is.”

That’s a common misconception.

In reality, imaging usually can’t lead to a back pain diagnosis.

Dr. Alexis Tingan:
It gives us a snapshot in time of what may be going on structurally. It doesn't tell us how everything fits together mechanically. It doesn't tell us about your state of mind as regards to your body.

Dr. Jen Gunter:
This is Dr. Alexis Tingan, the physiatrist, again…

Dr. Alexis Tingan:
When I'm giving lectures to different groups, I often start with an image of a herniated disc in the spine. And I ask the audience, what would you do for this patient? And, you know, some people will say therapy, somebody say surgery, some say injections. And what I present to them is that this particular patient, when I saw them, had no pain whatsoever. And so, the bottom line is there's not a direct relationship between the findings on the imaging and the symptoms that a person may experience as it regards to back pain.

Dr. Jen Gunter:
So you can be in a lot of back pain and get an MRI showing a pristine spine, nothing out of the ordinary. And the reverse is true…if I stopped 100 people on the street between the ages of 40 and 50 who have no back pain and convinced them to get a free MRI, we’d find that HALF of them have a bulging disc and 68% have disc degeneration, another “abnormality”.

Dr. Alexis Tingan:
And I spend a lot of time with my patients trying to break that down. Let's say someone who's 70 years old, a patient will come see me like, oh, doc, my back is really messed up. And I say, well, really what you have is a 70 year old back. And you contrast this with, for example, an x-ray of the, of the knee. Well, there's only one knee joint, so there's only so much you can say, but with the back, there's like five different segments. And so, there's five different areas that can have an abnormality. So the report often looks worse than what's actually going on.

Dr. Jen Gunter:
That can be really harmful, because it can make people feel like their spine is damaged beyond repair. Dr. Tingan says an MRI makes sense if you have back pain and what he calls a red flag…
Dr. Alexis Tingan:
First of all, if the symptoms are due to a trauma and this could be a fall, it could be a car accident.. The other one, a sudden loss of bowel and bladder, which could be indicative of a nerve or a spinal cord type problem. I would also be concerned with someone who has sudden onset weakness. That's a concern that there's a more serious nerve or spinal cord problem going on. The other symptoms that I would look out for are fever and feeling ill associated with the back pain, because that could be a sign of an infection going on in the back. And the last symptom that I would look out for would be night pain, dull pain that does not get better. Sometimes that could be due to a tumor.

Dr. Jen Gunter:
If you have any of those red flags, an MRI could help rule out a serious problem. If not, get a second opinion on whether an MRI could help you. You often don’t need one. And imaging has been associated with worse patient outcomes and unnecessary surgeries. Like imaging, back surgery might seem really powerful… a real solution for real pain. But as Cathryn learned, it’s not a guaranteed fix. Dr. Alexis Tingan says surgery can help in very specific cases…like a fracture, a spinal cord injury…or when there’s a clear structural problem causing back pain: for example, a herniated disc, where part of a disc squeezes out and puts pressure on the spine and nerves…

Dr. Alexis Tingan:
If it's a disc problem, the surgeon will go in and take off part of the disc that may be irritating that nerve. And now you've relieved that structural problem. Now you've relieved the compression on the nerve and ostensibly, can help with the pain. Now this is opposed to someone who has multilevel degenerative changes, right? And so unfortunately we don't have a spine replacement. And so there's no way to get rid of all of that degeneration.

Dr. Jen Gunter:
Researchers analyzed studies on 10 of the most common elective orthopedic surgeries, including lumbar spine fusion for degenerative disk disease. they found this surgery was not more effective than non surgery treatment.! And spine surgery has far more complications than non-surgical therapies.

Dr. Alexis Tingan:
There are very sound reasons for spinal fusions to be performed. That being said, fusions are done for less than, I would say medically appropriate reasons. And you can look at this by looking at the map of the rate of lumbar fusion across the United States. And by region, you see the rates are wildly different from one region to the other. And it's not that the pathophysiology in one geographical area of the United States is that much different than the other. It’s that there may be different incentives or different culture practices that are in different regions that, that lead to this.

Dr. Jen Gunter:
Generally, surgery should be thought of as a LAST RESORT. Surgery is not reversible and there’s never a 100% guarantee it will get rid of back pain.

Dr. Alexis Tingan:
As I'm counseling my patients as regards to surgery, and there are some that I do refer to surgery, I'm explaining these to them. I said, look, you have a very clear structural problem. This is something that surgery I expect surgery to help with, but there is a chance that you get surgery and you're not better. And so the question I ask them, if you got surgery for this and you weren’t better, how would you feel? If a patient tells me you know what I would say, I've done everything to try to get better. And you know, this is the kind of where I'm at, but if the patient has some hesitation about that, then we may talk about other non-surgical treatments that we may want to consider prior to going the route of surgery.

Dr. Jen Gunter:
Like with so many things related to our health, there is no quick fix for back pain, especially if it’s chronic. One of the big harms of these quick fixes is they compete with therapies that CAN work. So what’s the first step towards treating back pain? When a patient shows up in Dr. Dr. Alexis Tingan’s office, he rules out those red flags we talked about. Then, he starts figuring out what could be causing the pain.

Dr. Alexis Tingan:
The most important step in evaluating back pain is attentive listening, listening to how long the symptoms have been going on, what factors exacerbate or alleviate the symptoms, just to kind of give a brief example disc related pain is worse with bending forward and better with extending backward. What treatments have worked or not work up to that point. And also how it’s affecting a particular patient's overall life and lifestyle. Now, as you progress from that subjective history, then you're able to hone in a little bit more specifically on what may be going on through the physical exam. And any time someone is seeing a physician for back pain they should have a very thorough physical exam performed. And so between taking a careful history and doing a thorough physical exam for the most part, you're actually able to have a good sense of what's going on.

Dr. Jen Gunter:
The good news is a lot of ACUTE back pain – pain that has lasted less than a month – may actually go away on its own. But CHRONIC pain that’s been around for 3 months or more, often requires some treatment. Dr. Alexis Tingan uses an exercise program or physical therapy to treat BOTH types of pain…

Dr. Alexis Tingan:
Because we are trying to address the mechanical causes of the back pain. So if it's chronic, undoing all those months of abnormal dynamics and mechanics. If it's acute, what I'm doing is actually not just treating the pain in the current state, but also working on prevention because anywhere from 30 to 60% of those with acute back pain will experience a recurrence within one year. And so I'm not just treating it in the present time. I'm also treating as a preventative measure for these patients.

Dr. Jen Gunter:
If you’re in a good physical therapy program, you’ll go into the office AND get a home exercise program so that you’re doing the recommended exercises regularly. This is like learning to play the piano…if you only practice once a week, you probably aren’t going to make progress! And, in fact, a good physical therapy program will ask you to come in for some follow-ups.

Dr. Alexis Tingan:
When I'm prescribing therapy for one of my patients, I'm very often sending them to a specific office office and, and. At that, often sending them to see specific physical therapists and often even talking directly with the physical therapist.

Dr. Jen Gunter:
And while you may have heard to “rest” if you’re in pain, that’s generally BAD advice for most kinds of back pain.

Dr. Alexis Tingan:
When you don't do activity, the muscles shorten, the joints can get stiff. And then that in of itself can, can cause pain. And so I'm encouraging all my patients with back pain to do something. And sometimes I joke that some patients say, well, okay, you say you can't do anything, but do you watch TV? Yes. You watch TV. Okay. I want you during every commercial break now take a few steps and sit back down.

Dr. Jen Gunter:
There are some situations where a doctor might recommend a steroid injection in your back. That can reduce inflammation around a nerve and hopefully ease the pain enough for you to start physical therapy. These types of injections are not usually a CURE — they’re best as part of a multidisciplinary therapy.
Dr. Alexis Tingan:
You're treating the chemical aspect of pain. And so if you're treating a structural and or mechanical problem with just a chemical treatment, then you're not addressing the issue.

Dr. Jen Gunter:
Though many of us will experience back pain, there are things we can do to PREVENT it in the first place. Dr. Dr. Alexis Tingan says, first, maintain a healthy weight.

Dr. Alexis Tingan:
The back doesn't get any stronger when you gain weight. And so I have many patients for whom the only treatment has been weight loss, and they've had significant reduction in their pain.

Dr. Jen Gunter:
Second, strengthen your core – step away from your desk and do some crunches, glute bridges, or a plank…

Dr. Alexis Tingan:
If I'm able to maintain that strong core as I'm going about my daily life picking up bags, picking up my kids, doing yard work, I'm not having to ask my back to do more than what it’s meant to do.

Dr. Jen Gunter:
I'm gonna make sure. Do my Romanian deadlifts tonight.

Dr. Alexis Tingan:
Yes.

Dr. Jen Gunter:
And it's funny. You mentioned kids. I have twins. They're 18 now, but there's no greater core work than carrying two three-year-old three-year-old toddlers one on each hip.

Dr. Alexis Tingan:
No, without a question, I have a two and a half a year old and a newborn relatively. And they require, well, at least the two and a half year old, a lot of carrying, a lot of core work. And I can tell the difference when I'm working on the core, between my ability to kind of carry my son with one hand and whenever it's a little bit of a struggle.

Dr. Jen Gunter:
And finally, it’s important to remember that your emotional health can affect your experience of pain. Depression, anxiety, and stress are all linked to changes in the brain, in neurotransmitters, and in hormones, that can amplify pain.

Dr. Alexis Tingan:
And so by practicing good, healthy mental health habits, that outlook also helps with my ability to be able to prevent back pain. But even when the back pain happens, to not catastrophize it and put it in the appropriate context and be able to ride it out and then treat it to live another day.

Dr. Jen Gunter:
So, show your back some love. If you’re at a desk all day, pay attention to your posture. Try to get up and stand or stretch every hour. Take a walk. If you are looking for a way to start moving for your back, consider some Tai Chi, which is a practice of slow, gentle meditative movements. And, by the way…Diane (who we met at the beginning of the episode) is in physical therapy now. She says, so far, it’s made her pain much better.

Body Stuff is brought to you by the TED Audio Collective. It’s hosted and developed by me, Dr. Jen Gunter. The show is produced by TED with Transmitter Media. Our team includes Mitchell Johnson, Poncie Rutsch (rutch), Gretta Cohn, Michelle Quint, Banban Cheng, Sammy Case, Roxanne Hai Lash, Will Hennessy, Alex Segell, Daniella Balarezo, Marie Kim, Nicole Edine, Julia Ross, Annie O’Dell, Valentina Bojanini, Anna Phelan, Emma Taubner, Maya Sariahmed.

Phoebe Wang is our sound designer and mix engineer. This episode was written and produced by Camille Petersen and edited by Sara Nics.
Fact checking by the TED fact checking team.

That’s it for this season of Body Stuff. Thanks for listening, and take care!