Why the Most Challenging Back and Neck Pain Often Responds Best to Individualized Physical Therapy

Lessons from Crooked — and What We See Every Day at MMPT

If you’ve been living with stubborn back or neck pain — the kind that hasn’t budged after surgery, injections, chiropractic adjustments, or even other rounds of physical therapy — you’re not alone. And more importantly, you’re not out of options.

Cathryn Jakobson Ramin spent six years investigating the back pain industry for her bestselling book Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery. What she uncovered should matter to anyone who’s been told “we’ve tried everything.”

Because the truth is, in most cases, we haven’t.

The Back Pain Industry: A $100 Billion Problem

Ramin’s investigation revealed an uncomfortable reality: the United States spends over $100 billion per year on back pain treatment, yet outcomes for many patients remain poor. Spinal fusion alone accounts for $40 billion annually — making it the most expensive elective surgery in the country at roughly $80,000 per procedure.

And yet, spinal fusion has a reported success rate of only about 35%.

Perhaps the most striking finding from the book: when Ramin asked spine surgeons whether they themselves would undergo the procedures they perform on patients, nearly all of them said no.

A 2025 report from the Lown Institute put an even finer point on the problem: U.S. hospitals performed over 200,000 unnecessary back surgeries on Medicare patients over just three years — one low-value procedure every eight minutes — costing Medicare more than $1.9 billion.

Why Surgeries, Injections, and Adjustments Often Fall Short

This isn’t about vilifying any single treatment. Each has a role. But the research tells a clear story about their limitations for complex, chronic spine pain:

Surgery: Diminishing Returns

Failed Back Surgery Syndrome (FBSS) affects an estimated 10–46% of lumbar surgery patients. What’s worse, repeat surgeries offer diminishing odds of success:

• 1st surgery: ~50% success rate
• 2nd surgery: ~30%
• 3rd surgery: ~15%
• 4th surgery: ~5%

Surgeons themselves acknowledge that in an estimated 80–85% of cases, they cannot pinpoint the exact source of a patient’s pain — even when imaging shows structural abnormalities.

Injections: Temporary Relief, Not a Solution

Epidural steroid injections provide meaningful short-term relief for some patients, but the evidence for long-term benefit is limited. Studies show that approximately 40% of patients experience no treatment effect at all, and for chronic pain lasting 12 months or more, injections offer minimal benefit according to the American Academy of Family Physicians.

When injections do work, the relief typically lasts weeks to months — and patients often require 3–4 procedures per year just to maintain that temporary improvement.

Chiropractic: Helpful for Some, Limited for Complex Cases

Chiropractic manipulation can be a reasonable frontline intervention for acute, uncomplicated back pain. But for complex chronic conditions involving multiple pathologies, central sensitization, or post-surgical pain, the evidence supporting manipulation alone is more limited. A 2022 review in Frontiers in Pain Research found that the evidence for spinal manipulation’s efficacy in chronic pain cases remains inconclusive.

Why Individualized Physical Therapy Is Different

Here’s what Ramin ultimately concluded — and what we see confirmed with our patients at Mindful Movement PT every single day:

For most people with chronic back and neck pain, the answer isn’t another procedure. It’s better movement.

But not just any movement. And not the kind of cookie-cutter PT where you do 10 minutes on a bike and get sent home with a generic handout. We’re talking about individualized, specialized physical therapy that addresses why you’re in pain — not just where it hurts.

What the Research Shows

The evidence supporting individualized PT approaches for the most challenging spine cases is strong and growing:

Targeted Exercise and Movement Retraining

High-intensity, supervised exercise protocols lead to faster improvement than generic low-intensity programs. Motor control exercises — which retrain how your deep trunk muscles activate and coordinate — show moderate-quality evidence for reducing both pain intensity and disability. Starting structured rehabilitation even after surgery improves outcomes significantly compared to no formal rehab program.

Pain Neuroscience Education

Many of our patients arrive believing their spine is fragile, damaged, or “bone on bone.” This fear itself becomes a driver of pain. Pain neuroscience education (PNE) — helping patients understand how pain works — produces clinically significant reductions in pain intensity, fear of movement, and catastrophic thinking. Recent umbrella reviews with meta-analyses have confirmed that PNE combined with exercise is among the most effective approaches for chronic non-specific low back pain.

Hands-On Manual Therapy

When combined with exercise, manual therapy provides greater improvements in short-term pain, function, and disability than exercise alone. There is moderate-to-strong evidence supporting manual therapy’s effectiveness, particularly for chronic low back pain.

Dry Needling

For patients with persistent myofascial trigger points and muscle guarding, dry needling combined with physical therapy shows superior pain reduction compared to physical therapy alone — providing an additional tool for cases that haven’t responded to conventional approaches.

The Whole-Person Approach

The most compelling evidence comes from combined approaches: exercise rehabilitation paired with cognitive-behavioral strategies and patient goal-setting produces significant improvements in disability, pain, fear avoidance, mental health, and quality of life. This is exactly how we practice at MMPT.

What We See at MMPT

Many of the patients who walk through our doors at Mindful Movement PT have already been through the gauntlet. They’ve had one, two, sometimes three surgeries. They’ve tried rounds of injections. They’ve been adjusted hundreds of times. They’ve done physical therapy that felt like going through the motions.

And they still hurt.

What they haven’t had is a physical therapist who spent an hour understanding their full story — their movement patterns, their pain triggers, their fears, their goals. They haven’t had someone who combined advanced manual therapy with progressive loading, neuroscience-based pain education, and a genuine plan for getting them back to the life they want.

That’s what advanced PT looks like. And that’s why it works when other approaches haven’t.

The Bottom Line

The back pain industry has spent decades defaulting to increasingly expensive, increasingly invasive interventions — often without strong evidence to support them. As Cathryn Jakobson Ramin documented in Crooked, the system isn’t always set up to guide you toward what’s most likely to help.

The research is clear: for the most challenging back and neck pain problems, advanced physical therapy isn’t the last resort — it should be the first call.

If you’ve been told you’ve exhausted your options, we’d respectfully disagree. Schedule a consultation at Mindful Movement PT or call/text me at (385) 332-4939 and let’s find out what’s possible.

References include: Cathryn Jakobson Ramin, Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery (HarperCollins, 2017); Lown Institute, “Unnecessary Back Surgery in Medicare” (2025); Cochrane Database of Systematic Reviews; JOSPT Clinical Practice Guidelines; Global Burden of Disease Study, The Lancet (2023). Specific studies cited are available upon request.

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• Why Challenging Back & Neck Pain Responds to Individualized PT
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