Ever since a hard fall while horseback riding as a teenager, Cathryn Jakobson Ramin has had intermittent back pain.

It got worse over the years. While traveling the country to promote her first book, Ramin found herself clutching a podium while giving a speech—and not out of nervousness. She missed a train to Philadelphia because she couldn’t make it up the three large steps it would take to board. A long-desired trip to Machu Picchu seemed impossible.

Ramin’s search for better treatments, paired with four decades as an investigative journalist, resulted in her latest book, “Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery.”

The book’s conclusions are a sweeping indictment of a $100 billion industry: There’s a dearth of evidence supporting medical and surgical interventions in most cases of back pain, she says, from surgery to injections to opioids.

How back pain is treated has broad implications for the more than 77 million people in the U.S. who have experienced it. For about 20% of them, symptoms persist in the long term as a chronic condition.

Back pain is the most common cause of job-related disability and a leading contributor to missed work days, according to the National Institute of Health. The condition appears to be getting worse in the U.S.: in 2010, it jumped to third place in a ranking of most burdensome diseases in terms of mortality or poor health.

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Ramin spoke to MarketWatch in New York City about where back pain comes from, what helps and what doesn’t and who exactly is profiting from all of this.

Below is an edited version of the conversation.

MarketWatch: People assume when someone is sick or has a condition that it can be alleviated with medication or surgery. With back pain, is that the case?

Cathryn Jakobson Ramin: No. Back pain has been medicalized very intentionally by numerous stakeholders in a very large industry.

It was not until the early 1980s that there was a surgical device manufactured that would make it possible for your average orthopedic surgeon to do a spine surgery without catastrophic outcomes.

Back pain used to be something that was a part of life, something that would pass, did not require nor should have medical intervention.

But that changed because of the invention of that particular piece of instrumentation, followed by a tremendous number of devices that continue to come onto the market today, all of which make tremendous amounts of money for the device manufacturers, for the hospital, for surgeons and for device manufacturers, for insurance companies.

The numbers have grown significantly over the years, with more and more spinal fusion procedures, although there has never been good evidence supporting those procedures or epidural steroid injections or standard, insurance-paid, cookie cutter physical therapy.

Patients are expending tons of money, they don’t get good outcomes and they don’t get past the problem.

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Cathryn Jakobson Ramin is the author of the May book “Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery.” HOWARD SCHATZ

MW: Your book looks at the range of back pain interventions out there. Which ones does it cover?

CJR: The first half of the book is heavy duty investigative reporting, looking at all of what is typically offered to patients, whether that is physical therapy, chiropractic, injections, MRI, surgery, opioids, other drugs, all of those. And each one of those is examined and debunked for extreme lack of evidence.

The second half of the book is entirely devoted to what does work.

MW: Did you try some of these? What was your experience, and how much did you spend on them?

CJR: Over the years I have done several sessions of physical therapy, each one of those being four or five different meetings with a physical therapist.

I had tried every type of exercise, joined a gym, had a trainer, done Pilates and yoga, been to chiropractors, had massage, all kinds of medical massage—all costly, none of it paid for by insurance. I had spent thousands and thousands of dollars, over many years, which most people don’t have.

But the problem was that it didn’t help me. Every day that you can’t go to work and you can’t go play ball with your kids and you can’t go on a trip, you have to stay home because you can’t stand to sit in a car, every single time you do that, that’s opportunity cost.

Chronic pain conditions, which includes back pain, last longer than three months.

MW: Where does back pain come from? Is all back pain created equal?

CJR: There are circumstances that are structural, that involve the skeleton. Those things require surgery, it’s not elective.

But for most people, and the readers of this book, what we’re talking about is a cranky back that needs exercise.

What’s also very important is the concept of central sensitization, a very important idea that is overtaking this industry and the way that people think about managing not only back pain but other pain. In the case of chronic back pain, the problem is no longer in the spine, it’s not in the bones, it’s in the brain.

The notion is that in order to be able to get past the pain, you’re going to have to convince the brain that the emergency is over.

One of the reasons exercise works well is not only that you’re moving around and you’re convincing yourself you can move, but that you’re letting your brain get the message that there’s no emergency, you can turn it off. It’s really not just the physical, that’s the thing.

MW: Is it just any kind of exercise?

CJR: In the grand range of exercise classes that exist, there’s dozens and dozens of new names for exercise classes, right? A lot of them are really rigorous, and people like that, especially younger people.

This is all fine for everyone who does not have a back problem. CrossFit is fine for people who do not have back problems, except for the best place for a chiropractor to set up is across the street from a CrossFit unit, because people get hurt all the time.

But what people just don’t realize is if you have a problem with your back, it typically means that you have failed to balance out your muscles properly. What you’re looking for, beyond anything else, is a way to start using the muscles that need to be used to support your spine, and those muscles are not where you think they are.

When you start looking for ways to exercise, you’re looking for approaches that are going to build those glutes and build your core and improve your posture.

We talk in the book about finding a “back whisperer,” and we talk about other approaches, such as Feldenkrais, Iyengar yoga, tai chi, and Alexander technique.

It’s hard to do alone, because back pain patients cheat. People with back pain cheat terrifically, and I do that myself. It hurts.

When you’re in physical therapy, you hear very often ‘If it hurts, stop.’ Well the one thing about back pain, which I’m just terribly sorry to say, if you go by ‘If it hurts, don’t do it,’ you’re not doing anything—you’re getting on the couch.

Everything is going to hurt in the beginning, and it is a matter of learning the difference between serious pain and ‘this is hard exercise’ pain, and that is very difficult for people to discern by themselves. So they really need to be in the hands of someone who is going to assure them that there’s no chance of them dying while doing this.

MW: You mention that exercise also cause back problems, right?

CJR: Right. Because in group exercise classes, typically there is no way the instructor is going to be able to keep that detailed an eye. If you’re not doing it right you’re not helping yourself at all; you’re wasting a lot of time and a lot of money.

MW: What are the costs of these effective interventions?

CJR: It depends on where you are, it really does.

In the book I talk a lot about Stuart McGill, he is a spine biomechanist, now retired but for many years at University of Waterloo in Canada. He devised something called ‘The Big Three,’ a set of three exercises that really balance and strengthen the muscles that need to be strong. And they’re free.

Feldenkrais can be very reasonable — $20 a session or less. It’s inexpensive, it will get them moving, it may allow them enough mobility so they can move into some other forms of exercise.

MW: Why are all these procedures and treatments being done if there isn’t good evidence for them?

CJR: It’s just business. It’s a business, and it does not take into consideration the welfare of the patient. Across the board in medicine this is happening, it’s just that spine medicine is the poster child for what is wrong.

But I should point out that all of this is changing, and changing quickly. In the period of time I wrote the book, we went from basically very few people having any willingness to say there’s a problem with prescribing opioids. Now we have a full understanding that opioids should never be prescribed for back pain.

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People were typically and standardly receiving injections, now we understand that they have risks and they are frequently not successful. And when I started there was already some thinking that spinal fusion was probably a bust, and now that is very well understood.

So there has been progress, but I do believe that under this current administration we’re going to see a reversal of that.

MW: We’ve talked about what to do when you have back pain, but what about if you don’t? Can you do anything to prevent getting it?

CJR: If you don’t have it at all, I don’t think this is time to be worried.

But if you are occasionally having an episode of back pain, this is a really good time to start dealing with it, before you are decked by it. And certainly before you have decided that you’re in so much pain you can’t move. And then you become very deconditioned, and now you’re starting from a place that’s going to be a long climb.

If you do have pain, don’t take it lying down. Find yourself a physical therapist, according to the specifications in my book, and when that physical therapist says you’re ready to go into an exercise program—where you will need to stay. You can’t just ignore it.