Back pain is a tricky beast. Most Americans will at some point have a problem with their backs. And for an unlucky third, treatments won't work, and the problem will become chronic.
Believe it or not, there are a few cultures in the world where back pain hardly exists. One indigenous tribe in central India reported essentially none. And the discs in their backs showed little signs of degeneration as people aged.
An acupuncturist in Palo Alto, Calif., thinks she has figured out why. She has traveled around the world studying cultures with low rates of back pain — how they stand, sit and walk. Now she's sharing their secrets with back pain sufferers across the U.S.
About two decades ago, Esther Gokhale started to struggle with her own back after she had her first child. "I had excruciating pain. I couldn't sleep at night," she says. "I was walking around the block every two hours. I was just crippled."
Gokhale had a herniated disc. Eventually she had surgery to fix it. But a year later, it happened again. "They wanted to do another back surgery. You don't want to make a habit out of back surgery," she says.
This time around, Gokhale wanted to find a permanent fix for her back. And she wasn't convinced Western medicine could do that. So Gokhale started to think outside the box. She had an idea: "Go to populations where they don't have these huge problems and see what they're doing."
Over the next decade, Gokhale went to cultures around the world that live far away from modern life. She went to the mountains in Ecuador, tiny fishing towns in Portugal and remote villages of West Africa.
"I went to villages where every kid under age 4 was crying because they were frightened to see somebody with white skin — they'd never seen a white person before," she says.
Gokhale took photos and videos of people who walked with water buckets on their heads, collected firewood or sat on the ground weaving, for hours.
"I have a picture in my book of these two women who spend seven to nine hours everyday, bent over, gathering water chestnuts," Gokhale says. "They're quite old. But the truth is they don't have a back pain."
She tried to figure out what all these different people had in common. The first thing that popped out was the shape of their spines. "They have this regal posture, and it's very compelling."
And it's quite different than American spines.
If you look at an American's spine from the side, or profile, it's shaped like the letter S. It curves at the top and then back again at the bottom.
But Gokhale didn't see those two big curves in people who don't have back pain. "That S shape is actually not natural," she says. "It's a J-shaped spine that you want."
In fact, if you look at drawings from Leonardo da Vinci — or a Gray's Anatomy book from 1901 — the spine isn't shaped like a sharp, curvy S. It's much flatter, all the way down the back. Then at the bottom, it curves to stick the buttocks out. So the spine looks more like the letter J.
"The J-shaped spine is what you see in Greek statues. It's what you see in young children. It's good design," Gokhale says.
So Gokhale worked to get her spine into the J shape. And gradually her back pain went away.
Now her list of clients is impressive. She's helped YouTube CEO Susan Wojcicki and Matt Drudge of the Drudge Report. She has given classes at Google, Facebook and companies across the country. In Silicon Valley, she's known as the "posture guru."
Each year, doctors in the Bay Area refer hundreds of patients to Gokhale. One of them is Dr. Neeta Jain, an internist at the Palo Alto Medical Foundation. She puts Gokhale's method in the same category as Pilates and yoga for back pain. And it doesn't bother her that the method hasn't been tested in a clinical trial.
"If people are finding things that are helpful, and it's not causing any harm, then why do we have to wait for a trial?" Jain asked.
But there's still a big question looming here: Is Gokhale right? Have people in Western cultures somehow forgotten the right way to stand?
Scientists don't know yet, says Dr. Praveen Mummaneni, a neurosurgeon at the University of California, San Francisco's Spine Center. Nobody has done a study on traditional cultures to see why some have lower rates of back pain, he says. Nobody has even documented the shape of their spines.
"I'd like to go and take X-rays of indigenous populations and compare it to people in the Western world," Mummaneni says. "I think that would be helpful."
But there's a whole bunch of reasons why Americans' postures — and the shape of their spines — may be different than those of indigenous populations, he says. For starters, Americans tend to be much heavier.
"If you have a lot of fat built up in the belly, that could pull your weight forward," Mummaneni says. "That could curve the spine. And people who are thinner probably have less curvature" — and thus a spine shaped more like J than than an S.
Americans are also much less active than people in traditional cultures, Mummaneni says. "I think the sedentary lifestyle promotes a lack of muscle tone and a lack of postural stability because the muscles get weak."
Everyone knows that weak abdominal muscles can cause back pain. In fact, Mummaneni says, stronger muscles might be the secret to Gokhale's success.
In other words, it's not that the J-shaped spine is the ideal one — or the healthiest. It's what goes into making the J-shaped spine that matters: "You have to use muscle strength to get your spine to look like a J shape," he says.
So Gokhale has somehow figured out a way to teach people to build up their core muscles without them even knowing it. "Yes, I think that's correct," Mummaneni says. "You're not going to be able to go from the S- to the J-shaped spine without having good core muscle strength. And I think that's key here."
So indigenous people around the world don't have a magic bullet for stopping back pain. They've just got beefy abdominal muscles, and their lifestyle helps to keep them that way, even as they age.