An Environment for Back Pain

Starting today, the North American Spine Society holds a conference at the Moscone Center in San Francisco. According to the San Francisco Chronicle, the focus of the conference is treatments for back pain. “Roughly 4 in 5 Americans suffer some sort of back pain, doctors say, and it’s the third most common reason for people to visit their physician. Part of the reason back pain is so common is because the fairly narrow spine is expected to support a great deal of weight. That means that as Americans have gotten larger, so has the field of back care medicine.”

This is astonishingly sloppy journalism and astonishingly sloppy science and a good reason to follow the principle we talk about in Too Much Medicine, Not Enough Health: do the simplest things first.

I was startled by the number 4 in 5. That’s 80%. That’s a lot. I was suspicious. I found a study published in 2006 that used data from 2002 of back pain prevalence. That number was less than 25% of people who visited a doctor in 2002 for back pain, not the larger one third quoted in the Chronicle. And 25% of doctor visits translates into something much less than 25% of the population because during in any given year many people don’t see a doctor for anything. I returned to the article and noticed the qualifier “doctors say.” And generals say we desperately need to spill more blood from young Americans in Afghanistan.

On further fact checking, it turns out the 4 in 5 number is not the number of people with back pain, but the number of people who might experience back pain of some kind at some point in their life. That’s significantly different from 80% of the population in need of the ministrations of these back pain experts.

The article opens with this phrase: “As back pain has become an increasingly common ailment in the United States.” But the 2006 study says that the prevalence of back pain was essentially unchanged over the preceding decade. So how is it that since then back pain has been increasing? Aren’t journalists supposed to check facts before printing them? It would certainly help if journalists and the experts they use as their source actually understood the statistics they throw around.

Further sloppy science is illustrated in the article: “spine care experts say that after years of progress, it’s time to take a step back and re-evaluate the recent advancements.” But wait! If there’s been progress, why is the prevalence of back pain increasing? Shouldn’t it be decreasing?

Well, you see, the problem is that, as the Chronicle article says, Americans are getting fatter, which puts more stress on that delicate thing the spine. It isn’t a failure of treatment, it’s a failure of patients. So I looked into that claim. I found a study from 1989 that looked at two factors for back pain: smoking and obesity. A research review of 44 studies published a decade later (that is, ten years ago) supported the conclusions of the 1989 study.

Smoking was by far the more provocative, doubling the risk for back pain. On the other hand, only an extreme body mass index had any effect at all on the risk of back pain and even then it was nowhere near smoking. To draw a very crude and partial picture: smoking depletes vitamin D; vitamin D deficiency creates vulnerability to back muscle injury; in addition to smoking and exposure to second hand smoke, other environmental assaults deplete vitamin D. I hope you get the principle here: environmental stressors and subsequent nutrient deficiencies and hormone imbalances create vulnerability to back injury.

Moreover, most back injuries are work-related. They’re more likely for people doing shift work and extended hours. As you would expect, back injury is associated with social class because of work conditions. More broadly, during the Bush years the Occupational Safety and Health Administration was gutted. So it’s entirely possible that back injuries did increase between 2002 and 2009 because worker safety was undermined. That’s not the same as back injuries due to obesity, which has become the cause du jour for all our maladies but which is, I believe, not a cause but an effect of metabolic imbalance caused by social and environmental stress—there it is again.

Nevertheless, pain is pain and we need people to help us alleviate it. As the Chronicle article says, “The past 15 years have seen major advancements in spinal care, much of it expensive and invasive. Doctors seem to agree that most recent treatments are useful.” Again, I draw your attention to “Doctors seem to agree.” Do their patients agree? Is what is expensive and invasive as useful as what is inexpensive and noninvasive—methods such as yoga, acupuncture, therapeutic massage, nutrient and hormone therapy, and so on and so forth? I hope they talk about those at the conference.

But for you and me, I think the lesson is that (and I hope you’ll forgive me for using this well-worn analogy) a man with a hammer tends to treat everything as a nail and a doctor with expensive, invasive technology will tend to treat everything as needing what is expensive and invasive. If that’s the person you go to for back pain, guess what’s likely to happen?

A transcript of this editorial is available on The Blog at