CROOKED  |  Endnotes

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Introduction: A Terrible Affliction  

roughly $100 billion a yearJeffrey N. Katz, “Lumbar Disc Disorders and Low-Back Pain: Socioeconomic Factors and Consequences,” Journal of Bone and Joint Surgery 88, supp. 2 (2006): 21–24, http://dx.doi.org/10.2106/JBJS.E.01273.

“In an effort to resolve my back problems” Andrea Gardner, in correspondence with the author, June 12, 2016.

“optimism bias” “The Back Page,” The Back Letter 29, no. 12 (2014): 144, doi:10.1097/01.BACK.0000459121.79124.4f.

especially when in the presence of a health care provider  “The Back Page,” The Back Letter 29, no. 8 (2014): 96, doi:10.1097/01.BACK.0000453382.81786.22; and Daniel Kahneman, Thinking, Fast and Slow (New York: Farrar, Straus and Giroux, 2011): 263.

“There’s this very mechanical view of the human body”  Richard A. Deyo, MD, MPH, in discussion with the author, June 15, 2010.

Chapter One:  Back Pain Nation  

31.4 million people each year“Overconfidence Continues to Plague Spine Care—Are There Any Innovative Ways of Countering This Risky Bias?” The Back Letter 31, no. 4 (2016): 37–43, doi:10.1097/01.BACK.0000482344.95364.61.

he noted in British Medical JournalPeter R. Croft et al., “Outcome of Low Back Pain in General Practice: A Prospective Study,” BMJ 316 (1998): 1356, http://dx.doi.org/10.1136/bmj.316.7141.1356.

In a paper published in the Archives of Internal Medicine in 2006Janet K. Freburger et al., “The Rising Prevalence of Chronic Low Back Pain,” Archives of Internal Medicine 169, no. 3 (2009): 251–258, doi:10.1001/archinternmed.2008.543.

In 1992, roughly 4 percentTimothy S. Carey et al. “Care-Seeking Among Individuals With Chronic Low Back Pain,” Spine 20, no. 3 (1995): 312–317, http://journals.lww.com/spinejournal/Abstract/1995/02000/Care_Seeking_Among_Individuals_With_Chronic_Low.9.aspx.

“regular folks who happened to answer the phone”  Tim Carey, MD, in discussion with the author, June 17, 2009.

Historically, primary care doctors have prescribedSabrina Tavernise , “C.D.C. Painkiller Guidelines Aim to Reduce Addiction Risk,” The New York Times, March 15, 2016,  http://www.nytimes.com/2016/03/16/health/cdc-opioid-guidelines.html.

50 percent chance of having a second MRIFreburger et al., “The Rising Prevalence of Chronic Low Back Pain.”

“The system was designed”  Nortin Hadler, Stabbed in the Back: Confronting Back Pain in an Overtreated Society (Chapel Hill: University of North Carolina Press, 2009).

Damocles’ swordNortin M. Hadler, Raymond C. Tait, and John T Chibnall, “Back Pain in the Workplace,” JAMA 297, no. 14 (2007): 1594, doi:10.1001/jama.297.14.1594.

legislators liberalized disability laws in 1984Freburger et al., “The Rising Prevalence of Chronic Low Back Pain.”

the number who claimed “musculoskeletal disease”  David H. Autor and Mark G. Duggan, “The Growth in the Social Security Disability Rolls: A Fiscal Crisis Unfolding,” Journal of Economic Perspectives 20, no. 3 (2006): 71–96, http://www.nber.org/papers/w12436.

spends $143 billion on medical careSocial Security and Medicare Boards of Trustees, “A Summary of the 2016 Annual Social Security and Medicare Trust Fund Reports,” Table 2, Social Security Administration, accessed July 14, 2016, https://www.ssa.gov/oact/trsum/. 

about a third of which can be attributedSocial Security Administration, Annual Statistical Report on the Social Security Disability Insurance Program, 2014, SSA Publication No. 13-11826 (Washington, DC: 2015): 6, https://www.ssa.gov/policy/docs/statcomps/di_asr/2014/di_asr14.pdf. 

Per capita, the United Kingdom spends  Daniel Martin, “Britain Leads the World in Handing Out Disability Cash,” Daily Mail, December 26, 2012, http://www.dailymail.co.uk/news/article-2253509/Benefits-Britain-UK-leads-world-doling-disability-cash-spending-twice-U-S-times-Japan.html#ixzz4DkhFIT2v.

The idea that you should be compensatedGregory P. Guyton, “A Brief History of Workers’ Compensation,” The Iowa Orthopaedic Journal 19 (1999): 106–110, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888620/pdf/IowaOrthopJ-19-106.pdf. 

In 1871, in a wily political moveIbid. 

The idea caught on  Ibid. 

Everything changed in 1934Hadler, Stabbed in the Back, 105. 

“diskal rupture”  William Jason Mixter and Joseph S. Barr, “Rupture of the Intervertebral Disc with Involvement of the Spinal Canal,” New England Journal of Medicine 211 (1934): 210–215, doi:10.1056/NEJM193408022110506.

almost nine hours a day in a seated position“Your Office Chair Is Killing You,” BloombergBusinessweek Magazine, April 29, 2010, http://www.businessweek.com/magazine/content/10_19/b4177071221162.htm. 

“are engineered, physically and socially, to be sitting-centric”  Brigid M. Lynch and Neville Owen, “Too Much Sitting and Chronic Disease Risk: Steps to Move the Science Forward,” Annals of Internal Medicine 162, no. 2 (2015): 146–147, doi:10.7326/M14-2552.

When circulation is inadequateChristoph Handschin and Bruce M. Spiegelman, “The Role of Exercise and PGC1α in Inflammation and Chronic Disease,” Nature 454, no. 7203 (2008): 463–469, doi:10.1038/nature07206.

roughly a quarter of the population reportedUnited Health Foundation, America’s Health Rankings (Minnetonka, MN: United Health Foundation, 2014), http://cdnfiles.americashealthrankings.org/SiteFiles/AnnualDownloads/Americas%20Health%20Rankings%202014%20Edition.pdf.

The World Health Organization reports“Physical Inactivity: A Global Public Health Problem,” World Health Organization, accessed July 14, 2016, http://www.who.int/dietphysicalactivity/factsheet_inactivity/en/. 

Researchers have found an independent relationshipAviroop Biswas et al., “Sedentary Time and Its Association With Risk for Disease Incidence, Mortality, and Hospitalization in Adults: A Systematic Review and Meta-analysis,” Annals of Internal Medicine 162, no. 2 (2015): 123–132, doi:10.7326/M14-1651.

The World Health Organization saysWorld Health Organization, Global Health Risks (Geneva: World Health Organization, 2009), Part 2, 10.

Recent studies also show that long sittingBiswas et al., “Sedentary Time and Its Association With Risk for Disease Incidence, Mortality, and Hospitalization in Adults.”

Sitting around for most of the dayI-Min Lee et al., “Effect of Physical Inactivity on Major Non-communicable Diseases Worldwide: An Analysis of Burden of Disease and Life Expectancy,” The Lancet 380 (2012): 219–229, doi:10.1016/S0140-6736(12)61031-9.

“Sitting too much is not the same as exercising too little”  “Your Office Chair Is Killing You,” Bloomberg Businessweek.

Obesity is associated withRahman Shiri et al., “The Association Between Obesity and Low Back Pain: A Meta-Analysis,” American Journal of Epidemiology 171, no. 2 (2010): 135–154, doi:10.1093/aje/kwp356.

Bone mass loss isMeghan McGee-Lawrence et al., “Suppressed Bone Remodeling in Black Bears Conserves Energy and Bone Mass during Hibernation,” The Journal of Experimental Biology 218 (2015): 2067–2074, doi:10.1242/jeb.120725; and “Use It or Lose It? Some Spines Are Immune to the Ill Effects of Extended Rest and Inactivity,”

The Back Letter 31, no. 2 (2016): 18, doi:10.1097/01.BACK.0000480367.47859.61.

When the British Medical Journal published a studyPeter T. Katzmarzyk and I-Min Lee, “Sedentary Behavior and Life Expectancy in the USA: A Cause-deleted Life Table Analysis,” BMJ Open 2, no. 4 (2012), doi:10.1136/bmjopen-2012-000828.

Chapter Two:  A Tale of Two Tables

More than thirty-five million Americans William B. Weeks et al., “Public Perceptions of Doctors of Chiropractic: Results of a National Survey and Examination of Variation According to Respondents’ Likelihood to Use Chiropractic, Experience With Chiropractic, and Chiropractic Supply in Local Health Care Markets,”

Journal of Manipulative & Physiological Therapeutics 38, no. 8 (2015): 533–544, http://dx.doi.org/10.1016/j.jmpt.2015.08.001; and “The Back Page,” The Back Letter 30, no. 11 (2015): 132, doi:10.1097/01.BACK.0000473210.94357.80. 

roughly $7 billionMatthew A. Davis et al., “US Spending on Complementary and Alternative Medicine During 2002–08 Plateaued, Suggesting Role in Reformed Health System,” Health Affairs 32, no. 1 (2013): 45–52, doi:10.1377/hlthaff.2011.0321.

About nine million see PTsSteven R. Machlin et al., “Determinants of Utilization and Expenditures for Episodes of Ambulatory Physical Therapy Among Adults,” Physical Therapy 91, no. 7 (2011): 1018–1029, doi:10.2522/ ptj.20100343.

spending $13.5 billionIbid. 

The Cochrane Collaboration makes it very clearSidney M Rubinstein et al., “Spinal Manipulative Therapy for Acute Low-back Pain,” Cochrane Database of Systematic Reviews 9 (2012), doi:10.1002/14651858.CD008880.pub2; Sidney M Rubinstein et al., “Spinal Manipulative Therapy for Chronic Low-back Pain,” Cochrane Database of Systematic Reviews 2 (2011), doi:10.1002/14651858.CD008112.pub2; Bruce F. Walker et al., “Combined Chiropractic Interventions for Low-back Pain,” Cochrane Database of Systematic Reviews 4 (2010), doi:10.1002/14651858.CD005427.pub2; and Anita Gross et al., “Manipulation or Mobilisation for Neck Pain,” Cochrane Database of Systematic Reviews 1 (2010), doi:10.1002/14651858.CD004249.pub3.

they were unidentifiable on X-raysDavid Chapman-Smith, The Chiropractic Profession: Its Education, Practice, Research, and Future Directions (Des Moines, Iowa: NCMIC Group, 2000).

a group of experienced chiropractors could not muster consensusSimon Singh and Edzard Ernst, Trick or Treatment: The Undeniable Facts about Alternative Medicine (New York: W.W. Norton, 2008), 171.

World Health Organization’s list of contraindicationsWorld Health Organization, WHO Guidelines on Basic Training and Safety in Chiropractic (Geneva: World Health Organization, 2005), 21, http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf.

In Trick or TreatmentSingh and Ernst, Trick or Treatment, 171.

all that the popping or cracking noise meansSamuel Homola, DC, in discussion with the author, May 31, 2011.

Some patients developSamuel Homola, Inside Chiropractic: A Patient’s Guide (Amherst, New York: Prometheus Books, 1999), 73.

roughly half of all chiropractic patients   Edzard Ernst, “Adverse Effects of Spinal Manipulation: A Systematic Review,” Journal of the Royal Society of Medicine 100, no. 7 (2007): 330–338, doi:10.1258/jrsm.100.7.330.

the possibility that a cervical (neck) adjustmentSingh and Ernst, Trick or Treatment, 174.

1.46 strokesIan D. Coulter et al., The Appropriateness of Manipulation and Mobilization of the Cervical Spine (Santa Monica, CA: 1996), http://www.rand.org/pubs/monograph_reports/2007/MR781.pdf.

sixty strokes per millionHaymo W. Thiel, “Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey,” Spine 32, no. 21 (2007): 2375–2378, doi:10.1097/BRS.0b013e3181557bb1.

the American Heart Association and the National Stroke Association   José Biller et al., “Cervical Arterial Dissections and Association With Cervical Manipulative Therapy: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association,” Stroke 45, no. 10 (2014): 3155–3174, doi:10.1161/STR.0000000000000016. 

Daniel David PalmerSingh and Ernst, Trick or Treatment, 157.

“hearty blacksmith or ice-wagon driver”  H.L. Mencken, “Chiropractic (1924),” Chirobase, accessed September 9, 2015, http://www.chirobase.org/12Hx/mencken.html.

established the Committee on QuackerySingh and Ernst, Trick or Treatment, 163.

“rabid dogs and chiropractors”  Steve Agocs, “Chiropractic’s Fight for Survival,” Virtual Mentor/American Medical Association Journal of Ethics 13, no. 6 (2011): 384–388, http://journalofethics.ama-assn.org/2011/06/mhst1-1106.html. 

the U.S. Department of Health, Education, and Welfare announced“Independent Practitioners under Medicare: A Report to Congress (1968),” Chirobase, last revised March 19, 2000, accessed September 14, 2015, http://www.chirobase.org/05RB/HEW/hew00c.html.

To be reimbursed by MedicarePaul Benedetti and Wayne MacPhail, Spin Doctors: The Chiropractic Industry Under Examination (Toronto: Dundurn Press, 2002), 220.

In the nine years that followedOffice of Inspector General, Office of Analysis and Inspections, Chiropractic Services Under Medicare, (Chicago: 1986), 4,

https://oig.hhs.gov/oei/reports/oai-05-86-00002.pdf.

tripling between 1970 and 1990Singh and Ernst, Trick or Treatment, 147.

“Sore Throat”  Ibid., 164.

“contain and eliminate chiropractic as a profession”  Susan Getzendanner, “Permanent Injunction Order Against AMA,” JAMA 259, no. 1 (1988): 81, doi:10.1001/jama.1988.03720010059044.

The AMA, said GertzendannerSingh and Ernst, Trick or Treatment, 165.

“manipulation under anesthesia”  John Hill And Kevin Yamamura, “‘Manipulation under Anesthesia’ Stirs Controversy,” Scripps-McClatchy Western Service, April 4, 2007, http://www.gosanangelo.com/lifestyle/manipulation-under-anesthesia-stirs-controversy-ep-442767065-358402041.html. 

In 1990, the British Medical Journal describedT W Meade et al., “Low Back Pain of Mechanical Origin: Randomised Comparison of Chiropractic and Hospital Outpatient Treatment,” British Medical Journal 300, no. 6737 (1990): 1431–1437, doi:10.1136/bmj.300.6737.1431.

three quarters of the chiropractic participantsIbid., tables IV and V.

employed the figure 70 percentDavid Colquhoun, “Peter Dixon, Chair of the General Chiropractic Council, Seems To Be a Bit Careless about Evidence,” DC’s Improbable Science (blog), June 12, 2009, http://www.dcscience.net/?p=1718.

National Institute for Health and Care Excellence (NICE) had optedP. Savigny et al., Low Back Pain: Early Management of Persistent Non-specific Low Back Pain (London: National Collaborating Centre for Primary Care and Royal College of General Practitioners, 2009), http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0005442/.

published an editorial in the GuardianSimon Singh, “Beware the Spinal Trap,” The Guardian, Comment is Free (blog), April 18, 2008, http://www.theguardian.com/commentisfree/2008/apr/19/controversiesinscience-health.

“promotion of chiropractic”  “Simon Singh Appeals Judge Eady’s Bogus Libel Ruling,” Science Blogs, blog entry by Orac, June 4, 2009, http://scienceblogs.com/insolence/2009/06/04/simon-singh-appeals-judge-eadys-bogus-li/.

the British Chiropractic Association (BCA) suedPhil Plait, “UK Quackery on Trial,” Bad Astronomy (blog), Discover, Dec. 24, 2008, http://blogs.discovermagazine.com/badastronomy/2008/12/24/uk-quackery-on-trial/.

his costly defenseMark Colvin, “PM with Mark Colvin,” radio interview, ABC News (Australia), July 10, 2009, transcript available at http://www.abc.net.au/pm/content/2008/s2622856.htm.

In April 2010, the court heldPallab Ghosh, “Chiropractors’ Libel Case Dropped against Simon Singh,” BBC News, April 15, 2010, http://news.bbc.co.uk/2/hi/science/nature/8621880.stm; and Phil Plait, “Breaking: BCA Drops Libel Case Against Simon Singh!” Bad Astronomy (blog), Slate, April 15, 2010, http://www.slate.com/blogs/bad_astronomy/2010/04/15/breaking_bca_drops_libel_case_against_simon_singh.html.

more than five hundred allegationsLucas Laursen, “Chiropractic Group Advises Members to ‘Withdraw From the Battleground’,” Nature News (blog), Nature.com, June 10, 2009, http://blogs.nature.com/news/2009/06/chiropractic_group_advises_mem_1.html.

The British Chiropractic Association ordered  Ibid. 

one in four British chiropractors was under investigation  Martin Robbins, “Furious Backlash from Simon Singh Libel Case Puts Chiropractors on Ropes,” The Guardian, March 1, 2010, https://www.theguardian.com/science/2010/mar/01/simon-singh-libel-case-chiropractors. 

restrict their Medicare billings to “active therapy” Department of Health and Human Services, Centers for Medicare & Medicaid Services, “CMS Manual System, Pub. 100-02 Medicare Benefit Policy: Change Request 3449,” September 3, 2004, available at http://www.chirobase.org/19Insurance/CR3449.pdf. 

Medicare had paid chiropractors some $285 million  Office of Inspector General, Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis, OEI-09-02-00530 (June 2005), iii, https://oig.hhs.gov/oei/reports/oei-09-02-00530.pdf.

$496 million on chiropractic careCenters for Medicare and Medicaid Services, “Historic Release of Data Gives Consumers Unprecedented Transparency on the Medical Services Physicians Provide and How Much They are Paid,” news release, April 9, 2014, https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-04-09.html. Data available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html. 

“practice-building” James W. Parker, Textbook of Office Procedure and Practice Building for the Chiropractic Profession, 4th edition (Fort Worth: Parker Chiropractic Research Foundation, 1975); Stephen Barrett, “Some Notes on James W. Parker, D.C.,” Chirobase, January 16, 2012, http://www.chirobase.org/12Hx/parker.html; and George Magner, Chiropractic: The Victim’s Perspective (Amherst, NY: Prometheus Books, 1995). 

The chiropractor check-upsDean Moyer, Rebuild Your Back, 2nd ed, http://www.rebuildyourback.com/back_pain_books.php. 

some chiropractic schools leave copies of old testsIbid. 

In 2011, the Council on Chiropractic EducationU.S. Department of Education, “Staff Report to the Senior Department Official on Recognition Compliance Issues,” December 2011, available at https://opeweb.ed.gov/aslweb/Uploads%5CCCE_30%5C12142011%5CFinalProfile%5CFinalStaffReport.pdf.

enrollment at some chiropractic collegesAndrea Fuller, “Chiropractic Colleges Seek Legitimacy Amid Financial Woes,” The Chronicle of Higher Education, April 15, 2012, http://chronicle.com/article/Chiropractic-Colleges-Seek/131538.

A recent widely publicized Gallup poll “The Back Page,” Back Letter 30, no. 11 (2015): 132, doi:10.1097/01.BACK.0000473210.94357.80.

about sixty thousand chiropractors treatKatherine Ellison, “Chiropractic Care Grows, and Gains Acceptance,” The New York Times, October 5, 2015, http://well.blogs.nytimes.com/2015/10/05/chiropractic-care-grows-and-gains-acceptance/?emc=edit_tnt_20151005&nlid=31170580&tntemail0=y&_r=1.

the Texas Board of Chiropractic ExaminersMichael E. Speer, MD, president of the Texas Medical Association, in correspondence with Yvette Yarbrough, executive director of the Texas Board of Chiropractic Examiners, July 12, 2012. 

In 2011, two medical journalsPeter W. Crownfield, “Foundation Ad Turned Down by Medical Journals,” Dynamic Chiropractic 29, no. 26 (2011), http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=55660.

“We need to focus on function”  Craig Liebenson, DC, in discussion with the author, March 15, 2010. 

he invented a deviceSingh and Ernst, Trick or Treatment, 161.

Hippocratic benchIbid., 156.

When the FDA approved the first modern spinal decompression unitThomas Gionis and Eric Groteke, “Spinal Decompression,” Orthopedic Technology Review 6 (2003): 36–39, http://myfamilychiro.net/clients/2456/documents/Clinical_Study_Gionis.pdf.

one thousand spinal decompression machinesKris Hundley, “Insurers Back Off,” St. Petersburg Times, July 17, 2006, http://www.sptimes.com/2006/07/17/news_pf/Business/Insurers_back_off.shtml.

Agency for Healthcare Quality and Research reanalyzedMarie Jurecki-Tiller et al., Decompression Therapy for the Treatment of Lumbosacral Pain, (Rockville, MD: Agency for Healthcare Research and Quality, 2007), http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id47TA.pdf.

“free 19-point ‘squashed disk’ [sic] qualifying assessment,”   “Severe Back Pain, What Your Doctor May Be Missing…,” paid advertisement, San Francisco Chronicle, February 3, 2009.

When Blue Cross and Blue Shield of Georgia caught onStephen Barrett, “Be Wary of Spinal Decompression Therapy with VAX-D or Similar Devices,” Chirobase, last revised August 18, 2011, http://www.chirobase.org/06DD/vaxd/vaxd.html.

The late Robin McKenzie“The McKenzie Method—How It All Began,” The McKenzie Institute International, accessed September 9, 2015, http://www.mckenzieinstitute.org/about-us/the-legend-of-the-mckenzie-method/.

thirty-six hundred MDT practitioners in the United StatesTrish Elise, executive assistant to the CEO of McKenzie Institute International, in correspondence with the author’s assistant, June 28, 2016; and Stacey Lyon, executive director of The McKenzie Institute USA, in correspondence with the author’s assistant, June 24, 2016. 

“They don’t recognize”  John D. Childs, PT, PhD, MBA, in discussion with the author, January 16, 2013.

“At the end of the day”  Ibid. 

eighteen states allow unlimited direct access “Levels of Patient Access to Physical Therapist Services in the States,” American Physical Therapy Association, March 2016, accessed June 21, 2016, https://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/DirectAccessbyState.pdf.

Insurance providers are even more restrictive  See e.g., Heidi A. Ojha, Rachel S. Snyder, and Todd E. Davenport, “Direct Access Compared With Referred Physical Therapy Episodes of Care: A Systematic Review,” Physical Therapy 94, no. 1 (2014): 14-30, http://dx.doi.org/10.2522/ptj.20130096.

Medicare limits treatment  Justin Elliott, Vice President, Government Affairs at the American Physical Therapy Association, in discussion with the author’s assistant, May 12, 2016.

Shortly after the start of World War ILieutenant General Leonard D. Heaton, Army Medical Specialist Corp (through 1961), ed. Robert S. Anderson, MC et al. (Washington D.C.: U.S. Army Medical Department, 1968), Chapters 3–4, http://history.amedd.army.mil/corps/medical_spec/publication.html.

That stratified relationshipMargaret M. Plack, “The Evolution of the Doctorate of Physical Therapy: Moving Beyond the Controversy,” Journal of Physical Therapy Education (Spring 2002), http://www.paeaonline.org/index.php?ht=a/GetDocumentAction/i/69169SimilarYou.

The Stark Law“About Stark Law,” Stark Law.org, accessed June 27, 2013, http://starklaw.org/stark_law.htm.

“When physicians hire physical therapists”  John D. Childs, PT, PhD, MBA, in discussion with the author, January 16, 2013.

in an episode of television’s The Dr. Oz Show“Cutting-Edge Solutions for Back Pain,” The Dr. Oz Show, January 10, 2013, http://www.doctoroz.com/videos/cutting-edge-solutions-back-pain. 

“What was demonstrated”  John D. Childs, PT, PhD, MBA, in discussion with the author, January 16, 2013.

Members sent a nasty letter  Paul A. Rockar, “APTA Responds to Dr. Oz Show Regarding Segment on ‘Cutting-Edge Solutions for Back Pain’,” American Physical Therapy Association, February 5, 2013, http://www.apta.org/Media/Letters/2013/2/5/. 

“It’s hoping the PT knows”  Heidi Prather, DO, in discussion with the author, November 14, 2009.

“If the therapist has ten people”  Sheila A. Dugan, MD, in discussion with the author, October 7, 2009.

“The capacity of the patient”  Craig Liebenson, DC, in discussion with the author, March 15, 2010. 

“Never let anyone do that to you again” Brian Beaudoin, in discussion with the author, January 14, 2009.

The surgery had put an end to all thatSamuel R. Ward et al., “Architectural Analysis and Intraoperative Measurements Demonstrate the Unique Design of the Multifidus Muscle for Lumbar Spine Stability,” Journal of Bone & Joint Surgery 91, no. 1 (2009):176–185, http://dx.doi.org/10.2106/JBJS.G.01311.

“I made a decision, years ago”  Brian Beaudoin, in discussion with the author, August 31, 2009.

Chapter Three:  Hazardous Images  

Who among us can lookNortin Hadler, Stabbed in the Back: Confronting Back Pain in an Overtreated Society (Chapel Hill: University of North Carolina Press, 2009), 45.

initiating a cascadeRichard A. Deyo, “Cascade Effects of Medical Technology,” Annual Review of Public Health 23 (2002): 23–44, doi:10.1146/annurev.publhealth.23.092101.134534.

“overwhelmingly preoccupied”  Richard Deyo, MD, MPH, in discussion with the author, June 15, 2010.

Then, in 1990, in a study of sixty-seven patientsScott D. Boden et al., “Abnormal Magnetic-resonance Scans of the Lumbar Spine in Asymptomatic Subjects. A Prospective Investigation,” Journal of Bone and Joint Surgery 72 (1990): 403–408.

“A diagnosis that is based”  Ibid.

“the beginning of a dangerous thought process”  Scott D. Boden, “Current Concepts Review:  The Use of Radiographic Imaging Studies in the Evaluation of Patients Who Have Degenerative Disorders of the Lumbar Spine,” Journal of Bone and Joint Surgery 78, no. 1 (1996): 114–124.

A 2009 study showed  Hoangmai H. Pham et al., “Rapidity and Modality of Imaging for Acute Low Back Pain in Elderly Patients,” Archives of Internal Medicine 169, no. 10 (2009): 972–981, doi:10.1001/archinternmed.2009/78.

Six years hence, Medicare and private health care plans would spendShubha V. Srinivas, Richard A. Deyo, and Zackary D. Berger, “Application of ‘Less Is More’ to Low Back Pain,” Archives of Internal Medicine 172, no. 13 (2012): 1016–1020, doi:10.1001/archinternmed.2012.1838.

Until the 1930s “Theories About the Origins of Back Pain Have Changed from Decade to Decade,” The Back Letter 26, no. 2 (2011): 19, doi:10.1097/01.BACK.0000394098.94631.27.

physicians in the Victorian eraGabriele K. Lutz et al., “Looking Back on Back Pain: Trial and Error of Diagnoses in the 20th Century,” Spine 28, no. 16 (2003): 1899–1905, doi:10.1097/01.BRS.0000083365.41261.CF.

The treatment for either lumbago or sciaticaArnold Cooley and Richard Tuson, Cooley’s Practical Receipts, Volume II (Project Gutenberg, 2013), accessed September 13, 2013, http://www.gutenberg.org/files/41957/41957-h/41957-h.htm.

X-rayMayo Clinic staff, “X-ray – Definition,” Mayo Clinic, February 16, 2012, accessed September 20, 2013, http://www.mayoclinic.com/health/x-ray/MY00307.

“The confusion about lumbago”  Lutz et al., “Looking Back on Back Pain.”

In 1964, the Swedish orthopedic surgeonAlf Nachemson and James M. Morris, “In Vivo Measurements of Intradiscal Pressure,” Journal ofBone & Joint Surgery 46, no. 5 (1964): 1077–1092.

Forty-two years later“A Tribute to Alf Nachemson: The Spine Interview,” The Back Letter 22, no. 2 (2007): 13, doi:10.1097/01.BACK.0000265328.79333.48. 

 CT (computerized tomography) scans“Computed tomography scan,” American Cancer Society, last revised August 9, 2013, accessed September 6, 2013, http://www.cancer.org/treatment/understandingyourdiagnosis/examsandtestdescriptions/imagingradiologytests/imaging-radiology-tests-ct.

Scan ten patients a dayJohn Sollenberger, National MRI Business Manager for Phillips, in discussion with the assistant to the author, August 27, 2013.

“You’d get a fast-talking salesman”  Brian Nelson, MD, in discussion with the author, July 21, 2010.

the results of an imaging study performed at a California hospitalMichael Brant-Zawadzki et al., “Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain,” New England Journal of Medicine 331, no. 2 (1994): 69–73, doi:10.1056/NEJM199407143310201.

“I hope this study”  Richard A. Deyo, “Magnetic Resonance Imaging of the Lumbar Spine. Terrific Test or Tar Baby?” New England Journal of Medicine 331, no. 2 (1994): 115–116, doi:10.1056/NEJM199407143310209.

should refrain from using imaging testsSteven J. Atlas and Richard A. Deyo, “Evaluating and Managing Acute Low Back Pain in the Primary Care Setting,” Journal of General Internal Medicine 16, no. 2 (2001): 120–131, doi:10.1111/j.1525-1497.2001.91141.x.

between 2000 and 2005, the number of MRI machinesLaurence C. Baker and Jacqueline Baras, “Magnetic Resonance Imaging And Low Back Pain Care For Medicare Patients,” Health Affairs 28, no. 6 (2009):W1133–W1140, doi:10.1377/hlthaff.28.6.w1133.

The number of MRI facilities grew so rapidlyMaggie Mahar, Money-Driven Medicine (New York: HarperCollins, 2009), 189.

a paper published in the journal Health Affairs  Laurence C. Baker, “Acquisition of MRI Equipment by Doctors Drives Up Imaging Use and Spending, ” Health Affairs 29, no. 12 (2010): 2252–2259, doi: 10.1377/hlthaff.2009.1099; and “Attacking Excessive Imaging Cause by Cause,” The Back Letter 26, no. 6 (2011): 66, doi:10.1097/01.BACK.0000398878.36637.70.

“The following findings are so common”  Brendan J. McCullough et al., “Lumbar MR Imaging and Reporting Epidemiology: Do Epidemiologic Data in Reports Affect Clinical Management?” Radiology 262, no. 3 (2012): 941–946, doi: 10.1148/radiol.11110618; and “A Novel Intervention for Low Back Pain: The Radiology Report,” The Back Letter 27, no. 6 (2012): 64–65, doi:10.1097/01.BACK.0000415404.82303.f9.

“We were surprised at the magnitude of the effect”  Ibid. 

Finally, in a policy statementRoger Chou et al., “Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians,” Annals of Internal Medicine 154, no. 3 (2011): 181–189, doi:10.7326/0003-4819-154-3-201102010-00008.

wait at least six to eight weeksRoger Chou et al., “Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society,” Annals of Internal Medicine 147, no. 7 (2007): 478–491, doi:10.7326/0003-4819-147-7-200710020-00006.

Even in the presence of sciatica“Timing of Disc Surgery,” The Back Letter 30, no. 3 (2015): 25–34, doi:10.1097/01.BACK.0000461991.56043.9b.

In Annals of Internal Medicine, physician Roger ChouChou et al., “Diagnosis and Treatment of Low Back Pain.”

cauda equina syndromeIbid.

“Progressive neurologic deficit”  Roger Chou, Richard A. Deyo, and Jeffrey G. Jarvik, “Appropriate Use of Lumbar Imaging for Evaluation of Low Back Pain,” Radiologic Clinics of North America 50 (2012): 569–585, doi:10.1016/j.rcl.2012.04.005.

Fever or vomitingIbid.

cancer patients or those in remission “Symptoms of Creeping Cancer,” The Back Letter 7, no. 5 (1992): 6.

obtained MRIs fromfty-three back pain patients  Estanislao Arana et al., “Influence of Nomenclature in the Interpretation of Lumbar Disk Contour on MR Imaging: A Comparison of the Agreement Using the Combined Task Force and the Nordic Nomenclatures,” American Journal of Neuroradiology 32 (2011): 1143–1148, doi:10.3174/ajnr.A2448.

In 2014 at the Mayo Clinic  W. Brinjiki et al., “Systematic Literature Review of Imaging Features of Spinal Degeneration in Asyptomatic Populations,” American Journal of Neuroradiology 36, no. 4 (2015): 811–816, doi:10.3174/ajnr.A4173.

The most recent data availableJohn M. Mafi et al., “Worsening Trends in the Management and Treatment of Back Pain,” JAMA Internal Medicine 173, no. 17 (2013): 1573–1581, doi:10.1001/jamainternmed.2013.8992.

As a result of this increaseIbid.

A significant number of practitioners acknowledged“Does Fear of Malpractice Drive High Rates of Imaging and Other Diagnostic Tests?” The Back Letter 28, no. 10 (2013): 114, doi:10.1097/01.BACK.0000436234.96556.16.

“There’s not enough diagnostic talent afoot” John Bruno, MD, in discussion with the author, June 30, 2015. 

Anti-MRI sentiment Srinivas, Deyo, and Berger, “Application of ‘Less Is More’ to Low Back Pain.”

Chapter Four:  Needle Jockeys

a 2015 review of the medical literatureRoger Chou et al., Pain Management Injection Therapies for Low Back Pain. Technology Assessment Report ESIB0813 (Rockville, MD: Agency for Healthcare Research and Quality, 2015).

an FDA statement warning“FDA Drug Safety Communication: FDA Requires Label Changes to Warn of Rare but Serious Neurologic Problems after Epidural Corticosteroid Injections for Pain,” U.S. Food and Drug Administration, April 24, 2014, page last updated May 29, 2014, http://www.fda.gov/Drugs/DrugSafety/ucm394280.htm.

the Journal of the American Medical Association (JAMA) advisedJ. Bart Staal, Patty J. Nelemans, and Rob A. de Bic, “Spinal Injection Therapy for Low Back Pain,” JAMA 309, no. 23 (2013): 2439–2440, doi:10.1001/jama.2013.5892.

more than ten million epidural steroid injections“Growing Furor Over Epidural Steroid Injections—And the Lack of Evidence Supporting Them,” The Back Letter 30, no. 11 (2015): 121–130, doi:10.1097/01.BACK.0000473201.77324.ef.

“The bottom line”  James Rathmell, MD, in discussion with the author, August 22, 2013.

a series of three“Lumbar Transforaminal Epidural Steroid Injections – Review & Recommendation Statement,” North American Spine Society, January 2013, https://www.spine.org/documents/researchclinicalcare/ltfesireviewrecstatement.pdf.

American Society of Anesthesiologists’ guidelinesThe American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine, “Practice Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine,” Anesthesiology 112, no. 4 (2010): 810–833, doi:10.1097/ALN.0b013e3181c43103.

“You always do three”  Charles Burton, MD, in discussion with the author, April 17, 2013.

when Colorado researchers mined David Armstrong, “Epidurals Linked to Paralysis Seen With $300 Billion Pain Market,” Bloomberg, December 28, 2011, http://www.bloomberg.com/news/2011-12-28/epidurals-linked-to-paralysis-seen-with-300-billion-pain-market.html.

The FDA had been issuing  Richard L. Koontz, “Epidural Injections and the Lumbar Spine,” The Burton Report, accessed September 6, 2013, http://www.burtonreport.com/infspine/AdhesArachEpiInjKoontz.htm.

the agency took a further step“FDA Drug Safety Communication: FDA Requires Label Changes to Warn of Rare but Serious Neurologic Problems after Epidural Corticosteroid Injections for Pain,” U.S. Food and Drug Administration, page last updated May 29, 2014, accessed January 27, 2015,

http://www.fda.gov/Drugs/DrugSafety/ucm394280.htm.

“serious neurologic events” “The Back Page,” The Back Letter 30, no. 2 (2015): 24, doi:10.1097/01.BACK.0000460754.75779.29. 

Cleveland Clinic’s Richard Rosenquist, toldDavid Armstrong, “Bristol-Myers Warning Ignored on Steroid Shots Tied to Deaths,” Bloomberg Business, January 24, 2012, http://www.bloomberg.com/news/articles/2012-01-25/bristol-myers-warning-ignored-on-steroid-shots-tied-to-deaths. 

Properly “consented,”  Charles Burton, MD, in discussion with the author, April 17, 2013.

hear about specific risksJoseph Neal and James P. Rathmell, Complications in Regional Anesthesia and Pain Medicine (Lippincott Williams & Wilkins, 2012), 343–353.

There are two dominant techniquesRay M. Baker, “Epidural Steroid Injections,” KnowYourBack.org, July 17, 2009, http://www.knowyourback.org/Pages/Treatments/InjectionTreatments/ES_Injections.aspx.

In “blind” injectionsJoshua H. Levin, Ryan Wetzel, and Matthew W. Smuck, “The Importance of Image Guidance during Epidural Injections: Rates of Incorrect Needle Placement during Non-Image Guided Epidural Injections,” Spine 1, no. 2 (2012), doi:10.4172/2165-7939.1000113.

In roughly 6 percentNancy E. Epstein, “The Risks of Epidural and Transforaminal Steroid injections in the Spine: Commentary and a Comprehensive Review of the Literature,” Surgical Neurology International 4, supp. 2 (2013): S74–S93, doi:0.4103/2152-7806.109446.

“having a blowtorch up your rectum”  “

In 2009 the FDA requiredU.S. Food and Drug Administration, “FDA Unveils Safe Use Initiative that Targets Preventable Harm from Medication Use,” FDA News & Events, November 4, 2009, accessed September 6, 2013, http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2009/ucm189081.htm.

In response, large pharmaceutical companies“The Meningitis Outbreak – An Important Announcement to the Public,” PainCare Centers, Inc., 2012.

increased long-standing wholesale pricesKurt Eichenwald, “Killer Pharmacy: Inside a Medical Mass Murder Case,” Newsweek, April 16, 2015, http://www.newsweek.com/2015/04/24/inside-one-most-murderous-corporate-crimes-us-history-322665.html.

Faced with a sudden shortageDavid Brown, “Compounding Pharmacies Rise in Popularity but Bring Questions about Safety,” Washington Post, October 13, 2012, http://articles.washingtonpost.com/2012-10-13/national/35499661_1_compound-drugs-methylprednisolone-pharmacy-board.

“From the practitioners’ point of view”  James Rathmell, MD, in discussion with the author, August 22, 2013.

NECC shipped nearly eighteen thousand vialsKay Lazar and Todd Wallack, “14 Executives, Staff Charged in Tainted Drug Case,” Boston Globe, December 17, 2014, https://www.bostonglobe.com/metro/2014/12/17/feds-arrest-tied-necc-closed-pharmacy-blamed-causing-deaths-with-tainted-drugs/24QytISVdaqXDNsSUOsNYJ/story.html.

NECC’s purchase orders includedEichenwald, “Killer Pharmacy: Inside a Medical Mass Murder Case.”

By spring of 2013, 751 patients“Multistate Outbreak of Fungal Meningitis and Other Infections – Case Count,” Centers for Disease Control and Prevention, October 23, 2013, accessed September 16, 2015, http://www.cdc.gov/hai/outbreaks/meningitis-map-large.html.

published a list of clinics and hospitals“Multistate Fungal Meningitis Outbreak: Healthcare Facilities,” Centers for Disease Control and Prevention, October 18, 2013, accessed September 5, 2013, http://www.cdc.gov/hai/outbreaks/meningitis-facilities-map.html.

patients and their families searched itDenise Grady, “‘Worried Sick’: Meningitis Risk Haunts 14,000,” The New York Times, October 21, 2012, http://www.nytimes.com/2012/10/22/health/meningitis-risk-haunts-14000-people.html?pagewanted=all&_r=0.

After her adult daughter’s lumbar fusion surgeryHarriet Hodgson, in correspondence with the author, October 31, 2012.

Experts suspected that physician accuracyDenise Grady, “Steroid Shot Near Spine Gives Illness an Opening,” The New York Times, October 15, 2012, http://www.nytimes.com/2012/10/16/health/tracing-crucial-components-of-meningitis-outbreak.html.

Within weeks of the NECC’s closureBeth Germano, “Lawsuit Against NECC Moves Forward After Meningitis Outbreak,” CBS Boston, September 19, 2013, 

http://boston.cbslocal.com/2013/09/19/lawsuit-against-necc-moves-forward-after-meningitis-outbreak/.

NECC filed for bankruptcyEichenwald, “Killer Pharmacy.”

Although the presiding judgeIbid.; and Department of Justice, “14 Indicted in Connection with New England Compounding Center and Nationwide Fungal Meningitis Outbreak,” news release, December 17, 2014, http://www.justice.gov/opa/pr/14-indicted-connection-new-england-compounding-center-and-nationwide-fungal-meningitis.

Then, in a series of predawn raidsKay Lazar and Todd Wallack, “14 Executives, Staff Charged in Tainted Drug Case,” Boston Globe, December 17, 2014, https://www.bostonglobe.com/metro/2014/12/17/feds-arrest-tied-necc-closed-pharmacy-blamed-causing-deaths-with-tainted-drugs/24QytISVdaqXDNsSUOsNYJ/story.html.

Cadden invoked the Fifth AmendmentEichenwald, “Killer Pharmacy,” and United States v. Cadden et al. No. 14-CR-10363-RGS (D. Mass, 2014), https://www.justice.gov/usao-ma/file/833216/download.

his contingency fee  James Hirbyand, “What Is the Average Contingency Fee of a Personal Injury Lawyer?” The Law Dictionary, accessed June 28, 2016, http://thelawdictionary.org/article/what-is-the-average-contingency-fee-of-a-personal-injury-lawyer/.

spinal cord infarction  NINDS Spinal Cord Infarction Information Page, National Institute of Neurological Disorders and Stroke, page updated March 23, 2016,  http://www.ninds.nih.gov/disorders/spinal_infarction/spinal_infarction.htm.

recognized as a factor in bone mass loss  Lee H. Riley IIIand Suzanne M. Jan de Beur, Back Pain and Osteporosis: The John Hopkins White Papers (John Hopkins Medicine, 2011). 

investigated the implications for bone healthAhmad Al-Shoha et al., “Effect of Epidural Steroid Injection on Bone Mineral Density and Markers of Bone Turnover in Postmenopausal Women,” Spine 37, no. 25 (2012): E1567–E1571, doi:10.1097/BRS.0b013e318270280e.

 bone density loss in the hipShlomo Mandel et al., “A Retrospective Analysis of Vertebral Body Fractures Following Epidural Steroid Injections,” The Journal of Bone and Joint Surgery 95, no. 11 (2013): 961–964, doi:10.2106/JBJS.L.00844.

In 1993, two radiologistsGina Kolata, “Spinal Cement Draws Patients and Questions,” New York Times, August 28, 2005, http://www.nytimes.com/2005/08/28/health/28spine.html?pagewanted=all.

by 2001, surgeons and pain interventionalistsDarryl T. Gray et al. “Costs and State-specific Rates of Thoracic and Lumbar Vertebroplasty, 2001-2005,”

Spine 33, no 17 (2008): 1905–1912, doi:10.1097/BRS.0b013e31817bb0a4.

But when the company’s researchers injected  Unless otherwise noted, information on Synthes and Norian comes from Mina Kimes, “Bad to the Bone: A Medical Horror Story,” Fortune, September 18, 2012, http://fortune.com/2012/09/18/bad-to-the-bone-a-medical-horror-story.

In conjunction with his management teamKimes, “Bad to the Bone;” and Peter Loftus, “Ex-Synthes Officers in Court,” The Wall Street Journal, November 21, 2011, http://www.wsj.com/articles/SB10001424052970203699404577046204020672824.

The government prosecutors employedLoftus, “Ex-Synthes Officers in Court.”

Kallmes made sure the two groups  Kolata, “Spinal Cement Draws Patients and Questions.”

almost thirty thousand vertebroplasty procedures annuallyGray et al. “Costs and State-specific Rates of Thoracic and Lumbar Vertebroplasty.”

Finally, in 2009, Kallmes publishedDavid F. Kallmes et al., “A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures,” The New England Journal of Medicine 361 (2009): 569–579, doi:10.1056/NEJMoa0900563. 

“We aren’t saying”  Mayo Clinic, “Study Results Raise Questions about Vertebroplasty for Osteoporotic Spinal Compression Fractures,” news release, August 5, 2009, http://www.eurekalert.org/pub_releases/2009-08/mc-srr080309.php.

the American Academy of Orthopaedic Surgeons retractedAmerican Academy of Orthopaedic Surgeons, The Treatment of Symptomatic Osteoporotic Spinal Compression Fractures: Guideline and Evidence Report (AAOS, 2010), 84, http://www.aaos.org/Research/guidelines/SCFguideline.pdf.

“kyphoplasty”  “2013 Profile of Hospital Spine Programs,” Orthopedic Network News 24, no. 4, (2013): 15.

When federal prosecutors caught onDepartment of Justice, U.S. Attorney’s Office Western District of New York, “Fifty-five Hospitals to Pay U.S. More Than $34 Million to Resolve False Claims Act Allegations Related to Kyphoplasty,” news release, July 2, 2013, http://www.justice.gov/usao/nyw/press/press_releases/2013/july/55_Hospitals.html.

130 U.S. hospitals returned $105 million Department of Justice, U.S. Attorney’s Office Western District of New York, “32 Hospitals To Pay U.S. More Than $28 Million To Resolve False Claims Act Allegations Related To Kyphoplasty Billing,” news release, December 18, 2015, https://www.justice.gov/usao-wdny/pr/32-hospitals-pay-us-more-28-million-resolve-false-claims-act-allegations-related.

they healed by themselves   Mehrsa Kherad et al. “Low Clinical Relevance of a Prevalent Vertebral Fracture in Elderly Men—The MrOs Sweden Study,” The Spine Journal  15, no. 2 (2015): 281–289, http://dx.doi.org/10.1016/j.spinee.2014.09.016.

Chapter Five: The Gold Standard

About 60 percent of patientsGary Michelson, MD, in discussion with the author, March 16, 2010.

succeeds in barely 40 percent of patients  Peter Waldman and David Armstrong, “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies,” Bloomberg, December 29, 2010, http://www.bloomberg.com/news/2010-12-30/highest-paid-u-s-doctors-get-rich-with-fusion-surgery-debunked-by-studies.html.

In one study, two years after spinal fusionUS Food and Drug Administration, Orthopedics and Rehabilitation Devices Advisory Panel Hearing, transcript, January 10, 2002, http://www.fda.gov/ohrms/dockets/ac/02/transcripts/3828t1.htm.

In another study, two years after surgeryPeter Fritzell et al., “2001 Volvo Award Winner in Clinical Studies: Lumbar Fusion Versus Nonsurgical Treatment for Chronic Low Back Pain: A Multicenter Randomized Controlled Trial from the Swedish Lumbar Spine Study Group,” Spine 26, no. 23 (2001): 2521–2534.

Eighty to 85 percent of the time  Brian Nelson, MD, in discussion with the author, July 21, 2010.

a hundred surgeons were polled   “Skepticism About Discogenic Pain,” The Back Letter 25, no. 8 (2010): 85, 94, doi:10.1097/01.BACK.0000387777.63229.a2.

They “have their own inherent conflict”  Hyun Bae, MD, in discussion with author, March 15, 2010.

about eighty thousand spine surgeries fail annuallyAshraf Ragab and Richard D. deShazo, “Management of Back Pain in Patients with Previous Back Surgery,” The American Journal of Medicine 121, no. 4 (2008): 272–278, doi:10.1016/j.amjmed.2008.01.004.

About one in five patientsB.I. Martin et al., “Reoperation Rates Following Lumbar Spine Surgery and the Influence of Spinal Fusion Procedures,” Spine 32, no. 3 (2007): 382–387, doi:10.1097/01.brs.0000254104.55716.46.

“adjacent segment deterioration”  Ragab and deShazo, “Management of Back Pain in Patients with Previous Back Surgery.”

A second back surgeryIbid.

“If [the surgeon] said”  Roger Chou, MD, in discussion with the author, June 15, 2010. 

In an article in a medical trade journal  Elizabeth Hofheinz, “70% Screw Misplacement, BS and Stalling from Insurers, and More,” Orthopedics This Week, August 8, 2012, http://ryortho.com/2012/08/70-screw-misplacement-bs-and-stalling-from-insurers-and-more/. Dr. Amaral is also an assistant professor of surgery at Albert Einstein College of Medicine.

grew from 61,000 in 1993“Spinal Fusion for DDD a Growth Industry for Two Decades—Despite an Uncertain Evidence Base,” The Back Letter 30, no. 4 (2015): 39–41, doi:10.1097/01.BACK.0000462970.63295.2c. 

to more than 465,000Peter Whoriskey and Dan Keating, “Spinal Fusions Serve as Case Study for Debate Over Whether Certain Surgeries Are Necessary,” Washington Post, October 27, 2013, http://www.washingtonpost.com/business/economy/spinal-fusions-serve-as-case-study-for-debate-over-when-certain-surgeries-are-necessary/2013/10/27/5f015efa-25ff-11e3-b3e9-d97fb087acd6_story.html.

more than 60 percent of the spinal fusion surgeryGlobalData MediPoint, Spinal Fusion: Global Analysis and Market Forecast (June 2014), http://www.marketresearch.com/product/sample-8230547.pdf.

costing about $40 billion annually“Spinal Fusion for DDD,” The Back Letter.

the Dartmouth Atlas of Health CareShannon Brownlee et al., “Improving Patient Decision-Making in Health Care: A 2011 Dartmouth Atlas Report Highlighting Minnesota,” The Dartmouth Atlas of Health Care, February 24, 2011, http://www.dartmouthatlas.org/downloads/reports/decision_making_report_022411.pdf.

“I end up sending most of my patients” Jeremy Fairbank, MD, in discussion with the author, October 29, 2009. 

in Asia-Pacific countriesGlobalData MediPoint, Spinal Fusion.

I met orthopedic surgeon Alexander GhanayemAlexander Ghanayem, MD, in discussion with the author, July 29, 2009.

“It’s gone now” Alexander Ghanayem, MD, in discussion with the author, October 6–7, 2009.

I’d read what Eugene CarrageeEugene J. Carragee et al., “2009 ISSLS Prize Winner: Does Discography Cause Accelerated Progression of Degeneration Changes in the Lumbar Disc: A Ten-year Matched Cohort Study,” Spine 34, no. 21 (2009): 2338–2345, doi:10.1097/BRS.0b013e3181ab5432.

two hundred thousand provocative lumbar discography procedures“Will a New Study End the Use of Discography as a Diagnostic Test for Painful Disc Degeneration?” The Back Letter 24, no. 7 (2009): 73,79–81, doi:10.1097/01.BACK.0000357539.86986.9e.

“Before Gene’s study”  Francisco Kovacs, MD, PhD, in discussion with the author, October 25, 2009. 

In 2015, in spite of its lack of diagnostic or prognostic value“Renewed Doubts About a Common Diagnostic Test—and the Safety of Novel Disc Injection Therapies,” The Back Letter 30, no. 12 (2015): 133–143, doi:10.1097/01.BACK.0000475387.60365.98.

resembled heavy phlegm  Stuart McGill, Low Back Disorders: Evidence-Based Prevention and Rehabilitation (Champaign, IL: Human Kinetics, 2002), 53. 

there was no demarcationIbid.

Among middle-aged male workers’ comp claimants  Sham Maghout Juratli et al., “Mortality After Lumbar Fusion Surgery,” Spine 34, no. 7 (2009): 740–747, doi:10.1097/BRS.0b013e31819b2176.

One orthopedist of that eraAmerican Academy of Orthopaedic Surgeons Digital Timeline, http://www.aaos75.org/collection/timeline/index.html. 

device approval process“Medical Devices and the Public’s Health: The FDA 510(k) Clearance Process at 35 Years,” Institute of Medicine, report brief, July 29, 2011, http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/Medical-Devices-and-the-Publics-Health-The-FDA-510k-Clearance-Process-at-35-Years/510k%20Clearance%20Process%202011%20Report%20Brief.pdf.

The green light allowed Steffee  Robin Young, “When No Good Deed Went Unpunished: The First Decade,” Spine-health, September 6, 2007, http://www.spine-health.com/physicians/when-no-good-deed-went-unpunished-first-decade.

Over the next twelve months“The Secret of the Backs Screws,” 20/20 transcript, ABC News, air date December 17, 1993.

sales of spinal instrumentation increased“2013 Spinal Industry Update,” Orthopedic Network News 24, no. 4, (2013): 3.

In the winter of 1993“The Secret of the Backs Screws,” 20/20.

AcroMed agreed to pay $112 millionMilt Freudenheim, “$112 Million Offered to End Legal Claims On Spine Pins,” The New York Times, December 10, 1996, http://www.nytimes.com/1996/12/10/us/112-million-offered-to-end-legal-claims-on-spine-pins.html.

In a policy paper, the Cato InstituteRobert Higgs, “Wrecking Ball: FDA Regulation Of Medical Devices,” Cato Policy Analysis No. 235, August 7, 1995, http://www.cato.org/pubs/pas/pa-235.html.

“It was part of the culture”  Larry Kessler, ScD, in discussion with author, November 24, 2010.

It was meant to make spinal fusion so simpleGary Michelson, MD, in discussion with the author, March 6, 2010. 

In the mid-1990s, as they competedJohn Carreyrou and Tom McGinty, “Taking Double-Cut, Surgeons Implant Their Own Devices,” The Wall Street Journal, October 8, 2011, http://online.wsj.com/news/articles/SB10001424053111904106704576582621677354508.

The U.S. Department of Justice unveiledReed Abelson, “Whistle-Blower Suit Says Device Maker Generously Rewards Doctors,” The New York Times, January 24, 2006, http://www.nytimes.com/2006/01/24/business/24device.html.

only $40 millionDepartment of Justice, “Medtronic to Pay United States $40 Million to Settle Kickback Allegations,” news release, July 18, 2006, http://www.justice.gov/archive/opa/pr/2006/July/06_civ_445.html.

For a while, this airtight process“Looming Legal Challenges,” The Back Letter 29, no. 8 (2014): 85–95, doi:10.1097/01.BACK.0000453375.66539.ad.

Studies showed that no matter how manyGary Franklin, MD, MPH, in discussion with author, June 23, 2010.

In search of a better technique“Scott Boden Wins Research Award,” The Back Letter 14, no. 2 (1999): 15. 

pulverized bone drilled from the patient’s hipLouis G. Jenis, MD, “Bone Grafts in Spine Surgery,” OrthoInfo, accessed July 14, 2016, http://orthoinfo.aaos.org/topic.cfm?topic=a00600. 

Patsy TrislerUS Food and Drug Administration, Orthopedics and Rehabilitation Devices Advisory Panel Hearing, transcript, January 10, 2002, http://www.fda.gov/ohrms/dockets/ac/02/transcripts/3828t1.htm.

nine were “key opinion leaders”  John Fauber, “Spinal Fusion Device: A Bone of Contention for FDA,” MedPage Today, August 29, 2010, http://www.medpagetoday.com/Surgery/Orthopedics/21908. 

“After this prototype is out in the marketplace”  John Fauber, “Bone-fusion Protein Raises Questions about Doctors’ Financial Stakes,” Journal Sentinal, August 28, 2010, http://www.jsonline.com/news/health/101732913.html.

“the secretaries in our clinic”  John Fauber, “Researcher Sounded Alarm on Medtronic’s Infuse Years Ago,” MedPage Today, June 28, 2011, http://www.medpagetoday.com/Orthopedics/Orthopedics/27308.

Between 2002 and 2008, the number of complex operationsRichard A. Deyo et al. “Trends, Major Medical Complications, and Charges Associated With Surgery for Lumbar Spinal Stenosis in Older Adults,” JAMA 303, no. 13 (2010): 1259–1265, doi:10.1001/jama.2010.338.

The product could boost the cost  Peter Waldman and David Armstrong, “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies,” Bloomberg, December 29, 2010, http://www.bloomberg.com/news/2010-12-30/highest-paid-u-s-doctors-get-rich-with-fusion-surgery-debunked-by-studies.html.

until July 2008, when the FDA received thirty-eight reportsDaniel G. Schultz, “FDA Public Health Notification: Life-threatening Complications Associated with Recombinant Human Bone Morphogenetic Protein in Cervical Spine Fusion,” Food and Drug Administration, July 1, 2008, http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm062000.htm.

Tomislav Smoljanović, a young orthopedic surgeonJohn Fauber, “Croatian Doctor Questioned Spine Surgery Product,” Journal Sentinel, May 25, 2011, http://www.jsonline.com/news/health/122598108.html.

awarded a Purple Heart and a Bronze Star  John Fauber, “Madison Surgeon’s Letter Bashes Author of Study Linking Spinal Fusion Product with Sterility,” Journal Sentinel, June 6, 2011, http://www.jsonline.com/watchdog/watchdogreports/125119809.html.

the June 2011 issue of the Spine Journal laid bareEugene J. Carragee et al., “A Critical Review of Recombinant Human Bone Morphogenetic Protein-2 Trials in Spinal Surgery: Emerging Safety Concerns and Lessons Learned,” The Spine Journal 11, no, 6 (2011): 471-491, doi:10.1016/j.spinee.2011.04.023.

“We were falsely reassured”  John Fauber, “Medtronic Helped Write, Edit Positive ‘Infuse’ Spine Studies,” MedPage Today, October 25, 2012, http://www.medpagetoday.com/PainManagement/BackPain/35551.

“There was evidence of a wide range of complications”  “The Controversy Over BMP-2 in Fusion Surgery Intensifies,” The Back Letter 27, no. 12 (2012): 138, doi:10.1097/01.BACK.0000424067.69650.2d.

In an interview with the New York TimesBarry Meier and Duff Wilson, “Spine Experts Repudiate Medtronic Studies,” The New York Times, June 28, 2011, http://www.nytimes.com/2011/06/29/business/29spine.html.

From the podium at the North American Spine Society’s annual meeting“Escalating Fears Over Cancer and BMP-2 in Spinal Fusion Surgery – In the Wake of a New Study,” The Back Letter 27, no. 1 (2012): 1, 7–9, doi:10.1097/01.BACK.000410728.68548.e4.

“If someone tells you that they have a really powerful bone growth factor”  “A Changing Pattern of Evidence: Who Do We Believe?” The Back Letter 27, no. 1 (2012): 7, doi:10.1097/01.BACK.0000410728.68548.e4.

assailed Carragee’s credibility  Fauber, “Madison Surgeon’s Letter Bashes Author.”

Medtronic had paid more than $210 millionJohn Carreyrou, “Medtronic Documents Spur New Questions,” The Wall Street Journal, October 25, 2012,

http://www.wsj.com/articles/SB10001424052970204530504578076993827301944.

The Wall Street Journal reportedIbid.

Cardiologist Harlan M. Krumholz  “Harlan M. Krumholz, MD, SM ,” NEJM Journal Watch, accessed July 13, 2016, http://www.jwatch.org/editors/u041. 

Medtronic wrote a check for $2.5 millionChristian Nordqvist, “Medtronic Awards $2.5 Million To Yale To Review Its Bone Growth Product,” Medical News Today, August 4, 2011, http://www.medicalnewstoday.com/articles/232280.php.

“Science has the power to be self-correcting”  “YODA: Clear Win For Open Science,” The Back Letter 28, no. 8 (2013): 94, doi:10.1097/01.BACK.0000433513.37538.06.

the Justice Department and the U.S. Attorney’s Office closedChristopher Weaver, “Federal Probe of Medtronic Ends,” The Wall Street Journal, May 16, 2012, http://www.wsj.com/news/articles/SB10001424052702303360504577408792467905180?mod=_newsreel_5.

In June 2013, YODA released independent reportsMark C. Simmonds et al., “Safety and Effectiveness of Recombinant Human Bone Morphogenetic Protein-2 for Spinal Fusion: A Meta-analysis of Individual-Participant Data,” Annals of Internal Medicine 158, no. 12 (2013): 877–889, doi:10.7326/0003-4819-158-12-201306180-00005; and Rongwei Fu et al. “Effectiveness and Harms of Recombinant Human Bone Morphogenetic Protein-2 in Spine Fusion: A Systematic Review and Meta-analysis,” Annals of Internal Medicine 158, no. 12 (2013): 890–902, doi:10.7326/0003-4819-158-12-201306180-00006.

sales of $809 million“Does a Once Dominant Spinal Technology Still Have a Future, Three Years After a Fall From Grace?” The Back Letter 30, no. 2 (2015): 13–23, doi:10.1097/01.BACK.0000460746.04488.90.

dropped to $409 million  Ibid. 

“No one is using it”  “Does a Once Dominant Spinal Technology Still Have a Future” Back Letter.

“vigorously defend the product”  John Fauber, “Medtronic Makes $22 Million Down Payment on Spinal Fusion Suits,” MedPage Today, May 5, 2014, http://www.medpagetoday.com/Surgery/Orthopedics/45624.

$22 millionFauber, “Medtronic Makes $22 Million Down Payment.”

“immunity by federal preemption”  See, e.g., Linda Greenhouse, “Justices Shield Medical Devices from Lawsuits,” New York Times, February 21, 2008, http://www.nytimes.com/2008/02/21/washington/21device.html; and John Fauber, “Trials of Spinal Surgery Option Infuse Were Too Little, Too Late,” Journal Sentinel, May 17, 2014, http://www.jsonline.com/watchdog/watchdogreports/trials-of-spinal-surgery-option-infuse-were-too-little-too-late-b99244456z1-259690251.html.

Charles Rosen, the orthopedic surgeon  Charles Rosen, MD, in discussion with the author, September 4, 2009, April 13, 2010, and November 8, 2012.

Together, he and medical marketing pro Gemma Cunningham“AME History,” Association for Medical Ethics, accessed October 16, 2013, http://www.ethicaldoctor.org/about-ame/history/.

When the Duke investigators found no conclusive evidenceDouglas C. McCrory et al., Spinal Fusion for Treatment of Degenerative Disease Affecting the Lumbar Spine (Rockville, MD: Agency for Healthcare Research and Quality, 2006), https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id41ta.pdf.

First, Blue Cross and Blue Shield of North Carolina“Corporate Medical Policy: Lumbar Spine Fusion Surgery,” BlueCross BlueShield of North Carolina, September 2010, accessed October 19, 2013, https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/lumbar_spine_fusion_surgery.pdf.

Then BCBS of Illinois  Walter Eisner, “New Policy Would Cut Some Spine Surgery Funding,” Orthopedics This Week, May 22, 2012, https://ryortho.com/2012/05/new-policy-would-cut-some-spine-surgery-funding/.

nine medical societies drafted a letterWalter Eisner, “Spine to Insurance: ‘United We Stand!’” Orthopedics This Week, December 20, 2010, https://ryortho.com/2010/12/spine-to-insurance-ldquounited-we-standrdquo/.

$100,000 to help with advocacy effortsNuVasive, Inc., “NuVasive Reports Fourth Quarter and Full Year 2013 Financial Results,” news release, March 3, 2014, http://www.nuvasive.com/news/4204/.

A full-time neurosurgeon makes“2013 Physician Inpatient/Outpatient Revenue Survey,” Merritt Hawkins (2013): 7, http://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Pdf/mha2013revenuesurveyPDF.pdf.

“Frankly, it made me acutely depressed and angry”  Robin Young, “Dr. Slosar’s Blast Email,” Orthopedics This Week 6, no. 39 (2010): 4–5, http://ryortho.com/wp-content/uploads/2012/11/12_14_10_Newsletter.pdf.

“Spinal instability” was vague enough  Groopman, How Doctors Think, 227. 

two decades of double-digit growth“2011 Spinal Industry Update,” Orthopedic News Network 21, no. 4 (2011): 3.

Between 2012 and 2013“2013 Spinal Industry Update,” Orthopedic Network News 24, no. 4 (2013): 3. 

The number of spinal fusion procedures in that nationGlobalData, “China’s Spinal Fusion Market to Surge in Value and Double its Global Share by 2020, Says GlobalData,” news release, June 12, 2014,

http://healthcare.globaldata.com/media-center/press-releases/medical-devices/chinas-spinal-fusion-market-to-surge-in-value-and-double-its-global-share-by-2020-says-globaldata.

To gain access to Chinese doctors and patientsRobin Young, “Medtronic Buys Access to 80% of China’s Tier One Hospitals,” Orthopedics This Week, October 8, 2012, http://ryortho.com/2012/10/medtronic-buys-access-to-80-of-chinarsquos-tier-one-hospitals/.

a network of freestanding orthopedic surgery hospitals in ChinaBiloine W. Young, “Growing Orthopedic Hospitals in China,” Orthopedics This Week, March 28, 2012, http://ryortho.com/2012/03/growing-orthopedic-hospitals-in-china/.

physician-owned medical device distributorshipsSenate Finance Committee Minority Staff, Physician Owned Distributors (PODs): An Overview of Key Issues and Potential Areas for Congressional Oversight (Washington D.C.: June 2011).

Before he operates, the surgeon tells  Complaint, United States v. Reliance Medical Systems et al., Civil Action No. 14-6979, *14 (C.D. Cal. 2014).

By 2011, physician-owned spinal device distributorshipsJohn Carreyrou, “Senators Request Probe of Surgeons,” The Wall Street Journal, June 9, 2011, 

http://www.wsj.com/articles/SB10001424052702304778304576373592455703056.

two or three fusion procedures weeklyJohn Carreyrou and Tom McGinty, “Hospital Bars Surgeon From Operating Room,” The Wall Street Journal, April 13, 2011, http://www.wsj.com/articles/SB10001424052748704336504576259142044058726.

when a hospital switched to buying from a PODAccording to information from a Medicare database; see Daniel R. Levinson, Spinal Devices Supplied by Physician-Owned Distributors: Overview of Prevalence and Use, OEI- 01-11-00660 (Washington, DC: Office of Inspector General, 2013), 14, http://oig.hhs.gov/oei/reports/oei-01-11-00660.pdf.

within weeks of his purchase of a five-thousand-dollar stakeComplaint, United States v. Sabit, Civil Action No. 13-03363, *17 (C.D. Cal. 2014); and United States v. Reliance, complaint.

In just eighteen months, the surgeon generatedJohn Carreyrou, “Surgeons Eyed Over Deals With Medical-Device Makers,” The Wall Street Journal, July 25, 2013, http://online.wsj.com/news/articles/SB10001424127887324263404578615971483271856.

“plagued with high infection rates”  Robert Lowes, “Physician Got $439K in Kickbacks for $5K ‘Investment,’ Feds Say,” Medscape Medical News, June 18, 2015, http://www.medscape.com/viewarticle/846677.

the California state medical board revokedMedical Board of California, Stipulated Surrender of License and Order, Case No. 05-2011-212383, August 18 2014, http://www2.mbc.ca.gov/BreezePDL/document.aspx?path=%5cDIDOCS%5c20140825%5cDMRAAAEC2%5c&did=AAAEC140825223311350.DID&licenseType=A&licenseNumber=108433#page=1; and Paul Glickman, “Former Ventura Spinal Surgeon Stripped of California Medical License,” KPCC, August 20, 2014, http://www.scpr.org/news/2014/08/20/46123/former-ventura-spinal-surgeon-stripped-of-californ/.

Sabit moved to Birmingham, MichiganCarreyrou, “Surgeons Eyed Over Deals.” 

billed providers for ghost devicesUnited States Department of Justice, “Detroit-Area Neurosurgeon Admits Causing Serious Bodily Injury to Patients in $11 Million Health Care Fraud Scheme,” news release, May 22, 2015, http://www.justice.gov/opa/pr/detroit-area-neurosurgeon-admits-causing-serious-bodily-injury-patients-11-million-health.

considered a flight riskRobert Snell, “FBI: Indicted Doc Stashed Cash in Kids’ Bank Accounts,” The Detroit News, January 1, 2015, http://www.detroitnews.com/story/news/local/wayne-county/2015/01/01/fbi-indicted-surgeon-stashed-cash-kids-accounts/21169593/.

He pleaded guiltyDepartment of Justice, “Detroit-Area Neurosurgeon Admits Causing Serious Bodily Injury.”

the judge tossed out Sabit’s guilty pleaTresa Baldas, “Judge Rejects Birmingham Neurosurgeon’s Plea Deal,” Detroit Free Press, October 2, 2015, http://www.freep.com/story/news/local/michigan/oakland/2015/10/02/birmingham-surgeon-aria-sabit/73194364/.

Sabit was sentencedUnited States Department of Justice, “Detroit-Area Neurosurgeon Sentenced to 235 Months in Prison for Role in $2.8 Million Health Care Fraud Scheme,” news release, January 9, 2017, https://www.justice.gov/opa/pr/detroit-area-neurosurgeon-sentenced-235-months-prison-role-28-million-health-care-fraud.

the hospital netted $250Complaint, Cavalieri v. Healthsmart Pacific, Civil Action No. BC-551813, *11 (Cal. Super. Ct. 2014).

In time, an incestuous relationship with PODsJohn Carreyou, Tom McGinty, and Joel Millman, “In Small California Hospitals, the Marketing of Back Surgery,” The Wall Street Journal, February 9, 2012, http://www.wsj.com/articles/SB10001424052970204319004577088712149447348.

“capping, running and steering”  Cavalieri v. Healthsmart Pacific, complaint, 12.

Allegedly, they paid $15,000Ibid., 8. 

Between 2001 and 2010  Ibid., 16. 

The Wall Street Journal reportedCarreyou, McGinty, and Millman, “In Small California Hospitals.”

The patients were typically Latino workersIbid. 

“false, fraudulent, fake, counterfeit, and non-FDA-approved”  Cavalieri v. Healthsmart Pacific, complaint, 17.

a single screw for $65Cavalieri v. Healthsmart Pacific, complaint, 11.

from $326,000 to $1.1 millionCarreyou, McGinty, and Millman, “In Small California Hospitals.”

post-op surgical notes always recordCavalieri v. Healthsmart Pacific, complaint, 24. 

In 2014, CBS News reporter Ben EislerBen Eisler, “Tapping into Controversial Back Surgeries,” CBS News, April 24, 2014, http://www.cbsnews.com/news/tapping-into-controversial-back-surgeries/.

“the head would fall off”  U.S. Attorney’s Office Southern District of Ohio, “Grand Jury Returns 10-count Indictment Against Spine Surgeon Alleging Health Care Fraud,” news release, August 7, 2013, http://www.justice.gov/usao-sdoh/pr/grand-jury-returns-10-count-indictment-against-spine-surgeon-alleging-health-care-fraud.

$7 million in Medicare reimbursementsGreg Noble, “Dr. Atiq Durrani: New Trial Begins With West Chester Hospital, UC Health as Co-Defendants,” WCPO Cincinnati, August 11, 2014, http://www.wcpo.com/news/local-news/butler-county/dr-atiq-durrani-new-trial-begins-with-west-chester-hospital-uc-health-as-co-defendants.

In 2013, the state of Ohio brought charges“Attorney: Accused Spine Doctor Used Unapproved Medical Implant,” WLWT Channel 5, August 27, 2013, http://www.wlwt.com/news/local-news/hamilton-county/attorney-accused-spine-doctor-used-unapproved-medical-implant/21668920.

Medical boards in both Kentucky and OhioCommonwealth of Kentucky Board of Medical Licensure, Case No. 1537, http://www.state.ky.us/agencies/kbml/finalorders/39372.pdf; and State Medical Board of Ohio, Case No. 13-CRF-110, http://med.ohio.gov/formala/35085087.pdf.

the surgeon fledGordon Graham, “Mason Surgeon Accused of Fraud Flees the Country,” FOX19, December 14, 2013, http://www.fox19.com/story/24223640/dr-atiq-durrani-accused-spine-surgeon-flees-the-country.

One lawsuit charged“Couple Files Suit against Durrani, Claiming He Isn’t Licensed Doctor,” WLWT5, January 19, 2015, http://www.wlwt.com/news/couple-files-suit-against-durrani-claiming-he-isnt-licensed-doctor/30805142.

It was “highly doubtful” Amanda Lee Myers, “Ohio Surgeon Found Negligent in 1 of Many Lawsuits,” Associated Press, January 14, 2014, http://www.ohio.com/news/ohio-surgeon-found-negligent-in-1-of-many-lawsuits-1.459284.

In 2015, one of several hospitalsGreg Noble, “West Chester Hospital, UC Health to Pay $4.1 Million for Fugitive Doctor’s Spine Surgeries,” WCPO Cincinnati, http://www.wcpo.com/news/local-news/butler-county/west-chester/west-chester-hospital-uc-health-to-pay-41-million-for-fugitive-doctors-spine-surgeries.

he had established his own spine surgery clinic Walter Eisner, “Spine Fugitive Durrani Found in Pakistan, Orthopedics This Week, June 26th, 2015, https://ryortho.com/2015/06/spine-fugitive-durrani-found-in-pakistan/

In Florida, between 2000 and 2012  Whoriskey and Keating, “Spinal Fusions Serve as Case Study.”

In a whistleblower case in 2009Ibid.

Ultimately, Halifax Health agreedSkyler Swisher, “Halifax Health Defends Whistleblower Settlement,” The Daytona Beach News-Journal, August 18, 2014, http://www.news-journalonline.com/news/20140818/halifax-health-defends-whistleblower-settlement.

Federico C. Vinas’ physician profile  “Federico C. Vinas, MD,” Halifax Health, accessed July 18, 2016, https://www.halifaxhealth.org/services-treatments/our-doctors/federico-c-vinas-md.

But his Healthgrades web profile“Dr. Federico Vinas, MD,” HealthGrades, accessed July 16, 2016, https://www.healthgrades.com/physician/dr-federico-vinas-y83fc/background-check#BackgroundBackgroundCheck_anchor.

Chapter Six: Google Your Spine Surgery

discography   “Discogram,” Mayo Clinic, accessed January 7, 2014, http://www.mayoclinic.org/tests-procedures/discogram/basics/definition/PRC-20013848.

electromyography (EMG)  “Electromyography (EMG),” Mayo Clinic, accessed January 7, 2014, http://www.mayoclinic.org/tests-procedures/electroconvulsive-therapy/basics/definition/prc-20014183.

Happy patients at LSI’s facility  “Patient Testimonials,” Laser Spine Institute, accessed January 7, 2014, http://www.laserspineinstitute.com/testimonials/.

“the premier health care provider in spinal surgery,”  Laser Spine Institute website, accessed November 8, 2008, www.laserspineinstitute.com.

“percutaneous procedure”  “Minimally Invasive, Endoscopic, and Laser Spine Surgery: Facts & Fiction,” Resurgens Spine Center, accessed January 11, 2014, http://www.resurgensspine.com/jeffords/spine-surgery-facts-fiction.php.

“endoscopic”  Ibid.

conventional microdiscectomy“Microdiscectomy,” USC Center for Spinal Surgery, accessed January 12, 2015, http://www.uscspine.com/treatment/microdiscectomy.cfm.

a well-designed Cochrane Collaboration review“Shining a Light on Laser Disc Surgery—A Quarter Century Late,” The Back Letter 30, no. 6 (2005): 61–69, doi:10.1097/01.BACK.0000466232.64004.93; and Patrick A. Brouwer et al. “Percutaneous Laser Disc Decompression Versus Conventional Microdiscectomy in Sciatica: A Randomized Controlled Trial,” The Spine Journal 15, no. 5 (2015): 857–865, http://dx.doi.org/10.1016/j.spinee.2015.01.020.

Kerr’s conventional microdiscectomy  Ramona Shelburne, “Steve Kerr Has Suffered More Than You Will Ever Know,” ESPN, April 6, 2016, http://espn.go.com/nba/story/_/id/15148955/on-top-nba-world-steve-kerr-found-struggling-just-stand; and Rusty Simmons, “Warriors Beat: Noted Surgeon Offers Prognosis for Steve Kerr,” SFGate.com, October 12, 2015, http://www.sfgate.com/warriors/article/Warriors-beat-Noted-surgeon-offers-prognosis-for-6567286.php. 

“I have no answer for that” “Is This the End for Tiger Woods?” Daily Mail, December 1, 2015, http://www.dailymail.co.uk/news/article-3342065/Is-end-Tiger-Woods-Golf-pro-39-reveals-forced-undergo-second-surgery-just-walk-no-timetable-play-again.html#ixzz497Gjpexv.

“It’s not because the procedure is good”  Hyun Bae, MD, in discussion with the author, March 15, 2010.

Sheryl WeberSheryl Weber, in discussion with the author, November 14, 2008.

Rob and Ginger StageRob and Ginger Stage, in discussion with the author, November 14, 2008.

Lauren,* who after many conversationsLauren*, pseudonym, in discussion with the author, November 20, 2008.

chymopapain“Papaya,” Drugs Information Online, accessed January 18, 2014, http://www.drugs.com/npp/papaya.html.

The enzyme dissolved proteins“The Tale of the Floppy Eared Bunny (The Saga of Chymopapain),” The Burton Report, accessed January 18, 2014, http://www.burtonreport.com/infspine/mininvasprocchemonucleolysis.htm.

When the FDA approved chymopapainIbid.

some patients experienced allergic reactionsDon Jacobs, “Test Evaluation,” UCSF Departments of Pathology & Laboratory Medicine, accessed January 18, 2014, http://labmed.ucsf.edu/education/educational/crit_reviews/XXXX_CriticalReview_DonJacobs.pdf.

Almost ten year after chymopapainW.J. Gogan & R.D. Fraser, “Chymopapain: A 10-year, Double-blind Study,” Spine 17, no. 4 (1992): 388–394.

In 2003, the only companyAnthony T. Yeung, “The Current Status of Chymopapain,” Desert Institute for Spine Care, November 23, 2011, http://www.sciatica.com/physician--information/scientific-articles/file/24-the-current-status-of-chymopapain.html.

two physiatrist brothersKaren Freeman, “For Back Pain Sufferers, a Technique Under Study May Offer Hope,” New York Times, October 24, 2000, http://www.nytimes.com/2000/10/24/health/for-back-pain-sufferers-a-technique-under-study-may-offer-hope.html?pagewanted=all&src=pm.

The Saal brothers designed their own clinical trialsJeffrey A. Saal and Joel S. Saal, “Intradiscal Electrothermal Treatment for Chronic Discogenic Low Back Pain,” Spine 25, no. 20 (2000): 2622–2627; and Jeffrey A. Saal and Joel S. Saal, “Management of Chronic Discogenic Low Back Pain with a Thermal Intradiscal Catheter: A Preliminary Report,” Spine 25, no. 3 (2000): 382–388. 

twenty-five hundred doctorsFreeman, “For Back Pain Sufferers;” and Clayton Simmons, “Pain Interventionists, CMS Tangle Over IDET Coverage,” Pain Medicine News 6, no. 7 (2008), http://www.painmedicinenews.com/ViewArticle.aspx?d=Policy%2B%26amp%3B%2BManagement&d_id=83&i=October%2B2008&i_id=457&a_id=11743&ses=ogst.

compared IDET with a sham procedureBrian J. Freeman et al., “A Randomized, Double-Blind, Controlled Trial: Intradiscal Electrothermal Therapy Versus Placebo for the Treatment of Chronic Discogenic Low Back Pain,” Spine 30, no. 21 (2005): 2369–2377.

Medicare and private insurers stopped paying“Decision Memo for Thermal Intradiscal Procedures (CAG-00387N),” The Centers for Medicare and Medicaid Services, September 29, 2008, http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=215&ver=10&NcaName=Thermal+Intradiscal+Procedures&bc=BEAAAAAAEAAA&&fromdb=true.

I’d been told I’d have “twilight anesthesia,”  See e.g., “Glossary of Spinal Terms: General anesthesia,” Laser Spine Institute, accessed June 7, 2016, https://www.laserspineinstitute.com/learn_more/glossary/definition/general_anesthesia/209/.

if I’d been a fly on the wall  James St. Louis, in discussion with the author, February 26, 2010. 

I was so sedatedDotty Bollinger, Chief Operating Officer of Laser Spine Institute, in correspondence with the author, February 3, 2012.

“I never stop trying” Sheryl Weber, in discussion with the author, September 12, 2011.

“It’s like he went to Las Vegas”  Ginger Stage, in discussion with the author, September 12, 2011.

“That’s Facebook life”  Lauren*, pseudonym, in discussion with the author, February 5, 2010.

“I want to be positive”  Lauren*, pseudonym, in discussion with the author, April 8, 2015.

“sucking down ten Percocet”  Carl Karnes, in discussion with the author, April 29, 2010.  

David Armstrong, reporting for Bloomberg BusinessweekDavid Armstrong, “Laser Spine Surgery More Profitable Than Google Sees Complaints,” Bloomberg, May 4, 2011, http://www.bloomberg.com/news/2011-05-04/laser-spine-surgery-more-profitable-than-google-sees-surge-in-complaints.html.

he developed surgical instruments and techniquesCollins Conner, “Is Surgeon Innovative, or Unfit?” St. Petersburg Times, November 20, 2000, 

http://www.sptimes.com/News/112000/TampaBay/Is_surgeon_innovative.shtml.

Sam Bailey, the Arkansas preacher, met Bonati  Sam Bailey, in discussion with the author, October 30, 2013.

Bailey ran about 150 “educational seminars”  Chris Lloyd, in discussion with the author, March 1, 2011. 

In 2002, anesthesiologist James St. LouisMelia Bowie, “Back Doctor Sues over Trade Secrets,” St. Petersburg Times, October 16, 2004, http://www.sptimes.com/2004/10/16/Pasco/Back_doctor_sues_over.shtml.

the Florida Board of Medicine sanctioned Bonati Conner, “Is Surgeon Innovative, or Unfit?”

$3.1 millionJacob Pillsbury, “Doctor Alfred Bonati’s Years of Legal Battles: Predecessor to Laser Spine Institute Found Liable Yet Again,” Dolman Law Group blog, March 11, 2013. 

later he would pursue LSI for reparationsBailey et al. v. St. Louis et al. 06-08498 Division L (2012).

Specifically, Rothstein had connected“About AccuraScope,” North American Spine, accessed January 23, 2014, http://northamericanspine.com/accurascope/.

Using light as an energy sourcePeter F. Ullrich, Jr., “Laser Disc Decompression for Spinal Stenosis: Does it Work?” Spine-Health.com, June 30, 2007, accessed January 18, 2014, http://www.spine-health.com/blog/laser-disc-decompression-spinal-stenosis-does-it-work.

Lawrence Rothstein’s many pending malpractice lawsuits  Doug J. Swanson, “Problems Persist for High-Profile Back Surgery Firm, Patients,” The Dallas Morning News, August 23, 2014, http://www.dallasnews.com/news/metro/20140823-problems-persist-for-high-profile-back-surgery-firm-patients.ece.

temporary 2001 suspension of his Ohio medical licenseLou Grieco, “Doctor Accused of Lying to Patients, Hiding Assets,” Dayton Daily News, July 4, 2010, http://www.daytondailynews.com/news/news/local/doctor-accused-of-lying-to-patients-hiding-assets/nNFBq/.

a salary of $700,000 Swanson, “Problems Persist;”

Three months after Rothstein joined  Swanson, “Problems Persist;” and Jon Newberry, “Jury: Greater Cincinnati Pain Management Centers Must Pay Plaintiff $1.3M,” Cincinatti Business Courier, March 30, 2009, http://www.bizjournals.com/cincinnati/stories/2009/03/30/story8.html.

“I knew exactly who I was getting in bed with”  Chris Lloyd, in discussion with the author, March 1, 2011.

Rothstein filed for bankruptcy  Swanson, “Problems Persist.”

Bailey and Lloyd agreed to pay RothsteinArmstrong, “Laser Spine Surgery More Profitable.”

the State Medical Board of Ohio permanently revokedSwanson, “Problems Persist.”

The surrender documentThe State of Ohio, “The State Medical Board Permanent Surrender of Certificate to Practice Medicine and Surgery Case No. 12 CRF-063,” April 10, 2013.

Instead, it sold marketing and office servicesSwanson, “Problems Persist.”

Health plans might not pay  Guide For Third Party Reimbursement Of Facility Fees American (Gurnee, IL: American Association for Accreditation of Ambulatory Surgery Facilities), http://leadformix.com/ef1/files/2128/ASC%20-%20Third%20Party%20Reimbursement%20Facility%20Fees.pdf.

a total bill of $94,514Swanson, “Problems Persist.”

Myrda Sue Ford sustainedIbid. 

“get him squared away in Texas”  Ken Miller, in discussion with the author, October 10, 2011.

More than 80 percent of LSI’s patientsYvette Hammet, “Spine Institute Adding 100 Jobs, IT Firm Hiring 400,” The Tampa Tribune, December 10, 2014, http://www.tbo.com/news/business/400-new-tech-jobs-coming-to-tampa-20141210/.

In 2010, LSI spentJohn Polikandriotis, Director of Business Strategy and Research at Laser Spine Institute, in discussion with author, February 22, 2010. 

LSI’s marketing budgetDavid Armstrong, “Back-Surgery Center Dangled Illegal Incentives, Lawsuit Alleges,” Bloomberg BusinessWeek, October 15, 2014, 

http://www.businessweek.com/articles/2014-10-15/laser-spine-institute-dangled-illegal-incentives-to-attract-back-surgery-patients-lawsuit-alleges.

LSI’s other new productBriley Cienkosz, Chief Marketing Officer at Laser Spine Institute, in correspondence with the author, August 20, 2012.

If things went according to planLaser Spine Institute, “Laser Spine Institute Launches New Innovative Procedures to Better Meet the Needs of Patients,” news release, August 1, 2012, http://www.businesswire.com/news/home/20120801005250/en/Laser-Spine-Institute-Launches-Innovative-Procedures-Meet#.VLgpb1r3f8F.

Jill Urban had learnedJ. P. G. Urban, S. Roberts, and J. R. Ralphs, “The Nucleus of the Intervertebral Disc from Development to Degeneration,” American Zoologist 40, no. 1 (2000): 53–61, http://www.jstor.org/stable/3884378; and Jill Urban, in discussion with the author, October 29, 2009.

In an article in Nature“The Darker Side of Stem Cells,” Nature 483, no. 7387 (2012): 5, http://www.nature.com/nature/journal/v483/n7387/full/483005a.html.

“It’s a litigious world out there”  Dotty Bollinger, in discussion with the author, March 7, 2011.

A new lawsuit had been filed by Alfred BonatiArmstrong, “Back-Surgery Center Dangled Illegal Incentives.”

professional wrestler Hulk HoganBollea v. Laser Spine Institute, 13-389CI021,

https://www.scribd.com/doc/124448175/Hulk-Hogan-Lawsuit.

Hogan’s lawyers asserted  Curtis Krueger and Letitia Stein, “Wrestler Hulk Hogan Sues Laser Spine Institute, Alleging Unnecessary Surgeries,” Tampa Bay Times, January 14, 2013, http://www.tampabay.com/news/courts/civil/wrestler-hulk-hogan-sues-laser-spine-institute-alleging-unnecessary/1270466/.

At the end of 2010, Hogan underwentDavid Armstrong, “Hulk Hogan Wrestles With Laser Spine Center in Lawsuit,” Bloomberg Business, January 14, 2013, http://www.bloomberg.com/news/articles/2013-01-14/hulk-hogan-wrestles-with-laser-spine-center-in-lawsuit; and “Ouch! Hulk Hogan Reveals Graphic Puncture Wounds on His Back after Having Spine Rebuilt,” Daily Mail, December 28, 2010, http://www.dailymail.co.uk/tvshowbiz/article-1341984/Hulk-Hogan-shows-graphic-puncture-wounds-having-spine-rebuilt.html#ixzz4EnSGdJX3.

Hogan had, however, won a jury award  Jeremy Stahl, “Jury Awards Hulk Hogan $115 Million in Gawker Suit, Punitive Damages Still to Come,” Slate, March 18, 2016, http://www.slate.com/blogs/the_slatest/2016/03/18/jury_awards_hulk_hogan_115_million_in_gawker_suit_punitive_damages_still.html.

By that time, LSI had expanded“Laser Spine Institute Locations,” Laser Spine Institute, accessed November 10, 2015, http://www.laserspineinstitute.com/about/locations/.

five thousand spine operations annuallyArmstrong, “Laser Spine Surgery More Profitable.”

Having outgrown the buildingAshley Gurbal Kritzer, “Inside Laser Spine Institute's $56 Million Deal for a New Westshore Office Development,” Tampa Bay Business Journal, September 3, 2014, 

http://www.bizjournals.com/tampabay/news/2014/09/03/inside-laser-spine-institutes-56-million-deal-for.html?page=all; and Laser Spine Institute, “Infographic: New Tampa Surgery Center to Serve 25% More Patients,” news release, August 20, 2015, http://news.laserspineinstitute.com/press-releases/laser-spine-institute-new-tampa-hq-infographic/.

Dotty Bollinger told meDotty Bollinger, in correspondence with the author, September 28, 2011. 

In early 2014, the trade journal Orthopedics This WeekWalter Eisner, “What’s Next for Spine’s Most Notorious Rogue?” Orthopedics This Week, January 7, 2014, https://ryortho.com/2014/01/whats-next-for-spines-most-notorious-rogue/.

Kaul completed his training  Alex Hannaford, “Trust Me, I’m a Doctor: The Case of the Rogue Spinal Surgeon,” The Guardian, November 1, 2014, http://www.theguardian.com/society/2014/nov/01/uk-anaesthetist-practised-as-us-spinal-surgeon.

A British jury found Kaul guiltyLindy Washburn, “Pompton Lakes’ Pain Doctor: A Shocking Story of Damaged Patients and Weak Oversight,” The Record, November 17, 2013, http://www.northjersey.com/news/pompton-lakes-pain-doctor-a-shocking-story-of-damaged-patients-and-weak-oversight-1.584714.

The state of New Jersey graciously renewedHannaford, “Trust Me, I’m a Doctor.”

did not discover his negligent manslaughter convictionWashburn, “Pompton Lakes’ Pain Doctor.”

Kaul began attending CME coursesHannaford, “Trust Me, I’m a Doctor;” and Walter Eisner, “Dr. Richard Kaul: Public Danger or Scope of Practice Pawn?” Orthopedics This Week, June 19, 2012, https://ryortho.com/2012/06/dr-richard-kaul-public-danger-or-scope-of-practice-pawn/. 

“certified Minimally Invasive Spine Specialist”  Susan K. Livio, “State Suspends License of N.J. Doctor for Performing Spinal Surgery Without Proper Training,” NJ.com, June 14, 2012, http://www.nj.com/news/index.ssf/2012/06/state_suspends_license_of_nj_s.html.

According to court documentsEisner, “Dr. Richard Kaul.”

The Bergen County Record reportedWashburn, “Pompton Lakes’ Pain Doctor.”

In March 2014, after twenty-three days of deliberationHannaford, “Trust Me, I’m a Doctor.”

“repeatedly subjected multiple patients” Livio, “State Suspends License of N.J. Doctor for Performing Spinal Surgery Without Proper Training.”

“one man…testified”  Washburn, “Pompton Lakes’ Pain Doctor.”

Instead of slipping away  Ibid. 

He pointed outEisner, “Dr. Richard Kaul.”

Chapter Seven: Replacement Parts

Alf Nachemson, the innovative Swedish surgeon and researcherPeter Frelinghuysen et al., “Lumbar Total Disc Replacement Part I: Rationale, Biomechanics, and Implant Types,” Orthopedic Clinics of North America 36, no. 3 (2005): 293–299, doi:10.1016/j.ocl.2005.02.014.

Ten years later, another Swedish surgeonJames J. Yue et al., eds. Motion Preservation Surgery of the Spine: Advanced Techniques and Controversies (Philadephia: Saunders, 2008), 12.

The ball bearings quickly migratedRobin Young, “FDA Rolls Fernstrom’s Ball,” Orthopedics This Week, January 10, 2014, https://ryortho.com/2014/01/fda-rolls-fernstroms-ball/.

Papers published in European journalsSee e.g. Michael Putzier et al., “Charité Total Disc Replacement – Clinical and Radiographical Results after an Average Follow-up of 17 Years,” European Spine Journal 15, no. 2 (2006): 183–195, doi:10.1007/s00586-005-1022-3.

to enter the FDA regulatory process“Charité Artificial Disc – P040006,” U.S. Food and Drug Administration, accessed January 25, 2014, http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm080693.htm.

Two members of the FDA’s Charité approval panelOrthopedic and Rehabilitation Devices Panel of the Medical Devices Advisory Committee, US Food and Drug Administration, meeting transcript, June 2, 2004, http://www.fda.gov/ohrms/dockets/ac/04/transcripts/2004-4049t1.htm.

At the same meeting, André van OoijIbid. 

Dallas spine surgeon John PelozaIbid.

a retrospective clinical and radiological study Putzier et al., “Charité Total Disc Replacement – Clinical and Radiographical Results after an Average Follow-up of 17 Years.”

FDA’s approval panel voted unanimously  Orthopedic and Rehabilitation Devices Panel of the Medical Devices Advisory Committee, meeting transcript. 

the approval’s labelingCharité’s labeling can be seen here: http://www.accessdata.fda.gov/cdrh_docs/pdf4/P040006C.pdf. 

worth $1.7 billionRhonda L. Rundle and Scott Hensley, “Back Fire: J&J’s New Device for Spine Surgery Raises Questions,” The Wall Street Journal, updated June 7, 2005, http://online.wsj.com/news/articles/SB111810358251652415.

three thousand American spine surgeonsMaggie Mahar, Money-Driven Medicine (New York: HarperCollins, 2006), 281.

Wall Street Journal reporters describedRundle and Hensley, “J&J’s New Device.”

implanted more than three thousand devicesMahar, Money-Driven Medicine, 284. 

“the most exciting thing in spine surgery”  “The Miracle Disc,” Boston.com, accessed January 25, 2014, http://www.boston.com/yourlife/health/hospitalguide/LoveChildren/.

“Patients were coming in”  Charles Rosen, MD, in discussion with the author, August 14, 2010.

the three-hundred-page transcriptOrthopedic and Rehabilitation Devices Panel of the Medical Devices Advisory Committee, meeting transcript.

“Real discs,” he explained  Charles Rosen, MD, in discussion with the author, August 14, 2010.

the Charité disc was compared to a deviceKarin D. van den Eerenbeemt et al., “Total Disc Replacement Surgery for Symptomatic Degenerative Lumbar Disc Disease: A Systematic Review of the Literature,” European Spine Journal 19, no. 8 (2010): 1262–1280, doi:10.1007/s00586-010-1445-3.

“the American people potentially at great risk”  Rundle and Hensley, “J&J’s New Device.” 

The start-up capitalReed Abelson, “Financial Ties Are Cited as Issue in Spine Study,” The New York Times, January 30, 2008, http://www.nytimes.com/2008/01/30/business/30spine.html?pagewanted=all&_r=0.

“You know,” he saidRudolf Bertagnoli, MD, in discussion with the author, October 18, 2009. 

In Europe, the procedure costRick Delamarter, MD, in discussion with the author, February 9, 2010.

Brian BohnBrian Bohn, in discussion with the author, June 25, 2010. 

In 2002, another patientMark Mintzer, in discussion with the author, June 3, 2010. 

In 2009, a Virginia law firmHauswiesner Fritz King, “HFK Law Files Lawsuit against Krankenhaus Stenum Hospital,” news release, August 31, 2009, http://hauswiesner.com/HFK%20Law%20Sues%20Stenum%20Hospital.pdf. 

I sent a request to Stenum HospitalMalte Peterson, in correspondence with the author, March 24, 2011.

“Every time my superior returned”  Charles Rosen, MD, in discussion with the author, August 14, 2010.

According to an article in the Orange County RegisterJennifer Muir, “From Medical Outcast to Surgeon General?” The Orange County Register, January 9, 2009, http://www.ocregister.com/articles/rosen-39211-says-medical.html.

With two colleagues at UC Irvine, Rosen launchedCharles Rosen et al., “Lumbar Disk Replacement Failures: Review of 29 Patients and Rationale for Revision,” Orthopedics 32, no. 8 (2009), doi:10.3928/01477447-20090624-08.

In ten patients, with a posterior surgical approachCharles Rosen, MD, in correspondence with the author, June 13, 2016. 

The other nineteen patientsIbid. 

“everything was scarred over”  Charles Rosen, MD, in discussion with the author, August 14, 2010.

Silverman, who had workedGary Silverman, in correspondence with the author, May 15, 2015 and February 6, 2016. 

In 2008 the U.S. Supreme Court had upheld  Robert J. Axelrod, Esq., in correspondence with Gary Silverman, December 17, 2008. 

“pittance”  Gary Silverman, in correspondence with the author, July 16, 2016.

His lawyer had told himGary Silverman, in correspondence with the author, February 6, 2016. 

wrote a strongly worded letterCharles D. Rosen, MD, in correspondence with Senator Chuck Grassley, February 12, 2006.                                                                               

Once again, Rosen explainedMelissa Davis, “Suits Target J&J Discs,” The Street, June 5, 2006, https://www.thestreet.com/story/10289585/1/suits-target-jj-discs.html?startIndex=0.

In response, Senator Grassley’s staffersReed Abelson, “Senator Queries F.D.A. and Spinal Disk Maker,” New York Times, February 28, 2008, http://www.nytimes.com/2008/02/28/business/28device.html?pagewanted=print&_r=0; and Lorraine McCarthy, “Device Maker Synthes to Disclose

Financial Ties to Doctors Under Agreement,” Association for Medical Ethics, accessed January 28, 2015,

http://www.ethicaldoctor.org/news-and-media/device-maker-synthes-to-disclose-financial-ties-to-doctors/.

By that time, DePuy Synthes Spine was also under scrutinyReed Abelson, “Medical Device Maker Settles Conflict Inquiry in New Jersey,” New York Times, May 6, 2009, http://www.nytimes.com/2009/05/07/business/07device.html; and Anne Milgram, Attorney General for the State of New Jersey, in correspondence with Joshua M. Sharfstein, MD, Acting Commissioner of the Food and Drug Administration, May 5, 2009, http://www.nj.gov/oag/newsreleases09/050509-FDA-letter.pdf. 

New Jersey’s attorney general  Office of the Attorney General, State of New Jersey, “Attorney General Announces Subpoena of Companies Involved in Development, Manufacture of Synthetic Spinal Disk,” news release, February 4, 2008, http://www.nj.gov/oag/newsreleases08/pr20080204b.html.

In a remarkably plainspoken letterAnne Milgram, in correspondence with Joshua M. Sharfstein, May 5, 2009.

about $600 an hourRichard Guyer, MD, of the Texas Back Institute, in discussion with the author, February 25, 2010.

pay $236,000Abelson, “Medical Device Maker Settles Conflict Inquiry in New Jersey.”

Delamarter had been one of the investigatorsSee e.g. Jack Zigler et al., “Results of the Prospective, Randomized, Multicenter Food and Drug Administration Investigational Device Exemption Study of the ProDisc-L Total Disc Replacement Versus Circumferential Fusion for the Treatment of 1-level Degenerative Disc Disease,” Spine 32, no. 11 (2007): 1155–1162; doi:10.1097/BRS.0b013e318054e377.

He was also an author of several papersSee, e.g., Rick B. Delamarter et al., “P37. 1 versus 2 versus 3-Level Lumbar Artificial Disc Replacement: A Prospective Report of Clinical Outcomes With the ProDisc-L Device,” The Spine Journal 6, no. 5 (2006): 101S–102S, http://dx.doi.org/10.1016/j.spinee.2006.06.296.

During our interview in 2010Rick Delamarter, MD, in discussion with the author, February 9, 2010.

“From the second I woke up”  Haley Smith, in discussion with the author, September 3, 2010. 

“four little beauties”  Lou Gram, in discussion with the author, April 30, 2010.

the British Medical Journal published resultsChristian Hellum et al., “Surgery with Disc Prosthesis Versus Rehabilitation in Patients with Low Back Pain and Degenerative Disc: Two Year Follow-up Randomized Study,” British Medical Journal 342 (2011): d2786, doi:10.1136/bmj.d2786.

more than thirty-five thousand ProDiscs had been implantedJack Zigler, “The Insurance Industry Strikes Again!” Orthopedics This Week, October 16, 2013, http://ryortho.com/2013/10/the-insurance-industry-strikes-again/.

By the time the Cochrane Collaboration reportedW. Jacobs et al., “Total Disc Replacement for Chronic Low-back Pain,” Cochrane Summaries, February 28, 2013, accessed January 26, 2014, http://summaries.cochrane.org/CD008326/total-disc-replacement-for-chronic-low-back-pain.

Anthem Blue Cross saidRobin Young, “Who’s in Charge of Safety: The FDA or Anthem Blue Cross?” Orthopedics This Week, October 3, 2013,

http://ryortho.com/2013/10/whos-in-charge-of-safety-the-fda-or-anthem-blue-cross/.

Aetna followed  Zigler, “The Insurance Industry Strikes Again!” 

Sales would peakSharon O’Reilly, “The Artificial Disc Bust: Lessons Learned,” MedTech Insight, August 1, 2010. 

“It’s intense all the time”  Lou Gram, in correspondence with the author, January 3, 2016.

the Centers for Medicare and Medicaid reportedThe database can be accessed at cms.gov/openpayments.

At Policy and MedicineSee http://www.policymed.com/physician-payment-sunshine-act/.

Chapter Eight: The Opioid Wars  

when I sat down in 2010 with epidemiologist Michael Von KorffMichael Von Korff, in discussion with the author, June 16, 2010.

Von Korff had written a highly controversial editorialMichael Von Korff and Richard A. Deyo, “Potent Opioids for Chronic Musculoskeletal Pain: Flying Blind?” Pain 109, no. 3 (2004): 207–209.

The history of opium  Unless otherwise noted, information on the history of opium and its derivatives is from Marvin D. Seppala, MD, Prescription Painkillers: History, Pharmacology, and Treatment (Center City, MN: Hazelden, 2010), Chapter 1, “The History of Opioids.”

Congress passed the Harrison Narcotics Tax ActIrfan A. Dhalla, Navindra Persaud, and David N. Jurrlink, “Facing up to the Prescription Opioid Crisis,” BMJ 343 (2011): d5142, doi:10.1136/bmj.d5142. See also Harrison Narcotics Tax Act, Pub. L. No. 223 (1914).

Arthur M. SacklerUnless otherwise noted, information on Arthur Sackler and his brothers comes from Barry Meier, Pain Killer: A “Wonder” Drugs Trail of Addiction and Death (Emmaus, PA: Rodale, 2003).

he and his younger brothers bought Purdue Frederick Katherine Eban, “OxyContin: Purdue Pharma’s Painful Medicine,” Fortune, November 9, 2011,

http://fortune.com/2011/11/09/oxycontin-purdue-pharmas-painful-medicine/.

Purdue Frederick received FDA approval for its first blockbuster “Orange Book: Approved Drug Products with Therapeutic Equivalence Evaluations,” U.S. Food and Drug Administration, accessed November 18, 2015, http://www.accessdata.fda.gov/scripts/cder/ob/docs/obdetail.cfm?Appl_No=019516&TABLE1=OB_Rx.

annual sales of $1.5 billion Eban, “OxyContin.”

revenues of $35 billionAlex Morell, “The OxyContin Clan: The $14 Billion Newcomer to Forbes 2015 List of Richest U.S. Families,” Forbes, July 1, 2015, http://www.forbes.com/sites/alexmorrell/2015/07/01/the-oxycontin-clan-the-14-billion-newcomer-to-forbes-2015-list-of-richest-u-s-families/. 

To that end, Purdue harnessedMeier, Pain Killer, 49.

superstar neurologist Kathleen M. FoleyRonald Piana, “Trailblazing Neurologist Leads the Way in Advancing Treatment of Cancer Pain,” The ASCO Post 3, no. 9, supp. 2 (2012): 

http://www.ascopost.com/issues/june-15-2012-supplement/trailblazing-neurologist-leads-the-way-in-advancing-treatment-of-cancer-pain.aspx.

In 1986, Portenoy and Foley published a paperRussell Portenoy and Kathleen Foley, “Chronic Use of Opioid Analgesics in Non-Malignant Pain: Report of 38 Cases,” Pain 25, no. 2 (1986): 171–186.

“be safely and effectively prescribed”  Ibid., 184.

hundred-word letter to the editorJane Porter and Hershel Jick, “Addiction Rare in Patients Treated with Narcotics,” New England Journal of Medicine 302, no. 2 (1980): 123.

he brought pharma money with himThomas Catan and Evan Perez, “A Pain-Drug Champion Has Second Thoughts,” The Wall Street Journal, December 17, 2012, http://www.wsj.com/articles/SB10001424127887324478304578173342657044604.

“There is a growing literature”  Elisabeth Rosenthal, “Patients in Pain Find Relief, Not Addiction, in Narcotics,” New York Times, March 28, 1993, http://www.nytimes.com/1993/03/28/us/patients-in-pain-find-relief-not-addiction-in-narcotics.html?pagewanted=all.

Doctors should not worry about “a ceiling dose”  Barry Meier, A World of Hurt (New York: The New York Times Company, 2013), Kindle edition, location 106.  

In the first five years that OxyContin was on the marketUnited States General Accounting Office, Prescription Drugs: OxyContin Abuse and Diversion and Efforts to Address the Problem, GAO-04-110 (Washington, D.C.: US General Accounting Office, 2003), 22.

$3,000 for telling their colleaguesMeier, Pain Killer, 96.

Purdue made a videotaped versionJohn Fauber and Ellen Gabler, “Anatomy of an Epidemic: The Opioid Movie,” Milwaukee Journal-Sentinel, September 9, 2012, http://www.medpagetoday.com/neurology/painmanagement/34650; General Accounting Office, Prescription Drugs, 27; and Purdue Pharma L.P., I Got My Life Back: Patients in Pain Tell Their Story, audiovisual recording, Purdue Pharma L.P. (Norwalk, CT: July 1997), DVD.

distributed another promotional videoGeneral Accounting Office, Prescription Drugs, 24. 

Purdue also produced a sequelPurdue Pharma L.P., I Got My Life Back: A Two-Year Follow Up of Patients in Pain, audiovisual recording, Purdue Pharma L.P. (Norwalk, CT: 2000), DVD.

Johnny Sullivan, whose future had looked so promisingJohn Fauber and Ellen Gabler, “What Happened to the Poster Children of OxyContin?” Milwaukee Journal-Sentinel, September 8, 2012, http://www.jsonline.com/watchdog/watchdogreports/what-happened-to-the-poster-children-of-oxycontin-r65r0lo-169056206.html.

Purdue had doubled the size of its sales forceGeneral Accounting Office, Prescription Drugs, 20, 28.

Reps were encouragedIbid. 

The average income  Ibid. 

Purdue’s collateral patient advocate websiteIbid., 24. 

By July 2001, patients had redeemed  Ibid., 23. 

“the fifth vital sign,”  June L. Dahl, “The Process of Pain Management,” in Behavioral and Psychopharmacologic Pain Management, Michael Ebert and Robert Kerns, eds. (Cambridge: Cambridge University Press, 2010), 4.

In the Joint Commission’s monograph

http://www.kevinmd.com/blog/2016/07/joint-commission-deserves-blame-opioid-crisis-heres.html; and National Pharmaceutical Council and Joint Commission on Accreditation of Healthcare Organizations, Pain: Current Understanding of Assessment, Management, and Treatments (National Pharmaceutical Council, Incorporated, 2001). 

As Oregon physician Jim Shames explainedLiam Moriarty, “Oregon Doctor Explains the Rise of Opioid Use,” Jefferson Public Radio, July 20, 2015, http://www.opb.org/news/article/oregon-opioid-heroin-epidemic/.

Even the Drug Enforcement Administration (DEA) climbed on board United States Drug Enforcement Administration, “DEA to Join Pain Advocates in Issuing Statement on Prescription Pain Medications,” news release, October 23, 2001, http://www.dea.gov/pubs/pressrel/pr102301.html.  

the Decade of Pain Control and ResearchVictims of Trafficking and Violence Protection Act of 2000, Pub. L. No. 106-386, 114 STAT. 1539 (2000); see Title VI, Sec. 1603 “Decade of Pain Control and Research.”

“The reality is that the vast majority of people”  United States Drug Enforcement Administration, “DEA to Join Pain Advocates.”

“The reason that we have a severe epidemic” “Doctor: Prescription Painkillers Kill More People Than Heroin,” NPR, September 9, 2015, http://www.opb.org/news/article/npr-doctor-prescription-painkillers-kill-more-people-than-heroin/.

enough painkiller prescriptions were writtenCenters for Disease Control and Prevention, “Prescription Painkiller Overdoses in the US,” November 2011, accessed November 20, 2015, http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html.

“When anyone starts”  Andrew Kolodny, in discussion and correspondence with the author, November–December 2013, during research for the author’s article on NewYorker.com; Cathryn Jakobson Ramin, “Why Did the F.D.A. Approve a New Pain Drug?” The New Yorker, December 2, 2013, http://www.newyorker.com/business/currency/why-did-the-f-d-a-approve-a-new-pain-drug.

Portenoy had appeared on Good Morning AmericaGood Morning America television broadcast, ABC News (August 30, 2010).

I’d speak with Portenoy on the phoneRussell Portenoy, MD, in discussion with author, November 15, 2011. 

“If I’d had an inkling”  Physicians for Responsible Opioid Prescribing, “Opioids for Chronic Pain: Addiction is NOT Rare,” YouTube video, 5:35, posted by Andrew Kolodny, October 30, 2011, https://www.youtube.com/watch?v=DgyuBWN9D4w; quote can be heard at 4:06.

Olivier LaudeOlivier Laude was gracious enough to provide the information about his condition and treatment over the course of several interviews conducted between April 2010 and January 2014. 

four out of five current heroin users reported  Stephen E. Lankenau et al. “Initiation into Prescription Opioid Misuse amongst Young Injection Drug Users,” International Journal of Drug Policy 23, no. 1 (2012): 37–44, doi:10.1016/j.drugpo.2011.05.014.

John Fauber, the Milwaukee Journal Sentinel investigative reporter See, e.g. Fauber and Gabler, “Anatomy of an Epidemic: The Opioid Movie;” Fauber and Gabler, “What Happened to the Poster Children of OxyContin?”; John Fauber, “Group Demands U.S. Senate Release Records on Opioid Industry,” Milwaukee Journal Sentinel, September 15, 2015, http://www.jsonline.com/news/health/group-demands-us-senate-release-records-on-opioid-industry-b99577445z1-327810151.html; and John Fauber, “Painkiller Boom Fueled by Networking,” Milwaukee Journal-Sentinel, February 18, 2012, http://www.jsonline.com/watchdog/watchdogreports/painkiller-boom-fueled-by-networking-dp3p2rn-139609053.html.

“I knew eventually”   “OxyContin Poster Children 15 Years Later,” YouTube video, 8:38, posted by OpioidAwareness, September 9, 2012, https://www.youtube.com/watch?v=hwtSvHb_PRk; quote can be heard at 3:35. 

she told Kolodny Andrew Kolodny, in correspondence with the author’s assistant, April 28 2016.

Risk Evaluation and Mitigation StrategyU.S. Food and Drug Administration, “Extended-Release (ER) and Long-Acting (LA) Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS),” July 9, 2012, http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf; and Barry Meier, “F.D.A. Won’t Order Doctors to Get Pain-Drug Training,” The New York Times, July 9, 2012, http://www.nytimes.com/2012/07/10/health/fda-rejects-mandatory-training-in-painkillers-for-doctors.html. 

Opioid Risk Tool (ORT)  City of Chicago v. Purdue Pharma et al., No. 1:14-cv-04361

(N.D. Ill. 2015), 28. See the complaint here: http://www.cityofchicago.org/content/dam/city/depts/cdph/tobacco_alchohol_abuse/RedactedComplaintJun22014.pdf

Utah anesthesiologist and pain management doctor Lynn WebsterDavid Armstrong, “Drug Companies Didn’t Want You to See These Allegations,” Bloomberg Business, November 14, 2014 http://www.bloomberg.com/bw/articles/2014-11-14/drug-companies-didnt-want-you-to-see-allegations-of-lavish-spending. 

“pseudo-addiction”  City of Chicago v. Purdue Pharma et al., complaint, 33.

“breakthrough pain”  Lynn R. Webster, “The Management of Noncancer Breakthrough Pain,” Medscape CME & Education, October 31, 2005, http://www.medscape.org/viewarticle/516583_7.

several patients deathsJohn Fauber, “Top Pain Physician Acknowledges Patients’ Fatal Overdoses,” Milwaukee Journal-Sentinel, February 19, 2013, http://www.jsonline.com/watchdog/watchdogreports/top-pain-physician-acknowledges-patients-fatal-overdoses-o78m2jb-191945161.html.

Ultimately, the feds were unableKirsten Stewart, “Prominent Utah Pain Doc No Longer under Scrutiny for Patient Deaths,” The Salt Lake Tribune, June 30, 2014, http://archive.sltrib.com/story.php?ref=/sltrib/news/58090348-78/pain-webster-patients-deaths.html.csp.

The institute’s reportInstitute of Medicine Committee on Advancing Pain Research, Care, and Education, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. (Washington, DC: National Academies Press, 2011). Summary available from: http://www.ncbi.nlm.nih.gov/books/NBK92510/.

nine of the nineteen expertsJohn Fauber, “Chronic Pain Statistic Called Exaggerated, Misleading,” Milwaukee Journal Sentinel, June 25, 2014, http://www.jsonline.com/watchdog/watchdogreports/chronic-pain-statistic-called-exaggerated-misleading-b99287713z1-264515601.html.

IOM issued an erratum statementInstitute of Medicine, Relieving Pain in America, 1.

“Nobody asked me”  Fauber, “Chronic Pain Statistic Called Exaggerated, Misleading.”

“I totally disagree”  Ibid. 

By 2015, the IOM’s tallyJae Kennedy et al., “Prevalence of Persistent Pain in the U.S. Adult Population: New Data from the 2010 National Health Interview Survey,” The Journal of Pain 15, no. 10 (2014): 979–984, http://dx.doi.org/10.1016/j.jpain.2014.05.009.

Expert groups like the Cochrane CollaborationLuis E. Chaparro et al. “Opioids for the Treatment of Chronic Low-back Pain,” Cochrane Database of Systematic Reviews 8 (2013), doi:10.1002/14651858.CD004959.pub4.

An investigation in the United KingdomJulie Ashworth et al., “Opioid Use among Low Back Pain Patients in Primary Care: Is Opioid Prescription Associated with Disability at 6-month Follow-up?” Pain 154, no. 7 (2013): 1038–1044, doi:10.1016/j.pain.2013.03.011.

A Scandinavian studyPer Sjogren, M. Gronbaek et al., “A Population-Based Cohort Study on Chronic Pain: The Role of Opioids,” Clinical Journal of Pain 26, no. 9 (2010): 763–769, doi:10.1097/AJP.0b013e3181f15daf.

The American Academy of NeurologyKristina Fiore, “AAN Warns against Opioids in Chronic Noncancer Pain,” MedPage Today, September 29, 2014, http://www.medpagetoday.com/PainManagement/PainManagement/47871.

Tom Frieden, had made it clearPress Briefing Transcript, “CDC Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999—2008,”

November 1, 2011, http://www.cdc.gov/media/releases/2011/t1101_prescription_pain_relievers.html.

ninety-two thousand opioid poisoning visitsLisa Giron and Karen Kaplan, “Opioids Prescribed by Doctors Led to 92,000 Overdoses in ER in One Year,” Los Angeles Times, October 27, 2014, http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-prescription-hospital-er-20141026-story.html; and Michael A. Yokell et al., “Presentation of Prescription and Nonprescription Opioid Overdoses to US Emergency Departments,” JAMA Internal Medicine 174, no. 12 (2014): 2034–2037, doi:10.1001/jamainternmed.2014.5413.

a study by Princeton economistsAnne Case and Angus Deaton, “Rising Morbidity and Mortality in Midlife among White Non-Hispanic Americans in the 21st Century,” PNAS 112, no. 49 (2015): 15078–15083, www.pnas.org/cgi/doi/10.1073/pnas.1518393112.

the CDC sent out a preliminary guidelineDeborah Dowell, Tamara M. Haegerich, and Roger Chou, Draft of CDC Guideline for Prescribing Opioids for Chronic Pain, 2016, 14, accessed November 25, 2015, available at http://morningconsult.com/wp-content/uploads/2015/09/CDC-Pre-Decisional-Guidelines.pdf; and Pat Anson, “Chronic Pain Groups Blast CDC for Opioid Guidelines,” Pain News Network, September 22, 2015, http://www.painnewsnetwork.org/stories/2015/9/22/chronic-pain-groups-blast-cdc-for-opioid-guidelines.

“behind closed doors”  Richard A. Samp and Mark S. Chenoweth, “Comments of the Washington Legal Foundation to the Centers for Disease Control and Prevention Department of Health and Human Services Concerning Proposed 2016 Guidelines for Prescribing Opioids for Chronic Pain,” Docket No. CDC-2015-0112, January 13, 2016, http://www.wlf.org/upload/litigation/misc/CDCComments-PrescribingOpioids.pdf.

a mostly unchanged guideline Deborah Dowell, Tamara M. Haegerich, and Roger Chou, “CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016,” MMWR Recommendations and Reports 65, no. RR-1 (2016): 1–49, http://dx.doi.org/10.15585/mmwr.rr6501e1.

“could be better tolerated”  Thomas R. Frieden and Debra Houry, “Reducing the Risks of Relief — The CDC Opioid-Prescribing Guideline,” New England Journal of Medicine

374 (2016): 1501–1504, doi:10.1056/NEJMp1515917.

in a North Carolina study“No Safe Threshold: Opioid Overdoses Can Occur at Both High and Low Dose Regimens,” The Back Letter 30, no. 11 (2015): 123–131, doi:10.1097/01.BACK.0000473204.00195.17.

combined with benzos, alcohol or sedativesJohn Fauber and Kristina Fiore, “Painkillers, Tranquilizers an Increasingly Fatal Mix,” Journal-Sentinel, February 25, 2014,

www.jsonline.com/watchdog/watchdogreports/painkillers-tranquilizers-an-increasingly-fatal-mix-b99198015z1-247184581.html; Andrew Kolodny, email to the author, December 23, 2013.

“Overall, one out of every 550 patients”  Dowell, Haegerich, and Chou, “CDC Guideline for Prescribing Opioids for Chronic Pain.”

American adults spend nearly $18 billionRafia S. Rasu et al., “Cost of Pain Medication to Treat Adult Patients with Nonmalignant Chronic Pain in the United States,” Journal of Managed Care & Specialty Pharmacy 20, no. 9 (2014): 921–928, http://dx.doi.org/10.18553/jmcp.2014.20.9.921.

In many parts of the country, cognitive psychologists“Has the Lack of Alternative

Treatments Fueled the Opioid Crisis?” The Back Letter 29, no. 2 (2014): 17. 

the Comprehensive Addiction and Recovery ActBrad Bachman, “U.S. Senate Shows Leadership in Bipartisan Response to Opioid Epidemic,” American Society of Addiction Medicine Magazine, March 16, 2016, http://www.asam.org/magazine/read/article/2016/03/16/u.s.-senate-shows-leadership-in-bipartisan-response-to-opioid-epidemic.

In 2013, the National Survey on Drug Use and HealthSubstance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863 (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014), http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf. 

eleven thousand short-term substance disorder treatment programsKatherine R. Levit et al., Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment, 2004–2014 SAMHSA Publication No. SMA 08-4­326. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2008), iv.

a drug called buprenorphineJason Cherkis, “Dying to be Free,” Huffington Post, January 28, 2015, http://projects.huffingtonpost.com/dying-to-be-free-heroin-treatment; Drug Enforcement Administration Office of Diversion Control, “Buprenorphine,” July 2013, http://www.deadiversion.usdoj.gov/drug_chem_info/buprenorphine.pdf; and 

Deborah Sontag, “Addiction Treatment With a Dark Side,” The New York Times, November 16, 2013, http://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-or-menace.html?_r=0.

Robert M. Califf   “Meet Robert M. Califf, M.D., Commissioner of Food and Drugs,” US Food and Drug Administration, last updated April 4, 2016, http://www.fda.gov/AboutFDA/CentersOffices/ucm452317.htm; and Sabrina Tavernise, “F.D.A. Nominee Califf’s Ties to Drug Makers Worry Some,” The New York Times, September 19, 2015, http://www.nytimes.com/2015/09/20/health/fda-nominee-califfs-ties-to-drug-industry-raise-questions.html.

“to comprehensively review our portfolio”  Robert M. Califf, Janet Woodcock, and Stephen Ostroff, “A Proactive Response to Prescription Opioid Abuse,” New England Journal of Medicine 374 (2016): 1480–1485, doi:10.1056/NEJMsr1601307.

“The standards DO NOT require the use of drugs”  David W. Baker, “Joint Commission Statement on Pain Management,” The Joint Commission, April 18, 2016, https://www.jointcommission.org/joint_commission_statement_on_pain_management/.

new posting as chief medical officer“The Staff,” MJHS Institute for Innovation in Palliative Care, accessed July 23, 2016, https://www.mjhspalliativeinstitute.org/the-staff/.

Chapter Nine: Head Case

French philosopher René Descartes had proposedRené Descartes, Treatise of Man, trans. Thomas Steele Hall (Amherst, NY: Prometheus Books, 2003).

Canadian psychologist Ronald Melzack and British neurobiologist Patrick WallRonald Melzack and Patrick D. Wall, “Pain Mechanisms: A New Theory,” Science 150 (1965): 971–979.

what they posited opened the door“Professor Patrick Wall,” The Telegraph, August 23, 2001, http://www.telegraph.co.uk/news/obituaries/1338208/Professor-Patrick-Wall.html.

In 1983, he was the first Kathleen Koman, “The Science of Hurt,” Harvard Magazine, November–December 2005, http://harvardmagazine.com/2005/11/the-science-of-hurt.html.

the phenomenon of “central sensitization” See, e.g., Clifford J. Woolf, “Central Sensitization: Implications for the Diagnosis and Treatment of Pain,” Pain 152, supp. 3 (2011): S2–15, doi:10.1016/j.pain.2010.09.030.

Woolf explored the ways in which neuronsKoman, “The Science of Hurt.”

Pain and Passions Lab  Apkarian Lab – Pain and Passions, Northwestern University, accessed July 27, 2016, http://www.feinberg.northwestern.edu/faculty-profiles/az/profile.html?xid=10330.

“When we started this research in 1999”  Apkar Vania Apkarian, PhD, in discussion with the author, October 5, 2009.

the brain itself would begin to generate the painMarwan N. Baliki et al., “Functional Reorganization of the Default Mode Network across Chronic Pain Conditions,” PLOS One, September 2, 2014, doi:10.1371/journal.pone.0106133.

the brain was structurally transformedA. Vania Apkarian et al., “Chronic Back Pain Is Associated with Decreased Prefrontal and Thalamic Gray Matter Density,” The Journal of Neuroscience 24, no. 46 (2004): 10410–10415, doi:10.1523/JNEUROSCI.2541-04.2004. 

this region was markedly smallerAmelia A. Mutso et al., “Abnormalities in Hippocampal Functioning with Persistent Pain,” The Journal of Neuroscience 32, no. 17 (2012): 5747–5756, doi:10.1523/JNEUROSCI.0587-12.2012.

as reported in the Journal of Pain  David A. Seminowicz et al., “Cognitive-behavioral Therapy Increases Prefrontal Cortex Gray Matter in Patients with Chronic Pain,” Journal of Pain 14 (2013):1573–1584, doi:10.1016/j.jpain.2013.07.020.

there was a noticeable changeAmelia A. Mutso et al., “Reorganization of Hippocampal Functional Connectivity with Transition to Chronic Back Pain,” Journal of Neurophysiology, published online December 11, 2013, doi:10.1152/jn.00611.2013.

The nucleus accumbensMarwan N. Baliki, “Corticostriatal Functional Connectivity Predicts Transition to Chronic Back Pain,” Nature Neuroscience 15, no. 8 (2012): 1117–1119.

The enzyme catechol-O-methyltransferase   I Belfer and S Segall, “COMT Genetic Variants and Pain,” Drugs Today 47, no. 6 (2011): 457–467, doi:10.1358/dot.2011.47.6.1611895.

One variant of COMTJules Desmeules et al., “Central Pain Sensitization, COMT Val158Met Polymorphism, and Emotional Factors in Fibromyalgia,” Journal of Pain 15, no. 2 (2014); and Po Bronson and Ashley Merryman, “Why Can Some Kids Handle Pressure While Others Fall Apart?” The New York Times, February 6, 2013, http://www.nytimes.com/2013/02/10/magazine/why-can-some-kids-handle-pressure-while-others-fall-apart.html?pagewanted=all&_r=0.

about 15 percent of the populationIrmgard Tegeder et al., “GTP Cyclohydrolase and Tetrahydrobiopterin Regulate Pain Sensitivity and Persistence,” Nature Medicine, Advance Online Publication, October 22, 2006, doi:10.1038/nm1490.

GCH1 geneNational Institutes of Health, “Genetics Home Reference,” GHC1, accessed August 29, 2014, http://ghr.nlm.nih.gov/gene/GCH1.

producing fewer gastrointestinal side effects Coxib and traditional NSAID Trialists’ (CNT) Collaboration, “Vascular and Upper Gastrointestinal Effects of Non-steroidal Anti-inflammatory Drugs: Meta-analyses of Individual Participant Data from Randomised Trials,” The Lancet 382, no. 9894 (2013): 769–779,

http://dx.doi.org/10.1016/S0140-6736(13)60900-9.

new studies that pitted COX-2 drugs against conventional NSAIDsHarriet A. Washington, “Flacking for Big Pharma,” The American Scholar, June 3, 2011, https://theamericanscholar.org/flacking-for-big-pharma/#.Vl4vQd-rT1A.

Vioxx and Bextra came off the shelves “COX-2 Selective (includes Bextra, Celebrex, and Vioxx) and Non-Selective Non-Steroidal Anti-Inflammatory Drugs (NSAIDs),” U.S. Food and Drug Administration, accessed February 17, 2017, https://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm429364.htm.

Celebrex, manufactured by Pfizer, was allowed to remainShannon Brownlee and Jeanne Lenzer, “Painkiller Trial Raises Questions for FDA, Pfizer,” The Center for Public Integrity, March 11, 2009, 

http://www.publicintegrity.org/2009/03/11/2929/painkiller-trial-raises-questions-fda-pfizer

equipped with the FDA’s black box warning“Public Health Advisory - FDA Announces Important Changes and Additional Warnings for COX-2 Selective and Non-Selective Non-Steroidal Anti-Inflammatory Drugs (NSAIDs),” U.S. Food and Drug Administration, April 7, 2005, 

http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm150314.htm. 

the FDA expanded the black box warningBrownlee and Lenzer, “Painkiller Trial Raises Questions for FDA, Pfizer.”

the PRECISION trialSee “Prospective Randomized Evaluation of Celecoxib Integrated Safety Vs Ibuprofen or Naproxen (PRECISION),” https://www.clinicaltrials.gov/ct2/show/record/NCT00346216. 

the outcomes were published in the New England Journal of Medicine Steven E. Nissen et al., “Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis,” New England Journal of Medicine 375, no. 26 (2016): 2519–2529, doi:10.1056/NEJMoa1611593.

the relative risk of heart attack or strokePatrice Wendling, “PRECISION: Celecoxib Similar to Ibuprofen, Naproxen for CV Risk,” Medscape, November 13, 2016, http://www.medscape.com/viewarticle/871835?src=WNL_confalert_161113_MSCPEDIT.

A study published in JAMA Internal MedicineMarcus A. Bachhuber et al.,

“Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010,” JAMA Internal Medicine 174, no. 10 (2014): 1668–1673, doi:10.1001/jamainternmed.2014.4005.

give the go-ahead to sixteen studies“Independently Funded Studies Receiving Research Grade Marijuana – 1999 to present,” National Institute on Drug Abuse, revised June 2014, accessed March 6, 2015, http://www.drugabuse.gov/drugs-abuse/marijuana/independently-funded-studies-receving-research-grade-marijuana-1999-to-present.

Sativex was tested in Phase III clinical trials  GW Pharmaceuticals, “GW Pharmaceuticals and Otsuka Announce Results from Two Remaining Sativex® Phase 3 Cancer Pain Trials,” news release, October 27, 2015, http://www.gwpharm.com/GWPOtsukaResults271015.aspx.

I had actually spoken with the rock star of the back worldJohn E. Sarno, MD, in discussion with the author, November 30, 2009.

Hans Kraus, had treated John F. Kennedy’s intractable back painSusan E.B. Schwartz, JFK’s Secret Doctor (New York: Skyhorse Publishing, 2012).

“Your muscles, your mind, your heart”  Hans Kraus, Backache, Stress and Tension (New York: Simon and Schuster, 1965), 71.

If he could convince a patientJohn E. Sarno, Healing Back Pain: The Mind-Body Connection (New York: Hachette Book Group, 2001).

“tension myositis syndrome”  Ibid. 

the patients who had the most successPippa Wysong, “An Expert Interview With Dr. John Sarno, Part I: Back Pain Is a State of Mind,” Medscape, June 7, 2004, http://www.medscape.com/viewarticle/478840; and Sarno, Healing Back Pain, 9–11.

significant physical and psychological adversity in childhoodSee, e.g., Randy A. Sansone, Daron A. Watts, and Michael W. Wiederman,“Childhood Trauma and Pain and Pain Catastrophizing in Adulthood: A Cross-Sectional Survey Study,” The Primary Care Companion for CNS Disorders 15, no. 4 (2013): PCC.13m01506, doi:10.4088/PCC.13m01506.

Sarno published his first bookJohn Sarno, Mind Over Back Pain (New York: Berkley Book, 1982). 

over a million copiesAlice Fried Martell, John Sarno’s literary agent, in discussion with the author’s assistant, May 2, 2012. 

In 1998, when Sarno published The Mindbody PrescriptionJohn Sarno, The Mindbody Prescription: Healing the Body, Healing the Pain (New York: Warner Books, 1998). 

a TV special on Sarno“Dr. John Sarno Healing Back Pain 20/20 episode—A Touch of Wellness Health Center” YouTube video, 14:47, from an episode of 20/20, posted by ATouchofWellnessVI, August 15, 2013, https://www.youtube.com/watch?v=2B2IE0o7diU.

Roughly 15 million people watched that segment  EW Staff, “What Ranked and What Tanked,” Entertainment Weekly, May 29, 1998, http://www.ew.com/article/1998/05/29/what-ranked-and-what-tanked.

“America’s back doctor”   Edward Siedle, “How America’s Best Pain Doctor—John Sarno—Took On The Medical Establishment and Won,” Forbes, November 28, 2012, http://www.forbes.com/sites/edwardsiedle/2012/11/28/how-americas-best-pain-doctor-took-on-the-medical-establishment-and-won/.

“chiefly responsible for the pain epidemic”  Sarno, Healing Back Pain, 9–11.

“He takes the fear out of the equation”  Tony Schwartz, in discussion with the author, November 20, 2012.

“Three or four times a year”  Renn Kaminski, in discussion with the author, January 20, 2010.

“they rolled their eyes”  Ken Malloy, in discussion with the author, January 26, 2012.

“They’re thinking like mechanics”  John Sarno, MD, in discussion with the author, January 18, 2011.

At the invitation of Senator Tom HarkinJohn E. Sarno, “Pain in America: Exploring Challenges to Relief,” US Senate Committee on Health, Education, Labor & Pensions hearing, February 14, 2012.

“The bias that common pain”  “Contribution of John E. Sarno, M.D., Professor of Rehabilitation Medicine, New York University School of Medicine for presentation at the Senate hearing entitled ‘Pain in America: Exploring Challenges to Relief.’ February 14, 2012,” US Senate Committee on Health, Education, Labor & Pensions, accessed July 30, 2014, http://www.help.senate.gov/imo/media/doc/Sarno.pdf.

Soon after his moment on Capitol Hill   Steven Peskin, MD, “A Tribute to Dr. John Sarno,” Managed Care Magazine, accessed July 30, 2014, http://www.managedcaremag.com/content/tribute.

“What if I just talked”  Ira Rashbaum, MD, in discussion with the author, March 16, 2014.

In 1961, the University of Washington School of Medicine“UW Pain Medicine—About Us,” UW Medicine, accessed August 11, 2014, http://depts.washington.edu/anesth/care/pain/.

sometimes they dropped off shopping bagsMeier, Pain Killer, 61.

in 1984, when Congress enacted reformsDavid H. Autor and Mark G. Duggan, “The Growth in the Social Security Disability Rolls: A Fiscal Crisis Unfolding,” The Journal of Economic Perspectives 20, no. 3 (2006): 78.

The percentage of claimsIbid., Table 1.

When Fordyce’s committee published its findings  Wilbert E. Fordyce, ed., Back Pain in the Workplace: Management of Disability in Nonspecific Conditions: A Report of the Task Force on Pain in the Workplace of the International Association for the Study of Pain (Seattle: IASP Press, 1995).

the American Medical Association’s metric of range of motionStuart McGill, Low Back Disorders: Evidence-Based Prevention and Rehabilitation (Champaign, IL: Human Kinetics, 2002), 3.

Within six weeks that worker wouldJohn Loeser, MD, in correspondence with the author, September 15, 2014.

between 1980 and 2010, the number of disabled worker beneficiaries  “The Financing Challenges Facing the Social Security Disability Insurance Program,”

Testimony by Stephen C. Goss, Chief Actuary, Social Security Administration; House Committee on Ways and Means, Subcommittee on Social Security, March 14, 2013, https://www.ssa.gov/oact/testimony/HouseWM_20130314.pdf, 4.

shut down their chronic pain rehab programs  Marek Wyszynski, physical therapist and co-founder of the Feldenkrais Institute of New York, in discussion with the author, March 17, 2012.   

The Cleveland Clinic “Chronic Pain Rehabilitation Program,” Cleveland Clinic, accessed April 1, 2015, 

http://my.clevelandclinic.org/services/neurological_institute/neurological-center-for-pain/treatment-and-services/chronic-pain-rehabilitation-program.

Mayo Clinic   “Pain Rehabilitation Center in Minnesota,” Mayo Clinic, accessed August 2, 2014, http://www.mayoclinic.org/departments-centers/physical-medicine-rehabilitation/minnesota/pain-rehabilitation-center/overview.

Dartmouth-Hitchcock’s Functional Restoration Program“Back Pain Rehabilitation: Functional Restoration Program,” Dartmouth-Hitchcock, accessed April 14, 2015, http://www.dartmouth-hitchcock.org/spine/functional_restoration_program.html.

moved from the University of Vermont  Elizabeth Ossen, Continuing Care Manager at Dartmouth-Hitchcock’s Spine Center, in correspondence with the author’s assistant, April 26, 2016.

PRIDEProductive Rehabilitation Institute of Dallas for Ergonomics, accessed December 7, 2015, http://www.pridedallas.com. 

A study at the University of Washington  Dennis C. Turk and Tasha M. Burwinkle, “Assessment of Chronic Pain in Rehabilitation: Outcomes Measures in Clinical Trials and Clinical Practice,” Rehabilitation Psychology 50 (2005): 56–64.

Jacksonville, Florida, Mayo Clinic chronic pain rehabilitation programChristopher D. Sletten et al. “Economic Analysis of a Comprehensive Pain Rehabilitation Program: A Collaboration Between Florida Blue and Mayo Clinic Florida,” Pain Medicine 16, no. 5 (2015): 898–904, doi:10.1111/pme.12679.

only sixty-six CPRP programs were certified“Find an Accredited Provider,” CARF International, accessed April 4, 2015, http://www.carf.org/advancedProviderSearch.aspx.

Rehabilitation Institute of ChicagoRehabilitation Institute of Chicago, accessed August 2, 2014, http://www.ric.org/conditions/chronic-pain/.

a twelve-thousand-square-foot facility  Tom McDonough, “Rehabilitation Institute of Chicago’s Pain Center Takes Proactive Approach,” Pain Medicine News 8, no. 4 (2010), http://www.painmedicinenews.com/ViewArticle.aspx?d_id=83&a_id=15043.

a fifth of those who enter do not graduate  Steven Stanos, DO, in discussion with the author, April 8, 2011.

“this [was] training for life”  Ibid.

one administrator calculatedDana Nelson, clinical manager, The Center for Pain Management, RIC, in discussion with author, December 29, 2011. 

“We’ve seen some patients”  Steven Stanos, DO, in discussion with the author, April 8, 2011.

Her academic research   “Caryn S Feldman, PhD,” Northwestern University Feinberg School of Medicine, accessed August 2, 2014, https://fsmweb.northwestern.edu/faculty/FacultyProfile.cfm?xid=11270.

“I try to help present people”  Caryn Feldman, PhD, in discussion with the author, April 8, 2011.

About half of lower back pain sufferers report clinical insomniaGrainne M. O’Donoghue et al., “Objective and Subjective Assessment of Sleep in Chronic Low Back Pain Patients Compared with Healthy Age and Gender Matched Controls: A Pilot Study,” BMC Musculoskeletal Disorders 10 (2009): 122, doi:10.1186/1471-2474-10-122.

“There’s no way patients are going to manage”  Steven Stanos, DO, in discussion with the author, April 8, 2011.

Gayle ParseghianGayle Parseghian, in discussion with the author, April 18, 2011.

Melinda Wilson*  Melinda Wilson*, in discussion with the author, May 10, 2011.

one hundred times more potent than morphineDrug Enforcement Administration Office of Diversion Control, Drug & Chemical Evaluation Section “Fentanyl,” March 2015,  http://www.deadiversion.usdoj.gov/drug_chem_info/fentanyl.pdf.

a mortal risk to pets, infants and toddlersU.S. Food and Drug Adminstration “Fentanyl Patch Can Be Deadly to Children,” FDA Consumer Health Information, September 2013, http://www.fda.gov/downloads/forconsumers/consumerupdates/ucm300807.pdf.

detox program at Alexian Brothers Behavioral Health’s Center for Addiction Medicine “Alexian Brothers Behavioral Health Hospital,” Alexian Brothers Health System, accessed August 2, 2014, http://www.alexianbrothershealth.org/abbhh.

When I checked in with WilsonMelinda Wilson *, in correspondence with the author, September 12, 2014.

“As I got better”  Melinda Wilson*, in correspondence with the author, December 22, 2012.

Nearly half were workers’ compensation claimants  Elizabeth Ossen, Continuing Care Manager at The Spine Center at Dartmouth Hitchcock Medical Center, in correspondence with the author’s assistant, May 8, 2015.

thirteen eight-hour sessions  Rowland Hazard, MD, in correspondence with the author, July 12, 2012.

“frankly, their jaws drop”  Rowland Hazard, MD, in discussion with the author, December 2, 2009.

“People cry”  Eric Hartmann, in discussion with the author, December 2, 2009.

“The people who get well”  Raynee Carlson, in discussion with the author, December 2, 2009.

“So, this is how you start”  Clifford, patient at Dartmouth’s Functional Restoration Program, in discussion with the author, December 2, 2009.

Then, in November 2015Laura Landro, “New Help for Back Pain,” The Wall Street Journal, November 23, 2015, http://www.wsj.com/articles/new-help-for-back-pain-1448311243.

Chapter Ten: The Back Whisperers

“the guiding principle of all exercise”  Jane Brody, “Care and Treatment of Your Aching Back,” New York Times, January 13, 1982, http://www.nytimes.com/1982/01/13/garden/personal-health-care-and-treatment-of-your-aching-back.html.

“lack of exercise that can lead to”  Jane Brody, “Personal Health,” New York Times, October 16, 1996, http://www.nytimes.com/1996/10/16/us/personal-health-819204.html.

More than two hundred thousand people search   Social media research, Lily Casura, February 13, 2016.

physical therapist Brian BeaudoinBrian Beaudoin, in discussion with the author, August 31, 2009.

Some franchised extreme fitness programs  Chris Colucci, “Does CrossFit Lead to Injury?” T Nation, September 17, 2014, https://www.t-nation.com/training/does-crossfit-lead-to-injury.

Couldn’t I just follow a video instead?  Beaudoin had made one: InMotion Spinal Health & Flexibility, DVD, http://inmotionpt.com/index.php/thoracic.

Recent studies of older adults  See i.e. Henriette van Praag, “Exercise and the Brain: Something to Chew On,” Trends in Neurosciences 32, no. 5 (2009): 283–290, doi:10.1016/j.tins.2008.12.007; Patrick J. O’Connor, Matthew P. Herring, and Amanda Caravalho, “Mental Health Benefits of Strength Training in Adults,” American Journal of Lifestyle Medicine 4, no. 5 (2010): 377–396, doi:10.1177/1559827610368771; and Timothy J. Schoenfeld et al., “Physical Exercise Prevents Stress-Induced Activation of Granule Neurons and Enhances Local Inhibitory Mechanisms in the Dentate Gyrus,” Journal of Neuroscience 33, no. 18 (2013): 7770–7777, doi:10.1523/JNEUROSCI.5352-12.2013.

“There’s this faulty logic”  Alexander Vaccaro, MD, PhD, in discussion with the author, September 21, 2009.

“Patients come in to see me”  Todd J. Albert, MD, in discussion with the author, September 21, 2009.

“This process is not about feeling good or relaxed” Joe Zarett, in discussion with the author, September 21, 2009.

“you have a little bit of scoliosis”  Joe Zarett, in discussion with the author, September 22, 2009.

one of the most complex structures of the human anatomyBruce Latimer, “The Perils of Being Bipedal,” Annals of Biomedical Engineering 33, no. 1 (2005): 3–6, doi:10.1007/s10439-005-8957-8.

his YouTube videos   “YouTube,” BackFitPro, accessed June 8, 2015, http://www.backfitpro.com/articles.php.

textbooks  “Books,” BackFitPro, accessed June 8, 2015, http://www.backfitpro.com/books.php.

scientific papers“Full Refereed Journal Papers,” Stuart M. McGill, University of Waterloo, https://uwaterloo.ca/kinesiology/people-profiles/stuart-mcgill.

McGill was in command of two laboratories  Spine Biomechanics Laboratory, University of Waterloo, accessed Jun 8, 2015, http://www.ahs.uwaterloo.ca/kin/people/SpineBiomechanicsLab.html.

the in vitro labStuart McGill, Low Back Disorders: Evidence-Based Prevention and Rehabilitation (Champaign, IL: Human Kinetics, 2002), 20.

“virtual spine”  Ibid.

the notion that back pain is caused by an inciting eventIbid., 12.

“If you start strength training”  Stuart McGill, PhD, in discussion with the author, August 5, 2010.

“Since neither workers nor athletes”  McGill, Low Back Disorders, 261.

“Our job today” Stuart McGill, PhD, in discussion with the author, August 5, 2010.

“gimping along”  Rick, in discussion with the author, August 5, 2010.

discovered McGill in a New York Times articleGretchen Reynolds, “Core Myths,” New York Times, June 18, 2009, http://www.nytimes.com/2009/06/21/magazine/21FOB-physed-t.html?_r=0.

accompanied by a videoShayla Harris, “Core Values,” New York Times Magazine video, 2:54, June 17, 2009, http://www.nytimes.com/video/magazine/1194841000095/core-values.html.

McGill’s textbook McGill, Low Back Disorders.

spinal facet arthritis  “Facet Joint Arthritis,” UCLA Spine Center, accessed June 8, 2015, http://spinecenter.ucla.edu/body.cfm?id=120.

“If you had facet arthritis”  Stuart McGill, PhD, in discussion with the author, August 5, 2010.

“When people come in with their scans”  Stuart McGill, PhD, in discussion with the author, June 19, 2010.

Stuart McGill described a young woman patient  McGill, Low Back Disorders, 7.

“Too many exercises are prescribed”  McGill, Low Back Disorders, 104.

“Not only will abdominal exercises strengthen”  Michael F. Roizen and Mehmet C. Oz, You: The Owner’s Manual, Updated and Expanded Edition (New York: Harper Collins, 2008), 124.

“‘Child’s Pose’ is killing you”  Ibid. 

“the glutes are the motor.”  Ibid. 

cat-camel stretchChad Waterbury, “An Interview with Dr. Stuart McGill - Part 1,” T Nation, March 8, 2012, https://www.t-nation.com/training/interview-with-dr-stuart-mcgill-part-1.

the “Big Three”  McGill, Low Back Disorders, 245.

“It is not enough to simply perform an exercise”  McGill, “The Painful Lumbar Spine.” 

“Your back will be bulletproof”  Stuart McGill, PhD, in discussion with the author, August 5, 2010.  

McGill recommended keeping a journalMcGill, Low Back Disorders, 206.

“Then, when you have a series of setbacks”  Stuart McGill, PhD, in discussion with the author, August 5, 2010.  

“the midnight movement”  McGill, Low Back Disorders, 209.

“marked reduction in coital frequency”  Natalie Sidorkewicz and Stuart M. McGill, “Male Spine Motion during Coitus: Implications for the Low Back Pain Patient,” Spine 39, no. 20 (2014): 1633–1639, doi:10.1097/BRS.0000000000000518.

McGill and Sidorkewicz initially recruitedSidorkewicz and McGill, “Male Spine Motion during Coitus,” and “Sex and Back Pain: Assume the Position,” The Economist, September 13, 2014, http://www.economist.com/news/science-and-technology/21616889-copulating-comfort-assume-position.

“To my amazement”  Mark Schoene, in correspondence with the author, April 6, 2010.

kinesiophobia See, e.g., Tara Kernan and James Rainville, “Observed Outcomes Associated With a Quota-Based Exercise Approach on Measures of Kinesiophobia in Patients With Chronic Low Back Pain,” Journal of Orthopaedic and Sports Physical Therapy 37, no. 11 (2007): 679–687, doi:10.2519/jospt.2007.2480.

“People believe that they have no alternative”  Unless otherwise noted, Rainville’s quotes come from: James Rainville, MD, in discussion with the author, September 15, 2009.

“That process,” said RainvillePatti Neighmond, “Pain In The Back? Exercise May Help You Learn Not To Feel It,” NPR, January 13, 2014, http://www.npr.org/sections/health-shots/2014/01/13/255457090/pain-in-the-back-exercise-may-help-you-learn-not-to-feel-it.

“We began to simplify a lot”  Lisa Childs, in discussion with the author, February 29, 2012.

In 2009, Rainville’s program moved Scott Taylor, Clinical Supervisor at New England Baptist Hospital, in discussion with author, December 10, 2012.

“A lot of it is trust-building”  Lisa Childs, in discussion with the author, February 29, 2012.

In order to effectively manage the requirements of everyday lifeJames Rainville et al., “Decreasing Disability in Chronic Back Pain through Aggressive Spine Rehabilitation,” Journal of Rehabilitation Research and Development 34, no. 4 (1997): 386, http://www.rehab.research.va.gov/jour/97/34/4/pdf/rainville.pdf.

“You lift the crates filled with metal bricksJames Rainville, interview by Judy Foreman, Everyday Health, October 1, 2008, http://www.everydayhealth.com/healthy-living/webcasts/oh-my-aching-back-your-basic-back-care-guide.aspx.

a New Yorker articleJerome Groopman, “A Knife in the Back,” The New Yorker, April 8, 2002, http://www.newyorker.com/magazine/2002/04/08/a-knife-in-the-back.

his book The Anatomy of Hope  Jerome Groopman, The Anatomy of Hope (New York: Random House, 2004).

In his late twenties, he’d just completedJerome Groopman, MD, in discussion with the author, January 9, 2013.

Groopman continued to hunt for a willing orthopedic surgeonGroopman, The Anatomy of Hope, 148.

“The desire to be healed” Jerome Groopman, MD, in discussion with the author, January 9, 2013.

“the orthopedist postulated”  Groopman, The Anatomy of Hope, 148.

“I was in bed all day”  Ibid.

“because quick flexion was risky”  Ibid., 150.

“with severely arthritic hips and knees”  Ibid., 149.

“I would lie on my back”  Ibid.

“I would shift my legs” Ibid., 150.

“One had badly hurt me”  Ibid.

“I had a narrative in my head”  Jerome Groopman, MD, in discussion with the author, January 9, 2013.

Rainville performed a detailed physical examinationGroopman, The Anatomy of Hope, 154.

“incredibly forceful personality”  Jerome Groopman, MD, in discussion with the author, January 9, 2013.

“You are worshipping the volcano god of pain”  Ibid., 155.

“unsure how to respond”  Groopman, The Anatomy of Hope, 156.

“You think what I am saying”  Ibid., 155.

“It doesn’t mean anything serious”  Ibid., 156.

“To my mind, it looked like a Roman torture chamber” Jerome Groopman, MD, in discussion with the author, January 9, 2013.

“My body was so feeble” Groopman, The Anatomy of Hope, 158.

“I’d leave the sessions depleted”  Ibid., 159.

“cacophony of pain”  Ibid.

“What happened in there” Jerome Groopman, MD, in discussion with the author, January 9, 2013.

Yoga for the Rest of Us  Peggy Cappy, Back Care Basics - Yoga for the Rest of Us, DVD, http://www.peggycappy.net/aboutvideo3.html#video.

“about to scale Mount Everest”  Jerome Groopman, MD, in discussion with the author, January 9, 2013.

Siegel’s 2001 book  Ronald D. Siegel, Michael H. Urdang, and Douglas R. Johnson, Back Sense: A Revolutionary Approach to Halting the Cycle of Chronic Back Pain, (New York: Broadway Books, 2001).

“So when I started having pain”  Unless otherwise note, Ronald Siegel’s quotes come from: Ronald D. Siegel, PsyD, in discussion with the author, August 5, 2011.

“avoid going down unproductive paths”  Ronald D. Siegel, PsyD, in discussion with the author, January 6, 2011.

“the central emotional issue”  Ibid.

“There’s nothing like an image”  Ibid.

When a surgeon told a patient never to arch his backSiegel, Back Sense, 59.

“Most people thought it would be better”  Ronald D. Siegel, PsyD, in discussion with the author, January 6, 2011.

“I’m doing things I never dreamed I’d do”  Kim Greenberg, in discussion with the author, June 25, 2013.

“First, I took tons of Vicodin”  Bruce Kaiser, in discussion with the author, April 5, 2013.

Chapter Eleven: The Right Kind of Hurt

“None of us enjoys”  Brian Nelson, “A Rational Approach to the Treatment of Low Back Pain,” Journal of Musculoskeletal Medicine 10, no. 5 (1993): 67–82, http://pnbconline.com/rational-approach-to-the.

$2,500 for twenty-four individual sessions  Brian Nelson, MD, in discussion with the author, August 1, 2012. 

115 new patients each week  Ibid. 

In 2009, Health Partners  Chris Newmarker, “HealthPartners Buys Chain of Specialty Clinics,” Minneapolis/St. Paul Business Journal, December 20, 2009, http://www.bizjournals.com/twincities/stories/2009/12/21/story6.html.

1.5 million members  “Quick Facts,” Health Partners, accessed July 15, 2015, https://www.healthpartners.com/public/about/quick-facts/.

A Journal of Orthopaedics studyBrian W. Nelson et al., “The Clinical Effects of Intensive, Specific Exercise on Chronic Low Back Pain: A Controlled Study of 895 Consecutive Patients with 1-year Follow Up,” Orthopedics 18, no. 10 (1995): 971–81, http://pnbconline.com/the-clinical-effects-of. 

nearly three hundred thousand membersWerner Kieser, in discussion with the author, October 4, 2012.

“I ended up with the arms and legs of a gorilla”  Patricia Sullivan, “Arthur Jones; Revolutionized Exercise Industry,” The Washington Post, August 30, 2007, http://www.washingtonpost.com/wp-dyn/content/article/2007/08/29/AR2007082902246.html.

In 1970, Jones founded Nautilus Sports/Medical Industries  Ibid.

How much of his autobiographyArthur Jones, “My First Half-Century in the Iron Game,” accessed July 22, 2015, http://www.arthurjonesexercise.com/First_Half/FirstHalf.html.

a fleet of surplus B-25 medium bombersBrian Johnston, “An Interview with Arthur Jones,” accessed July 22, 2015, http://www.arthurjonesexercise.com/Extras/Interview1.PDF.

He filmed and produced wildlife movies  Ibid. 

Sixty-three baby elephants  Arthur Jones, “The Future of Exercise (1997 and Beyond),” accessed July 22, 2015, http://www.arthurjonesexercise.com/Future_Exercise/7.PDF.

three rhinoceroses and a gorilla named MickeyStephen Koepp, “Muscle Man,” Time, June 10, 1985, http://www.arthurjonesexercise.com/PlayboyPeopleSI/TimeJune1985.pdf.

the muscles that supported the lumbar spineLone Hansen, et al., “Anatomy and Biomechanics of the Back Muscles in the Lumbar Spine With Reference to Biomechanical Modeling,” Spine 31, no. 17 (2006): 1888–1899, http://www.medscape.com/viewarticle/542466_4.

other gym equipment manufacturers rushed to copy it  James Graves, in discussion with the author, August 9, 2012.

Jones recognized that this first effort had failedIbid.

It locked down the pelvis and the thighsArthur Jones, The Lumbar Spine, The Cervical Spine And the Knee: Testing and Rehabilitation, reconstruction of original manual by Joseph Anderson and Brian D. Johnston, available at http://arthurjonesexercise.com/TheLumbarSpine/RehabBook.pdf, 8.

Arthur Jones sold his controlling interest in NautilusSullivan, “Arthur Jones; Revolutionized Exercise Industry.”

“Arthur Jones has a reputation” “Back in Shape,” University of Florida, accessed July 15, 2015, http://medxonline.com/pdf/backinshape.pdf.

“It was like these muscles had never been trained before”  Ibid.

“like German tanks”  Dave Carpenter, in discussion with the author, April 7, 2011.

When a hurricane struck   Ibid.

“a license to print money”  Ibid.

a utilization steering committeeIbid.

issued guidelines  MedX Utilization Steering Committee, Consensus Guidelines for the Utilization of MedX Medical Testing and Exercise Machines in Spinal Rehabilitation Programs, (Gainesville, FL: MedX Utilization Steering Committee, 1995). Guidelines were approved by the committee in September 1995 and sent to MedX practitioners in January 1996. 

Medicare lumped it into the same categoryDave Carpenter, in discussion with the author, April 7, 2011.

MedX therapy would be reimbursedIbid. 

Arthur Jones announced  Sullivan, “Arthur Jones; Revolutionized Exercise Industry.”  

Jones had already agreed to sell MedX  Thomas Dreisinger, PhD, in correspondence with the author, July 29, 2015.

Werner Kieser and his wife, Gabi, bought Werner Kieser, in correspondence with the author, August 23, 2012. 

“the deadly enemy of orthopedists”  Ibid.

“I always tell people, when we’re talking about surgery”   Brian Nelson, MD, in discussion with the author, July 21, 2010.

“One of the things we ask”  Brian Nelson, MD, in discussion with the author, August 1, 2012.

“Back pain is an incurable disease”  Brian Nelson, MD, in discussion with the author, July 21, 2010.

A military guyBrian Nelson, in correspondence with the author, January 14, 2016.

one of his colleagues would tell meThomas E. Dreisinger, PhD, in discussion with the author, August 29, 2012; and in correspondence with the author’s assistant, July 28, 2015. 

“I prefer to say”  Brian Nelson, MD, in discussion with the author, April 7, 2011.

He looked for evidence of pathology  Brian Nelson, “A Rational Approach to the Treatment of Low Back Pain,” Journal of Musculoskeletal Medicine 10, no. 5 (1993): 67–82, http://pnbconline.com/rational-approach-to-the.

“If you had recent eye or abdominal surgery”  Brian Nelson, MD, in discussion with the author, July 21, 2010.

“We believe in objective measurements”  Ibid. 

“The kind of exercise done in health clubs”  Brian Nelson, MD, in discussion with the author, April 7, 2011.

“I often hear, ‘You guys almost killed me,’”  Brian Nelson, MD, in discussion with the author, April 7, 2011.

“We tell them that they will be worse”  Brian Nelson, MD, in discussion with the author, July 21, 2010.

“We want people to understand”  Brian Nelson, MD, in discussion with the author, April 7, 2011.

“It was the spring of 2008”  Heather Barnes, in discussion with the author, April 7, 2011.

the Consumer Reports issue that ranked spine surgery  “Treatment Traps to Avoid,” Consumer Reports, November 2007, http://www.consumerreports.org/cro/2012/08/treatment-traps-to-avoid/index.htm. 

Taken alone an elevated ESR level“Diagnosis of Ankylosing Spodylitis,” Spodylitis Association of America, accessed November 26, 2016, http://www.spondylitis.org/About-Spondylitis/Types-of-Spondylitis/Ankylosing-Spondylitis/Diagnosis. 

The gene is found in 8 percent  Ibid. 

Three PNBC clinics have CORE fitness programs  “About PNBC Core,” Physicians Neck and Back Center website, accessed July 23, 2015, http://pnbconline.com/about-core.

In 2013, sales throughout the franchises  Werner Kieser, in correspondence with the author’s assistant, July 30, 2015. 

For $1,050 a year  Werner Kieser, in discussion with the author, October 9, 2012.

When Werner Kieser, who is well into his seventies, picked me up  Unless otherwise noted, information about the Kiesers and Kieser Training come from this visit, October 9, 2012. 

“I realized that he was”  Werner Kieser, in correspondence with the author, August 23, 2012.

“Although I was quite strong and fit”  Ibid. 

Jumping on the treadmill for a half hour Hans Hoppeler et al., “Molecular Mechanisms of Muscle Plasticity with Exercise,” Comprenhensive Physiology 1 (2011):1383–1412, doi:10.1002/cphy.c100042.

Woody Allen’s infamous “orgasmatron”  “Sleeper - The Orgasmatron,” YouTube video, 1:59, scenes from Woody Allen’s 1973 film Sleeper, posted by KingofStrangePersons, June 17, 2011, https://www.youtube.com/watch?v=Isrd7E5nzIQ.

who said that Arthur Jones had “captured” him”  Thomas E. Dreisinger, PhD, in discussion with the author, August 29, 2012.

billions of dollars in lost work days  “Back in Shape,” University of Florida, accessed July 15, 2015, http://medxonline.com/pdf/backinshape.pdf.

Mooney described these outcomesVert Mooney et al., “The Effect of Workplace Based Strengthening on Low Back Injury Rates: A Case Study in the Strip Mining Industry,” Journal of Occupational Rehabilitation 5, no. 3 (1995), doi: 10.1007/BF02109956.

“one brief exercise session each week”  Jones, The Lumbar Spine, 42.

The buzzword in health care was “EBM”  Thomas E. Dreisinger, PhD, in discussion with the author, August 29, 2012.

With a proprietary computer software packageHenry A. Holzapfel, chief operating officer of Pure HealthyBack, in discussion with the author, September 20, 2012.

Pure HealthyBack opened its first facilityIbid.

The second Pure HealthyBack clinicRonald Wisneski, MD, in discussion with the author, August 26, 2014.

DelawareLeonard J. Paulozzi, Karin A. Mack, and Jason M. Hockenberry, “Vital Signs: Variation Among States in Prescribing of Opioid Pain Relievers and Benzodiazepines — United States, 2012,” Morbidity and Mortality Weekly Report 63, no. 26 (2014): 563–568, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6326a2.htm.

The investigation’s outcomes revealed  Ronald Wisneski, MD, in discussion with the author, August 26, 2014.

“MedX by itself is not a panacea” Ibid. 

“I do think there’s some progress being made” Brian Nelson, in discussion with the author, October 14, 2015. 

Chapter Twelve: The Posture Mavens

In the New YorkerSusan Orlean, “The Walking Alive,” The New Yorker, May 20, 2013, http://www.newyorker.com/magazine/2013/05/20/the-walking-alive.

“The erect posture looks very nice”  A.C. Mandal, “Balanced Sitting Posture on Forward Sloping Seat,” http://www.acmandal.com, accessed July 22, 2016. 

Scottish and Canadian researchers took measurements   Radiological Society of North America, “Aching Back? Sitting Up Straight Could Be the Culprit,” news release, November 27, 2006, https://www2.rsna.org/timssnet/media/pressreleases/pr_target.cfm?ID=294.

Beyond that, the conventional position  Bonnie Berkowitz and Patterson Clark, “The Health Hazards of Sitting,” The Washington Post, January 20, 2014, http://apps.washingtonpost.com/g/page/national/the-health-hazards-of-sitting/750/.

“No chair is perfect”  Galen Cranz, The Chair: Rethinking Culture, Body, and Design (New York: W. W. Norton & Company, 2000), 184.

 “The best posture”  Peter Opsvik, Rethinking Sitting (New York: W. W. Norton & Company, 2008), 37.

“When you are working in chairs that let you move”  David Kahl, in discussion with the author, April 16, 2014.

“our habits, our jobs, our social situations, our general dispositions”  Deane Juhan, Job’s Body (Barrytown, NY: Barrytown/Station Hill Press, 2003), 220. 

there were two aspects to this form of training  Marek Wyszynski, “The Feldenkrais Method for People with Chronic Pain,” The Pain Practitioner 20, no. 1 (Spring 2010): 56.

“rediscover the free, effortless sense of movement”  Dr. Andrew Weil, “Moving with Ease,” Self-Healing, May 1998, accessed July 27, 2016, http://www.bettermovement.com/wp/wp-content/uploads/2010/12/Weil_MovingwithEase.pdf.

physical therapist Marek WyszynskiWyszynski’s practice is Physical Therapy & Feldenkrais NYC, http://bettermovement.com. For the Feldenkrais Institute of New York, visit http://feldenkraisinstitute.com.

In our initial conversationMarek Wyszynski, in discussion with the author, March 17, 2012.   

a useful one called Learn to LearnMoshé Feldenkrais, Learn to Learn (San Diego, CA: Feldenkrais Resources, 1980).

born in what is now Ukraine  Biographical information about Moshe Feldenkrais comes from Elizabeth Beringer, ed., Embodied Wisdom: The Collected Papers of Moshe Feldenkrais (Berkeley, CA: North Atlantic Books, 2010); and Mark Reese, “A Concise Biography of Moshe Feldenkrais,” March 19, 2004, accessed July 27, 2016, http://www.feldenkrais.com/Files/download/moshe_bio.pdf.

“heavy water”  “Nuclear Power Reactors,” World Nuclear Association, updated May 14, 2012, http://www.world-nuclear.org/info/inf32.html.

From the beginning, he focused on  Marek Wyszynski, in correspondence with the author, May 6, 2012.

eight hundred hours of rigorous training“Professional Training,” The Feldenkrais Method of Somatic Education, accessed August 31, 2015, http://www.feldenkrais.com/professional-training. 

a cost of about $4,500“Feldenkrais Teacher Training Program,” Optimal Moves, accessed August 31, 2015, accessed July 27, 2016, http://www.optimalmoves.com/pg23.cfm.

Since 1999, the number of teachers worldwide  David Zemach-Bersin (co-founder, Feldenkrais Institute of New York), in correspondence with the author’s assistant, August 7, 2012; and Marek Wyzynski, in discussion with the author, March 17, 2012.

there was no right way  Wyszynski, “The Feldenkrais Method for People with Chronic Pain,” 56–61.

 “Do everything slowly” Feldenkrais, Learn to Learn.

“A year ago”  Courtney King, in discussion with the author, April 4, 2012. 

“So many people have been injured”  Deborah Bowes, in discussion with the author, June 12, 2010.

“This is about finding out”  Ibid.

“Some individuals may perceive”  Ida Rolf, Rolfing and Physical Reality (Rochester, VT: Healing Arts Press, 1978); and “Quotes from Dr. Rolf,” Rolf Method of Structural Integration, accessed December 14, 2015, http://www.structuralintegration.com/quotes/quotes.html. 

“sleeve sessions”  “Frequently Asked Questions: What Is the Rolfing Ten-Series?” Rolf Institute of Structural Integration, accessed December 14, 2015, http://www.rolf.org/rolfing_faq.php.

two strands of fasciaeChristopher McDougall, “Understanding Your Muscles: Everything You Know About Muscle Is Wrong,” Men’s Health, September 4, 2009, http://www.menshealth.com/fitness/understanding-your-muscles.

“If there is constant excess muscle tension”  Thomas Myers, in correspondence with the author, September 7, 2012.

she was a 1960s flower childUnless otherwise noted, information on Ida Rolf comes from Mirka Knaster, Discovering the Body’s Wisdom (New York: Bantam, 1996).

“the rehabilitation of internal subjective awareness” Michael Salveson, in discussion with the author, December 23, 2009.

“It’s is a lot like trying to calm down a mob” James Schwartz, in discussion with the author, January 26, 2010.

When the small intestine  James Schwartz, in correspondence with the author, September 7, 2012.

“I was suddenly in control”  David Homan, executive director of the America-Israel Cultural Foundation, in a discussion with the author, March 19, 2010.

F.M. Alexander, a Tasmanian actor and oratorBiographical information on F.M. Alexander comes from John B. Harer and Sharon Munden, The Alexander Technique and Resource Book (Lanham, MD: Scarecrow Press, 2009).

“Those of us who are conspicuously slovenly”  James Harvey Robinson, “The Philosopher’s Stone,” The Atlantic Monthly, vol. 123, January–June 1919, https://books.google.com/books?id=SmACAAAAIAAJ&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false, 477–478.

a group of nineteen doctors composed and signed a letterJ. R. Caldwell et al., “Constructive Conscious Control,” letter, British Medical Journal 1, no. 3986 (1937): 1137.2.  

But seventy-one years later, the BMJ publishedPaul Little et al., “Randomised Controlled Trial of Alexander Technique Lessons, Exercise, and Massage (ATEAM) for Chronic and Recurrent Back Pain,” British Medical Journal 337 (2008): a884, doi:10.1136/bmj.a884.

it generated sixty-seven such commentsSee, e.g. Tim Germon, “Are Scientific Standards Being Maintained by the BMJ & MRC?,” letter to the editor, British Medical Journal, August 24, 2008, http://www.bmj.com/rapid-response/2011/11/02/are-scientific-standards-being-maintained-bmj-amp-mrc.

Paul Watson“British Pain Society Head Comments on Ousting of Paul Watson,” Chartered Society of Physiotherapy, August 27, 2009, http://www.csp.org.uk/news/2011/02/25/british-pain-society-head-comments-ousting-paul-watson. 

“an extraordinary row” “Low Back Pain in Adults: Early Management,” NICE guidelines [CG88] Published date: May 2009, https://www.nice.org.uk/guidance/cg88/chapter/guidance; and Mark Pownall, “British Pain Society President Ousted after Row over NICE Guidelines,” Pulse, July 31, 2009, http://www.pulsetoday.co.uk/british-pain-society-president-ousted-after-row-over-nice-guidelines/11010745.fullarticle.

“When you’ve been in chronic pain for years” Judith Stern, in discussion with the author, December 4, 2009.

 In 2015, nearly twenty million people“New Study Finds More Than 20 Million Yogis in U.S.,” Yoga Journal, December 5, 2012, http://www.yogajournal.com/uncategorized/new-study-finds-20-million-yogis-u-s/.

worth $10 billion  Ibid. 

a Columbia College of Physicians and Surgeons survey  William J. Broad, The Science of Yoga (New York: Simon & Schuster, 2012), 134; and Loren Fishman, Ellen Saltonstall, and Susan Genis, “Understanding and Preventing Yoga Injuries,” International Journal of Yoga Therapy 19, no. 1 (2009): 47–53, doi:10.17761/ijyt.19.1.922087896t1h2180.

Improperly executed forward bendsSee, e.g., Roger Cole, “Protect the Disks in Forward Bends and Twists,” Yoga Journal, August 28, 2007,

http://www.yogajournal.com/for_teachers/1012.

often certified in one hundred hours of trainingBroad, The Science of Yoga, 135. 

Some have done their coursework onlineIbid.

The outcomes, published in the Archives of Internal Medicine and the journal PainKaren J. Sherman et al., “A Randomized Trial Comparing Yoga, Stretching, and a Self-care Book for Chronic Low Back Pain,” Archives of Internal Medicine 171, no. 22 (2011): 2019–2026, doi:10.1001/archinternmed.2011.524; and Kimberly Anne Williams et al., “Effect of Iyengar Yoga Therapy for Chronic Low Back Pain,” Pain 115, no. 102 (2005):107–117, doi:10.1016/j.pain.2005.02.016; Kimberly Williams, et al., “Evaluation of the Effectiveness and Efficacy of Iyengar Yoga Therapy on Chronic Low Back Pain,” Spine 34, no. 19, (2009): 2066–2076, doi:10.1097/BRS.0b013e3181b315cc.

about five years before aspiring Iyengar teachersBroad, The Science of Yoga, 135.

only two Iyengar instructors“Find a Teacher,” Iyengar Yoga National Association of the United States, accessed September 2, 2015, https://secure.iynaus.org/search.

Patricia Walden “About Patricia,” accessed December 14, 2015, http://www.yoganow.net/About_Patricia.html.

Manouso Manos “About Manouso,” The Abode of Iyengar Yoga, accessed September 2, 2015, http://www.manouso.com/manouso.htm.

“But when that needle went into the disc”  Lisa Miller, in discussion with the author, April 25, 2010.

“Some people call it ‘hope for the hopeless,’”  Lisa Miller, in discussion with the author, June 11, 2010.

“There is a hardening that has taken place”  Manouso Manos, in discussion with the author, June 11, 2010.

“This thing I do is an amazing kind of dance”  Ibid. 

Although twenty-five million people pursue Pilates“Is Pilates Bad for Your Back?” Daily Mail, March 7, 2007, http://www.dailymail.co.uk/health/article-440309/Is-Pilates-bad-back.html.

Joseph Pilates, who created the practice“An Exercise in Balance: The Pilates Phenomenon,” Pilates Method Alliance, accessed September 2, 2015, http://www.pilatesmethodalliance.org/i4a/pages/index.cfm?pageid=3277.

no known benefit to “drawing your navel to your spine,”  “Is Pilates Bad for Your Back?” Daily Mail.

Joseph Pilates trained his teachers“An Exercise in Balance: The Pilates Phenomenon,” Pilates Method Alliance.

As a dance medicine specialistElizabeth Larkam, in discussion with the author’s assistant, August 17, 2015

Larkam had second thoughtsElizabeth Larkam, in discussion with the author, March 23, 2011.

“Unlike most trainers”  Elizabeth Larkam, in discussion with the author, March 23, 2011.

The Gyrotonic protocol, developed by Juliu Horvath  “The Gyrotonic® & Gyrokinesis® Methods,” Gyrotonic website, accessed December 14, 2015, https://www.gyrotonic.com/article.aspx.

Many of the 10,500 trainers  Ibid. 

A 2015 study showed further benefits  Michael R. Irwin, “Cognitive Behavioral Therapy and Tai Chi Reverse Cellular and Genomic Markers of Inflammation in Late-Life Insomnia: A Randomized Controlled Trial,” Biological Psychiatry 78, no. 10 (2015): 721–729, http://dx.doi.org/10.1016/j.biopsych.2015.01.010.

“I also worked a lot”  Dwight Etheridge, in discussion with the author, August 21, 2015. 

more than 2.3 million Americans practice  Liz Szabo, “Tai Chi May Ease Fibromyalgia Pain,” USAToday, August19, 2010, http://usatoday30.usatoday.com/yourlife/health/medical/alternative/2010-08-19-taichi19_st_N.htm.

The movements are circular and never forced   “The Health Benefits of Tai Chi,” Harvard Women’s Health Watch, May 1, 2009, http://www.health.harvard.edu/staying-healthy/the-health-benefits-of-tai-chi.

Tai Chi is practiced with relaxed hipsD Q Xu, J X Li, and Y Hong, “Effects of Long Term Tai Chi Practice and Jogging Exercise on Muscle Strength and Endurance in Older People,” British Journal of Sports Medicine 40, no. 1 (2006): 50–54.

doi:10.1136/bjsm.2005.019273.

“It took a while for the aches and pains”  Nicholas Griepentrog, in discussion with the author, December 5, 2015. 

Their first study, a placebo-controlled trialAmanda M. Hall, et al., “A Randomized Controlled Trial of Tai Chi for Long-term Low Back Pain (TAI CHI): Study Rationale, Design, and Methods,” BMC Musculoskeletal Disorders 10, no. 1 (2009): 55, doi:10.1186/1471-2474-10-55.

The follow-up randomized controlled trialAmanda M. Hall et al. “Tai Chi Exercise for Treatment of Pain and Disability in People with Persistent Low Back Pain: A Randomized Controlled Trial,” Arthritis Care & Research, 63, no. 11 (2011): 1576–1583, doi:10.1002/acr.20594.

For $30, Lam sells an eight-hour DVD  Paul Lam, Tai Chi for Arthritis (Tai Chi Productions, 1996), DVD. Available at: http://us.taichiproductions.com/dvds/arthritis/12-lessons-free-first-lesson/.

In April 2013, the U.S. Centers for Disease Control and Prevention  Paul Lam, Pamela Kircher and Maureen Miller, “Tai Chi for Fall Prevention,” Tai Chi for Health Institute, 2013, accessed August 20, 2015, http://taichiforhealthinstitute.org/tai-chi-for-fall-prevention/.

The Arthritis Foundation of AustraliaHall et al., “Tai Chi Exercise for Treatment of Pain and Disability.”

“The philosophy is ‘relax and be comfortable’”  “Best Exercise for Balance: Tai Chi,” Harvard Health Letter 40, no. 3 (2015): 4, http://www.health.harvard.edu/staying-healthy/best-exercise-for-balance-tai-chi.

“Do everything slowly”  Feldenkrais, Learn to Learn.

“neck to be free so that the head can go forward and up” Judith Stern, in discussion with the author, December 4, 2009.

“to suspend the spine like a string of pearls from heaven”  Peter M. Wayne and Mark L. Fuerst, The Harvard Medical School Guide to Tai Chi: 12 Weeks to a Healthy Body (Boston: Shambhala, 2013), 46.