How to Avoid or Improve Back Pain Podcast with Stuart McGill

About 40% of people worldwide will get lower back pain at some point in life, and on any given day roughly 12% of adults are experiencing lower back pain. This crippling condition strongly influences quality of life, often affecting relationships with loved ones, impairing performance at work, and leading to substantial costs – not only healthcare ones but also expenses due to absenteeism and so on.

I first experienced back pain while playing rugby when I was 12. In retrospect, I’m grateful for the experience: My struggles catalyzed an interest in musculoskeletal health that ultimately seeded the increasingly broad fascination with health and performance that I have today. But the experience was avoidably frustrating too, for the “experts” who oversaw my rehabilitation often lacked the skills they needed to help me. Specifically, they knew little about how to identify the many ways in which I continued to move each day that were impeding my route to recovery.

Then serendipity struck. In my late teens, I e-stumbled upon some particularly interesting work by a spine biomechanist. The first material of his that I found jived with my own experience, so I soon ordered a copy of the first edition of Low Back Disorders. I quickly incorporated the ideas in my life, and it was remarkable how quickly my back pain subsided. As I continued to play several sports, I wanted to ensure my core was strong enough to support the high loads the activities entailed, so I then moved on to some of the more performance-centric exercises detailed in a follow-up book by the same author. This brings us to the latest episode of humanOS Radio.

In this episode, I speak with Dr. Stuart McGill. Dr. McGill is a professor emeritus at the University of Waterloo. He has published more than 240 peer-reviewed scientific articles in which he used an array of methods to explore the causes of back pain, the most effective ways to rehabilitate back pain, and strategies to optimize athletic performance while sparing people’s spines. Dr. McGill continues to help numerous people overcome back pain and has worked with a spectrum of people spanning Olympic medalists, members of the special forces, the government, and the general population too.

When I reached out to Dr. McGill he kindly sent me copies of his two most recent books, Back Mechanic and Gift of Injury. I sincerely think Back Mechanic is a must-read for anybody interested in their health. I like to think I’m not prone to hyperbole, so I hope you think twice about this. The book is easy to understand, dense with clinical insights, compellingly dispels common myths, and, most importantly, gives readers a comprehensive and practical set of tools to help them temper and prevent bouts of back pain. Gift of Injury is a great complement to Back Mechanic, and strength and power athletes and coaches will find it particularly useful.

With that introduction, what are some of things we cover in this episode?

Tune in below to find out more!

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Stu McGill - 00:00:06: Another million dollar question is, do you have good and bad days? Now, if they say yes, you must not fail with this patient. It's clear back pain has a cause. Figure out what's causing them to have a good day and what's causing them to have a bad day, and if you're good at that, you will isolate and get rid of the things that are causing them to have a bad day and you're off to the races.

Kendall Kendrick - 00:00:29: Human OS. Learn, master, achieve.

Greg Potter - 00:00:39: Today's guest is someone whose work I'm hugely grateful for. For it's been instrumental in helping me get out of my own back pain. In my late teens I read two clinical textbooks written by Professor Stuart McGill that did more to help me overcome the pain than anything else. More recently, Stu's written a book on back pain to the general public name, named Back Mechanic, and he was generous enough to send me a copy as well as a copy of Gift of Injury. I've just read Back Mechanic and it's exceptional. Stu's published more than 240 peer reviewed scientific papers on back pain and he's worked with the gamut of people. From Olympic medalists to the elderly. I couldn't be happier to speak with Stu today. Stu, welcome to Human OS Radio.

Stu McGill - 00:01:20: Well, thank you very much Greg. I am assuming that people can tell with your accent you're located in England and I'm in the Middle Ontario in Canada, but it's probably afternoon for you.

Greg Potter - 00:01:31: So I'd like to begin with the most important question. I used to think that my dad's mustache was peerless, but I think that you provide formidable competition. What is the secret to your mustache?

Stu McGill - 00:01:43: You should see my mother. A little bit of fun on that though, I've never been clean shaven without a beard or a mustache for close to 50 years now. I did shave once, my daughter said, "Dad, I've never seen your face," and it took me 30 milliseconds to decide and I went in and shaved it all off. When I went to my next speech, the people picked me up at the airport and they were so disappointed. They said, you're not Stu McGill. So I realized it was a bit of the showbiz trademark, so I had to grow back the mustache. The public demanded it.

Greg Potter - 00:02:21: My dad actually shade his off once. He's a teacher, he arrived at school the next day and one of the kids took one look at him and burst into tears. Let's get to back pain. I know you primarily work with difficult cases, so people who haven't been served well by other approaches to treating back pain, but at the societal level, just how problematic is back pain?

Stu McGill - 00:02:42: Greg, that's a fantastic question. It's a big question, but really it's not one that I deal with. I get asked to see patients who fly in from around the world every day, and so for me the more relevant question is why? Why is that individual front of me and when I ask them to tell me their story, I see that they are told very strange things. They've been told that perhaps oh the pain is in their head and they're very frustrated. These are educated people. Can you imagine having leg pain and some clinician, without even assessing your leg pain, would say, oh, the pain is in your head. It could be torn knee ligaments, it could be a fracture, it could be some vascular condition, and yet for some reason this default occurs with the back with some clinicians. So I ask them what can they do pain free, what causes pain. They're very savvy on this. They know it helps me to interpret their specific pain triggers and we show them very quickly that it isn't in their head, so that's for an epidemiologist. I'm the person who has to change the person's life who sits in front of me with debilitating back pain.

Greg Potter - 00:03:53: And that's a tall order. With that out of the way, let's begin with some basics of spine anatomy. Can you first overview different portions of the spine? The fundamentals of the structures of the vertebrae and discs, ligaments that support the joints in the spine.

Stu McGill - 00:04:07: I understand your motivation for asking that, but once again, I don't think a person with back pain cares a heck of a lot. It's much more important for them to understand the mechanics of how all of those parts go together. So let me answer the question this way. The spine is a flexible rod unlike every other segment in the body linkage that has a long bone down it. So the spine that's flexible, it allows you to have mobility, allows the person to dance and have sex and all these fun things in life, and yet when they bend down to pick their child up, they have to stiffen that flexible rod and stop it from bending and collapsing. So that's the first concept of how all those little parts go together. They need mobility for sure, but they also need at certain times to stiffen.

00:04:58: The joints of the spine are not ball and socket joints, so you have the torso or what may be referred to as the core. It's no coincidence that either end of the core has a ball and socket joint. Those are the joints that are mechanically designed to create and transmit power. It's quite easy to see in those who have certain types of back pain that their mistake is they try and create power with their spine, but the spine are not ball and socket joints. In fact, they fall into the category of an adaptable fabric. The collagen fibers that make up the disc are small fibers that are stuck together, if you will, with a ground substance. Now you can adapt that fibrous disk to become pliable and mobile, so if you want to do yoga and these kinds of things, you can stretch and adapt the spine to have this high movement.

00:05:57: However, if you've then loosened the collagen and allow the mobility, you've now made a trade off. You've danced with the devil and your spine will now be compromised for bearing heavy load, because to bear heavy load, the collagen fibers need to be stiffened and adhered together to withstand the very high pressures that are going to develop inside the nucleus, the middle core. So when we train, we have to train with purpose. We have to adapt the fabric. If you want to be a power lifter, for example, you'll notice the great grand old men and women of power lifting have very stiff spines. They have problems tying their shoes, but that allows them to bear hundreds and hundreds of pounds, but the yoga master may have lost the ability to bear heavy load with resilience because of the mobility that they've built.

00:06:47: So somewhere along the line there's a trade off in all of that. Once we identify some of the violations of this basic code of how the spine works and how it becomes injured and painful, we understand all these components to wind the pain down. Stop picking the scab, desensitize the pain, and then we build a foundation in their body linkage to prepare them for pain free activity, whatever that may be. We know that if it's more of a strength and heavy load type objective, our training is very different from those who just want much more of a mobility ability. So I don't think the patient cares about individual anatomical components. It's much more important for the clinician who's organizing their recovery to understand how all the parts fit together and this code that must be adhered to, to create resilience.

Greg Potter - 00:07:43: That makes perfect sense and I think you've touched on many concepts that are going to be useful going forward in this conversation. A couple of things that I just wanted to double click on briefly, one of them was the concept of spine power. Can you just explain what you mean by that? And the other thing is something that you speak about frequently, namely the idea of bracing the spine.

Stu McGill - 00:08:06: Power in terms of the body is force times velocity. So if we take a hip joint, for example, a ball and socket joint, it's designed for transmitting large force, having large gluteal muscle forces, hip flexor forces crossing the joint, and you can do it with high velocity as well. When you're running and sprinting and this kind of thing, but the spine is at much higher risk when it's creating high power. That's when both force and velocity is high. We do know that if you can keep spine power low, the spine is much more resilient. So let's look at the equation once again. Force times velocity equals power.

00:08:49: If you have high forces down your spine, keep the velocity low and therefore the power is low. So pick up a heavy object off the floor and let's go to the extreme here. Let's take a professional strong man picking up an atlas stone from the floor. They bend down, it's a very awkward lift. They curl their body, flex their spine around the stone, but then they crush down into the stone to grip it and they don't move their back. So it's a very high force, but zero velocity in terms of rotational velocity of the spine vertebra. The power is low, the risk of injury is low.

00:09:27: The risk of injury would be high if they started to extend their spine lifting the stone, but the great stone lifters crush down the ball. They hook around an inflection, and then at the very end they do what's called the hoick, which is to lift the stone up onto the platform. They do that through the hips or at least the great ones do that survive.

00:09:45: So now let's take the polar opposite. Let's look at very high velocity, low force. So now we get into things like golf. Golf is a very high velocity of spine movement, but when you measure the great golfers, we have measured many of them. The muscle activity is relatively low and that's how they are able to survive and avoid issues. Now the ones that get into trouble are the ones who might get stiffer hips, for example, so now they have to put more force through their spine in the golf swing and things start to head south.

00:10:21: Bracing is an entirely different issue because we have to demarcate the difference between performance enhancement and pain control. So if we look at pain, first of all, every joint in the body when it gets damaged, becomes a little bit lax. Consider the knee, if you've damaged a knee ligament, the orthopedist will do a drawer test which measures the shear laxity of the knee, and quite often that's associated with pain. Well, we do exactly the same instability tests with the spine, both in the sagittal plane and the lateral plane. If that triggers pain, that laxity or the shear loading causes pain, we then advise the patient, let's find a bracing pattern to see if the pain is immediately arrested. Here I'll push my fingers laterally into their abdominal wall, lateral to the navel, and I'll say, push my fingers out, and now I'm going to repeat the application of the destabilizing shear load.

00:11:22: They might say, oh, that's magical, you just took my pain away. So we just proved that that bracing procedure was appropriate for reducing their pain by arresting that shear load micro movement, but the patient might say, no, that increases my pain. Okay. The brace was either too much, because the brace costs in terms of a compressive penalty or we might say, that's an inappropriate brace. Let's try a different one. Stand tall, relax your abdominal wall, but compress down through your pec major and your latissimus dorsi. In other words, a very Okinawan karate strength motor control approach and then they might say, ah, that's what reduces my pain. So we search for different bracing patterns and a good clinician has many of these options in their tool box and they will discover immediately which way to take the patient.

Greg Potter - 00:12:18: So there are different ways of bracing that might be appropriate for different people and you should tune the degree to which you brace to the needs of the specific tasks that you're doing.

Stu McGill - 00:12:27: Well sure. Let's measure someone doing a deadlift off the floor that's close to their personal best. They will be bracing very heavily out of what we call the lifters wedge. We try and get zero motion in the spine and that unleashes the hips. It's so interesting when you measure, if there's a little bit of sloppy movement in the spine, in the deadlift, they will lose the deadlift. The motor control system has a fuse box and it shuts down the neural drive. On YouTube there's a summary of this year's world's strongest man. It was done in Africa this year, and if you look at that, one of the events was squatting 750 pounds for repetitions. Watch every strong man competitor do the squats and most of them failed somewhere between 12 and 15 repetitions. Look at the repetition before their final squat and you will see it every single time. The hips get a bit loose, the body sways a tiny bit. In other words, they lost the stiffness to control their spine. What happened? The motor control system detects that instability and it shuts down the strength in the neural drive. The next rep is a failure.

Greg Potter - 00:13:42: That made sense.

Stu McGill - 00:13:43: Well it does to you and I, but this is very mysterious to many medics I'm afraid.

Greg Potter - 00:13:49: I'd like to come to a few back pains scenarios that I think you're going to be germane to our listeners, but before we get there, can you just touch on some of the things that you go through during a back pain assessment?

Stu McGill - 00:14:01: The first thing with an assessment is to read the person. I remember the famous quote from coach, Vince Lombardi, I read men and of course it is really reading people. As soon as that person walks through the door, the assessment has started. I may ask them to take their shoes off. I'm in a clandestine way watching their movement habits. I might ask them to pick a bag up off the floor and hand it to me or I will purposefully drop my pen. In other words, I'm understanding the chronic stresses that they impose on their back because of their movement choices. Then I observe them sitting and how they get out of the chair and all of that. They sit down in front of a fireplace in that fireplace is always going. People think I'm a mechanical guy and I don't pay any attention to the psychosocial aspects. They have no idea what we do.

00:14:57: The patient sits in front of the fire. I don't sit in front of them. I sit at 45 degrees and I say, tell me why you're here, and it's as open as that, and some of them tell me exactly why they have pain. They tell me what hurts, what activities they can do pain free. They tell me about the impediments of why previous attempts of their back pain have only made them worse. They tell me reading the MRI report that says they have degenerative disc disease has been an enormous source of cognitive dissonance and fear among them. It's awful what some of the medics tell patients when none of it is true, and then I ask them very specific questions. For example, if they tell me, oh, I reached forward to flush the toilet and it felt as though someone put a knife in my back. That scenario is consistent with having joined instability and then I'll say, "When you roll over in bed, do you ever have a sharp pain in your back," and they'll say, "Well, yes, I do."

00:15:56: Good. That's a very pointed question. When I test them, I'm going to be testing for joint instability or they might say, I have morning stiffness, getting out of bed. Well then I'll be asking them questions about their bed. Have you ever slept in a hotel and got up the next morning and your back was much better? These are all indicators that the bed might be a component. Another million dollar question is, do you have good and bad days? Now if they say yes, you must not fail with this patient. It's clear back pain has a cause. Figure out what's causing them to have a good day and what's causing them to have a bad day. If you're good at that, you will isolate and get rid of the things that are causing them to have a bad day and you're off to the races.

00:16:39: Well that sometimes might take 20 minutes in front of the fire. It might take 45 minutes, but the person will then say, you're the first clinician who's ever listened to my story. It is so powerful to gain that much information. Then I take them downstairs to the clinic where we do provocative testing. Once we are downstairs in the clinic, we now have a fairly good idea of what we should be testing and assessing. So we begin by provoking the patient with very specific motions, postures, and loads, and we will find very quickly what is tolerable and what creates their pain. So now we get a fairly precise first diagnosis in terms of offending motions, postures, and loads. Are they extension intolerant, or flection intolerant, or intolerant of compressive load or shear load, whatever the case may be.

00:17:35: Let's take the example of compression intolerance. So we might have them stand completely relax, go up on the toes and bounce down on their heels. That creates about a one and a half times body weight compressive pulse down through their spine. If they tolerate that, wonderful. If they don't and they say, ah, that just created a numbness in my right big toe, well we then start to know we're dealing with a sciatic nerve root at l five on the right side from a pain pathway point of view, but then we try and mitigate it. I might poke my fingers into their abdominal wall, lateral to rectus abdominis and I'll say, push my fingers out. Now repeat the bump. Was the pain better or worse, and if they say the pain was better, immediately we found a strategy that reduces their pain. We also have a good indication as to what the mechanism is if they report that. It's usually a micro movement at the joint because of some joint laxity in previous damage.

00:18:40: But what happens if they say no, bracing with the abdominal wall increases their pain? Well, there was a compressive cost to the spine of that bracing procedure. They don't have the compressive tolerance yet to make that a viable clinical strategy. So we might change it up a bit and say, relax your abdominal wall and pull down and compress by activating your pec major and latissimus dorsi and of course we would queue those muscles with touch, and then repeat the heel drop. If the patient then says that took my pain down a notch or it completely took it away, so it allows us to converge immediately on a strategy that allows them to be more tolerable of load, but then we get into very specific tissue testing and there are those who don't have the expertise and say, oh, no one can reliably understand where the pain source is. I so disagree.

00:19:34: We spent 30 years with patients measuring internal tissues stresses and linking that to pain. We had a full radiology suite in the clinic and we were able to match specific findings with specific pain patterns. We took cadaveric spines in our in-vitro lab, applied very specific loading protocols and came up with very specific injuries. So all of these levels of evidence are put together to allow us to converge on specific tissues. Then once we have our precise understanding of their pain mechanism or diagnosis, we'll then try sham procedures and alternative tests that would rule out any alternate explanations as to why that person has pain. Once we've ruled out all other possibilities and we've proven that we can take their pain away immediately, we're quite confident now in writing a program to desensitize their pain and then once the pain is desensitized, shift gears into building the foundation that they need for pain free movement.

00:20:44: So my assessments, I book out three hours. There's nowhere in the medical system for a three hour assessment, so it's all private. Some clinicians say, well, I can't afford to do a three hour assessment, but once we teach them how to do it, they then realize they cannot not afford to spend three hours with a patient and get this precision that shows the path to alleviating their pain.

Greg Potter - 00:21:11: So it sounds like diagnosing patients based on scans alone probably isn't smart.

Stu McGill - 00:21:16: It can be very misleading. The typical medical practice is to have a scan and then a radiologist reads the anatomy, but this should be illegal in my view because when you look at a scan, let's take an MRI image. The MRI image shows the full history of the person's life. It shows all the old scars and all the recent wounds. The wounds may cause pain and the scars do not, so you have to see and assess the patient first. That's what allows you to interpret the medical image and when you do that, you get a much higher concordance between the findings and what causes pain, but people who don't understand this say, oh, images aren't related to pain patterns, no kidding. They're looking at the entire history of the person, but following the assessment, the scans become quite helpful and when you think of the worst case scenario is a surgeon will put a scan of a back pain patient up on the computer screen and they'll see, oh, there's a nasty disc bulge at l four. Then they go and operate on l four, not realizing that all the edema in the bone at l five was really the cause of the patient's pain, so of course it's a failed surgery.

00:22:29: Anyway. There's a few thoughts on what is required and I might add something else that just came to mind. The dynamicism of it all. I don't know how MRIs became the gold standard. When we watch spines move on video fluoroscopy, we will see the micro movements occurring at certain ranges of movements. That's a perfect correlation between that micro movement and the shot of pain that they just experienced as they were moving through the mid range of motion. Again, you've got to match the type of radiological techniques with the type of pain trigger that the patient has, but I don't buy this idea at all that images aren't helpful. They're only not helpful for those who don't understand all of these features.

Greg Potter - 00:23:17: Speaking of fluoroscopy, I understand that you had a unique experience studying the Canadian power lifting team in the late eighties.

Stu McGill - 00:23:26: Yeah. Again, we've been measuring these things for 30 years. I was working with some elite power lifters back in the eighties and one hurt his back while we were watching their spine move with video fluoroscopy and he picked up the bar off the floor. I can't remember, it was 4 or 500 pounds I believe, and he dropped it after he got it to about 20 centimeters off the ground. Anyway, and he said, oh, I've just hurt my back, but when we went back and watched the fluoroscopy tapes, just one joint, it happened to be l two, l three went to its full flection angle that we had calibrated previously and past it by half a degree. Then it had self corrected within about two seconds, so that was our first indication of a buckling micro movement leading to injury, but we've seen and documented all kinds of micro movements on video fluoroscopy since in whiplash victims and whatnot.

00:24:24: That allowed us to come up with tests where we will apply a force in standing and in prone. Some clinicians are familiar with the prone instability test. It's not a repeatable test. You have to have expertise to apply the test, but it certainly is a valid test in terms of showing very precisely the level of the application of shear load that replicates the person's pain triggers.

Greg Potter - 00:24:52: And do you just briefly want to mention the distinction between shear and compression.

Stu McGill - 00:24:54: Yes. If a person is standing upright and you put load on the top of their head, that's in line with the axis of the spine, so that is a compressive load. A shear load is 90 degrees to that, so if you were to bend forward the rib cage is shearing forward on the pelvis and that shear load is seen by every joint in the low back, for example. We might apply a lateral shear with a clinical technique to see if that triggers pain, but interestingly enough, more patients are triggered by the application of shear load than they are compression and that's much more linked to joint stability. When you damage a joint, it loses stiffness and that's universal throughout the body, and that loss of controlling stiffness is what allows the tissues to become stressed and painful.

Greg Potter - 00:25:48: Right. So you've covered a few situations and one of the things that I really appreciate about you is that you often find yourself saying it depends. So I'd like to cover a few relatively common scenarios in which people experience back pain and please feel free to take this in a different direction if you wish, but one of the ones is the kind of flex intolerant spine, typical of young adults who spend lots of time sat in offices. Only to the gym, do a yoga class or crossfit workout, or sit on an exercise bike. So what might be at play in these people and what are some of the things that they might find helpful in addressing their pain?

Stu McGill - 00:26:25: That's a terrific question because we're now down to a sub category of pain. Interestingly enough, in the virgin spine, that is people who don't really report any back pain. More sitting doesn't seem to cause pain. It doesn't matter to them, they're not sensitized, but someone who gets back pain sitting, they have micro damage. Some people will say, oh, we can't find the damage and again, my answer to that is they're not thorough enough in their techniques to document the damage. Over our years, we would damage spines and we'd take an MR of them, or a plain film, or a micro CT and the damage may or may not show. Eventually we'll then go through a micro dissection and the old vertebrae just falls apart once you cut through the bone periosteum. It has been so fractured at the micro level of the small trabeculae and whatnot.

00:27:22: So people who say there's no tissue damage, they just don't have the bench experience in that particular case, but let's take the person now who sits at work and then they go to yoga class or a crossfit workout to use some of your examples and they use poor technique and they overload the joints. There's two or three pathways to get a disc bulge. One of them is to repeatedly flex the spine while you're under heavy load. So if you do repeated dead lifts and allow too much spine bending, over time the collagen fibers of the disk will delaminate and you've got a good risk of creating a posterior disc bulge. Now, when you sit the spine flexes, puts posterior pressure on the disc bulge, and all of a sudden back pain occurs and it might become intolerable after 20 minutes.

00:28:11: If that person was to understand that and sit with a lumbar support to preserve that curve, even though they had that damage, it might not become painful because they avoided flection while they were setting. Anyway, there's a start on people who sit. So if you sit a lot, be good to your spine, in the gym by using good technique, sit with a lumbar support. If you sit all day, chances are the tone of the muscles around your hips will change and people dismiss this, but again, we've measured it. Hip pain and back pain as a generalization, causes neurogenic facilitation of the psoas muscle. People refer to that as a tight psoas and it cause neurogenic inhibition of the gluteal muscles. So when they stand up out of a chair, they use their hamstrings and walk their hands up.

Stu McGill - 00:29:03: ... stand up out of a chair, they use their hamstrings and walk their hands up their thighs. It's a dead giveaway. But they can address their hips through specific mobility and training exercises of their hips.

00:29:12: So, anyway, a lot can be done if you recognize these common patterns of prolonged sitting.

Greg Potter - 00:29:18: Just to pick up on something [inaudible 00:29:20], one thing I'm interested in your thoughts on is what to do between sets at the gym? I did an undergraduate and a masters at [Loughborough 00:29:27] University and it's an incredible training facility, there are loads of very high caliber athletes, and what's interesting is if you watch the weight lifters or athletes doing very heavy squats, so often, they will slump in a chair in between their sets and that strikes me, based on your work is being unwise. What do you think people should do in between their sets of lifting at the gym?

Stu McGill - 00:29:49: Oh, well first of all, I'm so glad you went to Loughborough, fabulous institution and they have people that recognize a lot of what we're talking about so good on you. Apart from that, the answer is it depends. When we have done our studies on professional NBA basketball teams, for example, there will be some of the players who fall into the category of having discogenic back pain, and if they don't manage it, they're unable to play. Obviously, it's not in their heads. If they play in the NBA on the floor for 15 or 20 minutes and then they sit down, they actually sensitize their back and they are in worse shape after their 10 minute of rest for their next round of play on the floor. And what we did with those players was we sat them in very tall chairs and angled the seat pan forward so that their spines never slumped, they preserved the lumbar curve so when they got out of the chair, they were ready to play.

00:30:48: Some of them who are even more progressed in their syndrome, we got them to stand up and they had to go and pace down the back halls for a little bit to prepare their back to play and allow a temporary desensitization. So there's some strategies to enhance the rest, so if a weight lifter has never had back pain, I'm not tremendously worried about them sitting between sets. Again, as a coach, I would never allow them to adopt poor form if they're elite. I don't think you'll see elite lifters do that, I might add. You might see second-tier lifters lose that opportunity. But if they have a history of pain, we will assess the specificity of the trigger and we will know whether or not they need to practice spine hygiene when they're sitting with better form.

Greg Potter - 00:31:37: Okay, so we're gonna move on to another situation now, and that is somebody who experiences pain running from the spine, to the buttocks, down the posterior thigh and into the lower leg. Is this like [inaudible 00:31:50], another case of piriformis syndrome and what might be going on here?

Stu McGill - 00:31:54: Yeah, well what a beautiful question because piriformis syndrome has become a very popular diagnosis to those who have buttock pain. But when we measure it, it's rarely the case. I have had a few cases of true piriformis mechanism that we've documented, one was a very high-level soccer player from one of the super clubs in Europe. He was kicked in the piriformis and he truly did have pain emanating from that. We had another cyclist where the sciatic nerve actually pierced the muscle, it was an anatomic anomaly and it was through piriformis syndrome and stretching did relieve. But most of the time, the overwhelming majority of patients we get who've been told they have piriformis syndrome and they've been stretching the hip and the piriformis muscle, but have not gotten better, they actual mechanism was a sciatic nerve disc bulge, either at L4 or at the fifth lumbar level. It passes right behind the hip joint and goes very close to the piriformis's ....

00:33:05: But when we treated them as a disc patient and mechanism and not piriformis, most often, the pain resolves. So the piriformis stretches that they were doing, no question, they got 20 minutes of analgesia or pain relief but it was a pure trick. They created a stretch reflex which give them the short term pain relief. But in stretching it, it's very difficult to stretch away nerve compression pain from a disk bulge, for example. You can mobilize it, but very difficult to stretch it away. So stop the stretching, treat it like a disk bulge and quite often what they thought was piriformis syndrome was not and they were able to address it.

Greg Potter - 00:33:47: One of the things you mentioned that mechanic is the fact that quite often treating sciatica and irritation of the femoral nerve requires relatively similar rehabilitation strategies. Can you just speak about that a little bit?

Stu McGill - 00:34:01: Well yes. The lower two lumbar vertebra are the sciatic nerve roots and they have a characteristic pain distribution but L1, 2 and 3, have the femoral route association. And typically it runs down the front of the thigh and doesn't often go to below the knee. But then, if we suspect a femoral route, we provoke the femoral route and it's usually a prone test will position the neck to set a certain tone or tension in the spinal cord and neural pathway, and then we flex the knee and [scour 00:34:38] the hip joint with circles of the foot. And if the patient has a true femoral nerve route pathology, they'll say "Oh yeah, I'm feeling a creepy crawly feeling in my low back," or they might display what's called [Eli's 00:34:54] sign which is a twist of the pelvis as we flex the knee because the tightening of the femoral nerve in front of the thigh. Or it might be simply a tightening of the rectus femoris muscle for example, that crosses the knee and the hip. But then we do a rectus femoris test. We get right down to finding out whether or not it truly is a femoral nerve route and then we treat it appropriately.

00:35:19: Usually, it's a discogenic cause but sometimes it's more of a stenosis or a bone arthritic cause. And obviously, we put together the patterns. If a person is a little bit older and they've got some bone changes that we might see on a scan.

Greg Potter - 00:35:35: Okay, so you mentioned stenosis there. My understanding is that earlier in life, perhaps even their 30s, are more likely to experience flexion tolerance but as people get older, they arthritic stenotic spine becomes more and more problematic. What I'm wondering is whether you can perhaps just explain what that is and why that is the case.

Stu McGill - 00:35:57: Yes, of course. I won't always say Flexion intolerant but I would certainly say the categories tend to involve the discs much more in younger people. Older people rarely display discogenic back pain, although some still do. They're more commonly in what we call the stenosis pattern. Stenosis simply means the narrowing of. So the spinal cord as you know, follows the path central down through the spine itself. If the person did a lot of movement in their life, the studies on twins and runners versus soccer is very interesting. The twin who played soccer tends to have more spine stenosis than the one who just did recreational running. So it was the extra movement that caused a little but of arthritic growth. The ligamentum flavum, the ligament behind the central spinal cord gets a bit thick in those who did a lot of movement in their spine.

00:36:59: This causes a narrowing of the central space for the cord, but also the facets might grow a bit thicker, or the foraman, the holes that the lateral nerve routes exit from, become a little bit smaller with our arthritic bone. So we consider all of these and test what is the mechanism. And now another mechanism, for stenosis radiating type of pain is vascular [aclaudication 00:37:27], it's sort of like having varicose veins in your regions surrounding the nerves. And if you were to walk upstairs, for example, it causes pooling and the compression of the nerve routes. But nonetheless, we will clamp off the blood supply with a belt around the thigh, or whatever it takes to understand what is the cause of their stenosis.

00:37:49: But here, I'll give you one patterns because many stenosis patients who fall into the arthritic category are told "Well, don't stand upright because that triggers your pain, Do a pelvic tilt and flex forward, ride a bike, but avoid walking. And these kinds of flexion based activities. About half of those patients, we get much better success by doing the opposite.

00:38:15: So let's say they can only walk for three minutes before the back and radiating symptoms cause them to sit down. What we would then say is don't walk to the point where you cause the symptom. If that's a three-minute cycle, just walk for two minutes. Do it in a park, and then walk over to the park bench, put the heels of your hands on the back of the bench, and stand up nice and tall but then allow your hips to come towards the back of the bench. In other words, you're creating a traction with extension.

00:38:48: Half of those patients hold that position for 30 or 40 seconds, and then when they stand up, they say "You know what, I'm restored. My symptoms are now reduced." We say "Fabulous, go walk for another two minutes and keep repeating what we call a park bench decompression strategy with interval walking. Well, if they do that 10 times for the first time now, they've just had 20 minutes of pain free walking and if we can keep that going, they will extend, usually, their walking times. Again, I keep getting back to this common theme. Understand the pain mechanism, treat it with precision, and your results greatly increase.

Greg Potter - 00:39:29: And one thing I'd just like to ask you about is traction, specifically. I suspect that you're asked about that relatively frequently by people. Whether tractioning the spine is wise. Is it wise in the arthritic stenotic spine and any other conditions.

Stu McGill - 00:39:45: Well, the answer is it depends. There are many clinicians who sell these decompression therapies where the person goes and signs up for 30 treatments and that kind of thing. I would advise a patient never to sign up for thirty. Go and try to or three and if you're not better, stop. I get too many patients who have actually been made worse by those therapies and here's the reason. Traction is very destabilizing to a joint. So if you already have spine instability or [inaudible 00:40:16] at a joint, and then you stretch it, that's the worst think that you can do to it, they should be stiffening it. But as specific subcategory of back pain, and it tends to be an older people, where traction has been shown to be quite helpful on average but now, I'd say it has to be more precise than that. Don't hang upside down on an inversion table, it's not precise enough. How much traction should be applied, at what angle should it be applied, but we do know traction, for some conditions are helpful.

00:40:50: So let's take a posterior disc, for example, in an older person that's been diagnosed with sciatica and stenosis. Have them lay prone, and then apply two or three kilos of traction to their ankles along the line of the table, so a horizontal force. And ask them "Does this feel better, or are you ramping up your symptoms?" If they say better, great. That is a nice way to decompress a posterior disc bulge and create space. If they have a femoral nerve route overtone though, and you bend the knees, do you see one is exacerbating a femoral nerve route by butting too much tension on it, and the traction might be very helpful. So that's why I say to have a skilled clinician apply the traction, it's much more precise than a decompression table. So bottom line, it depends , but a skilled clinician will test and then be guided as to what precisely to do.

Greg Potter - 00:41:51: Let's pivot now to treatment. We live in a word where misaligning [inaudible 00:41:56] can be a tool barrier to hurdle and surgery sometimes exemplifies this. How often you you think the cause of somebody's back pain can be cut out and what are some potential problems with back surgery?

Stu McGill - 00:42:06: Okay, well to answer the question, absolutely, there's a time and place for surgery. If you've had a major fracture, or there are some disc bulges that are quite nasty,, and it's a good risk. But I have an entire chapter in my book Back Mechanic that is a checklist that people go through to measure the risk that they're going to take in that surgery. Some of the worst patients we get, the most difficult challenges are those who have had spine surgery when they never should have, and the scarring tissues have grabbed on to a nerve route, and they have wat we call arachnoiditis, which is a terrible condition, they move their hand a certain way, and it causes raging back pain from the nerve tensions.

00:42:52: So if you're going to take the risk, please make sure that it's a good risk and go through the checklist. But now I've got two things to say. Surgery works in a lot of people simply because it's forced rest. You know the client or patient that comes in and you say "Well, tell me about your daily routing and they say "Well, every day, I go to the gym and I ride the elliptical bike for 20 minutes, and then I do X and then I do Y." And I say "Well, I think I know why you have back pain, you're just over driving the system all the time, back off for a while," and they say "Oh no, I can't do that, my mental health requires me to do this aerobic work" and then I'll say "Okay, well you can have surgery, but tomorrow, you won't be on the elliptical trainer. You will be, for the most part, in bed and every two or three hours, you're going to get up, take a short interval walk to the toilet, and that kinda thing. And then the next day, you're going to add a little bit more activity so slowly, you're going to build yourself back into activity."

00:43:53: But the point of it all was for stress. Let's mimic that instead of doing the surgery, we're going to do what we call virtual surgery, and I make a grand deal out of it. I say Good, there you are, there's your surgery, now tomorrow, you're going to behave like a post-surgical patient. You're going to learn to move well, have graded exposures to load, and we're slowly gonna build you back. Now, I can stand by this statistic and that is when people do that, 95% of them will avoid surgery. So that's 19 out of 20 patients who've done all this physical therapy and chiropractic and seen the shrink and the surgeon and everyone else, you've been told surgery is the only thing that's going to work, but try virtual surgery. 19 out of 20, we'll avoid the surgery. So that's a pretty impressive statistic that I measured, we follow up with every patient that we ever see and I can stand by that.

Greg Potter - 00:44:47: Suppose [inaudible 00:44:49] about not picking the scab and some people, probably all of us, need to relearn how to move to keep back pain at bay. I love your use of the term spine hygiene, I often find myself speaking about sleep hygiene. Cane you touch on some key, spine hygiene strategies that people with back pain can put to use?

Stu McGill - 00:45:08: You just caught me, I just changed my position in my chair and sat up. There's an example of spine hygiene. So going back to the scientific principle, pain sensitization comes from cumulative irritation. So you may have heard of chronic low back pain. I think that is such a poor term. Most people do not have chronic back pain. What they have are repeated, acute, mini-insults to their back all day long. Because of the way that they move and sit, et cetera. Once we understand the pain-causing insult from the testing, we then give them a movement technique to avoid it. Those techniques are called spine hygiene.

00:45:50: How'd he get up and down off the floor, how'd he get on and off the toilet, how do you tie your shoe? Let's take that one for example, so let's say they have discogenic back pain or pain cased by flexion and we narrow that right down to say very precisely, you have a dynamic disc bulge. In other words, when you walk, it's relieving, sitting causes your pain, but when you bend forward, we measure this, that creates hydraulic pressure on the posterior part of the disc and on the disc bulge. And then I'll say tie your shoe, and if the person sits on a chair and bends forward and ties their shoe, they've just replicated they mechanical cause of their pain. But if we then show them a basic spine hygiene technique, stand tall, put up one foot on the chair, so you're doing a lunge basically, take your hips down to the targe, let your knee, that's on top of the foot on top of the chair, drift forward, the stance leg knee bends, you take your hips down to the target, you keep your spine nice and tall, and now you tie your shoe. So now there's a spine hygiene technique that eliminates the documented pain trigger, we've stopped picking the scab, and we've allowed that tissue now to continue its desensitization so there's an example.

00:47:13: We teach people basic forms of movement and every single thing in life except swimming, wrestling, and doing jiu-jitsu, you can do everything in life following the rules of spine hygiene and you can wind down your pain trigger. People say this is so empowering. Instead of being told "Oh, just continue to move," it's much more precise than that, they move in a specific way and now all the fear comes out. They might say "The last time we had sex, three months ago, we knackered our backs so badly, we're now fearful." But when we show them, the techniques of spine hygiene, they become empowered, and they're back to enjoying life once again. So it's a very powerful technique.

Greg Potter - 00:47:57: One thing that I continue to find fascinating is how eager people are to micromanage their diet and not do so with their physical activity. And I think that raising awareness about those things is really important.

00:48:08: Stu, let's now talk about some motor skills that help people avoid back pain. Many coaches think that the best way to build strength endurance is to first build strength, but adding strength fitness to dysfunctional movement patterns is probably problematic. Can you speak a bit more about this?

Stu McGill - 00:48:25: Yeah, from many different perspectives. First of all, many strength coaches, the only tools that they have in their toolbox ar strength rather than strength with purposeful movements that then translates into the real world. And that's what back patients need. They don't need to learn to deadlift to be a dead lifter. They need to learn the hip hinging movement so they can pick their child out of the crib at two o'clock in the morning. Now we're into this whole world of transference. We've got very good evidence on this, we did the only study that I know of that good coaches are worth their weight in gold because they transfer movement skill from the gym out into real life, the poor coaches don't.

00:49:10: And the evidence I use there is our study on the Pensacola fire department. We took one group of fire fighters and they trained. Strength and endurance, and they got stronger and more endurable. I should say that before the study, we measure their movement competency out on the fire ground. Specifically how to set up a ladder, how to advance a loaded fire hose, how to chop a hole into the roof of a burning building. We spent half a million dollars doing this with my colleagues [Jack Callaghan 00:49:39], [Tyson Beach 00:49:40] and [Dave Frost 00:49:40] who are all now professors in their own right. But nonetheless, the first group just trained. The second group were with very good coaches. We trained [Exos 00:49:53] coaches, [Mark Verstegen's 00:49:53] company used to be called Athlete's Performance and their coaches are highly trained and we added some more training, and they coached the firefighters very precisely with every movement, they told them what their objectives were, and why they're thinking of different muscles when they're doing these different activities and different postures and whatnot.

00:50:12: And we measured the firefighters going back out on to the fire ground. The ones who trained with expert coaches then had far fewer injury markers, and they moved with more competence out on the foreground. We never trained them how to do foreground activity, all we trained them was good movement when they were training in the gym. But the other group that just trained and did sets and reps, they went back on to the fire ground with more strength and worse movement competency. So there is the only study that I know of that is a testament and a justification of why you want to have a very good coach.

00:50:53: So that's the first part of the answer, the second part is think of when you, or other people, hurt their back. Generally, they hurt their back when they break form, they're out of position. Now, the think about endurance is endurance allows a person to do more repetitions with good form. You break form when you get tired. I'm gonna quote another study. We measured guys combing car bumpers for Chrysler cars, some of them, every year, had an acute back attack where they missed days from work. The other group never had back pain. We measured all sorts of fitness variables, health profiles, and we also measure the way that they move, movement competency. Interestingly enough, do you think the stronger guys at Chrysler were the ones that had higher back injuries and pain and lost time work, or zero pain?

Greg Potter - 00:51:51: I suspect they had more time.

Stu McGill - 00:51:52: They did. The stronger backs had more pain. When we analyzed the ones who had more endurance versus the ones who had more strength, the ones who had more endurance weren't as strong, but they lifted the car bumpers the same way every time and they didn't stress their back, they used their hips. The strong guys use they backs and then they broke form as they got more tired throughout the day. The worst combination for risk was to have a really strong back with poor endurance and you break form very quickly whereas the resilient ones had much less strength and much more endurance' and they kept better lifting form all day long.

Greg Potter - 00:52:35: I hope that coaches are tuning in 'cause there's a lot to learn there. And actually one of the first bits that I ever read on strength conditioning was Mark Verstegen's book called Performance. I've benefited a lot from incorporating variants of your big three in my own training, can you tell us more about what these big three are, and also the concept of super stiffness?

Stu McGill - 00:52:55: Okay, those are two quite different things, I think. Over the 30 years, I was always seeking the best exercises that spared the spine for people with back pain, but really created the foundational athleticism that we were seeking. So I was trying to find exercises that didn't cause much compression or shear load, but created stiffness and stability. We had to engineer out those joint [laxities 00:53:26] that were causing the pain. The three exercises that kept bubbling up to the top, every time we ran an exercise trial, were the bird dog, the side plank, and the curl up.

00:53:38: Now, I'm gonna backtrack just a little bit. If you're an engineer and you know how to build a bridge, the loading on a bridge is called a three point bend. Either side of the bridge is held up, the traffic going down the middle, causes the third point of bend. But there's no shear load in a three-point bend. So if you do a side plank, that is a perfect three- point bend. When you consider a bird dog, it's supported on one arm and one knee with the spine in the middle, forming a three-point bend.

00:54:10: Shear load is created with a cantilever load. So if you stand up and bend over and do a rowing exercise with a bar, that's a cantilever and creates very high shear force. Or you can stand up and do a paloff press, for example, which once again, is very high load in terms of shear. So there's nothing wrong with those exercises if the person is shear tolerant. But most back pained people are not. You have to build that over time and let the adaptation take place.

00:54:37: So it was a matter of honing those three exercises coming up with specific sets and reps for different populations and all this is guided in back mechanic. And here I learned a lot from the Russian exercise and rehabilitation science. So we prescribe it on what I called the Russian Descending Pyramid, they were so clever with organizing sets and reps for maximum effect. Say you have someone who has a knee replacement, they can't get down on their hands and knees. Great, we will modify the bird dog to a standing position and you do that supporting one arm on the kitchen table, for example. That's the start on my answer on the big three.

00:55:17: When we get into a discussion of super stiffness, that came from people asking me "Well, you've worked with top MMA fighters, power lifters, many, many different Olympic sports, what is common among the great athletes in terms of their back?" And I wrote down what was common and then there was commonality to those nine points and it all had to do with what we called super stiffness in their back. But in order for people to get a good understanding of what I'm gonna talk about there, can I introduce the three key elements of spine stability? Because very few people understand what spine stability is.

Greg Potter - 00:56:02: Yeah, please do.

Stu McGill - 00:56:03: All right. There's lots of people who are hand waving about spine stability but there's only been three or four universities that have actually measured spine stability and we were one of them. Here are the first three essential, non-negotiable components of spine stability. Let's take a pushing exercise and let's say you're a very impressive bench presser and you can bench press three or four hundred pounds. But if you stand up and push an opponent or push a heavy door, let's use the bench press muscle, which is the pec major muscle, it crosses the shoulder at the front. As that muscle crosses the shoulder, distal to the shoulder joint, it's effect on the arms, it flexes the arm around, so it creates distal athleticism. But when you look at the effect of pec major proximally, it connects the rib cage, so it bends the rib cage towards the shoulder joint. So if all you use is your bench press muscle, your core rotates and collapses, it's called an energy leak.

00:57:05: You are useless in using that bench press muscle in a push until you create proximal stiffness. You lock down the core by muscular bracing patterns so 100% of the athleticism, goes distally to the ball and socket joint so now the arm pushes with competency and your spine doesn't collapse and bend towards the joint. So do you see how all movement, in a linkage like the body, requires proximal stiffness. Simply take your finger and wiggle it back and forth as fast as you can, you had to stiffen your wrist to get that competency. So the mother of all proximal stiffness and control is the core. To run fast, et cetera, you need it.

00:57:50: I'll give you another very impressive piece of evidence. Go to the neurology ward and find a young girl who has a paralyzed quadratus lumborum. That's the big muscle that runs down either side of the spine. What-

Stu McGill - 00:58:03: … the big muscle that runs down either side of the spine. What cannot they do? Walk. You can't even walk without sufficient core stability. If they had a paralyzed right side quadratus, they can stand on the right leg and swing their left; no problem. But when they stand on their left leg and swing their right leg, the whole pelvis collapses down on that one side because the quadratus lumborum is needed to hold that pelvis up. So do you see how important proximal stability is? Because, without it, you can't even walk. That's the first element you have to create through appropriate motor patterns, proximal stiffness to unleash distal mobility. It's non-negotiable.

00:58:45: The second element of core stability is one that we already discussed, in that the spine is a flexible rod, but if you are going to pick your baby up, you have to stiffen that flexible rod; otherwise, it will collapse. So the muscles form a natural guy-wire system around the spine. The erectors, the quadratus, the psoas, the abdominal wall all form this guy-wire system and allow you to be very robust at supporting compressive load. Failure to do so, and we were the first to measure this, your spine will buckle and collapse. We see all kinds of buckling behavior in people with back pain. So stiffness is required and it must be appropriate to match the demands, but stiffness comes at cost. Too much, and you start to overload the spine with compression.

00:59:40: The third key element to core stability is any kind of joint damage, particularly to the spine, causes the disc to lose a little bit of height, or not every kind of damage, but it's a very common sequelae to overload. Once that disc loses a bit of height, the joint becomes a little bit loose and a little bit sloppy, and it allows micro-movements. The patient who has these micro-movements might report migrating pain.

01:00:08: For example, on one day it's the right toe that goes asleep when they move a certain way. The next day they have left-sided back pain. The next day they have something else. This is a sign of micro-movements as the joints are triggering different pain pathways. But if they can organize appropriate stiffness, and you coach this through trial and error, they can engineer out their pain. We published a paper in Spine, the top orthopedic journal. Four top athletes, an Olympic volleyball player, a top power lifter, when we changed their stiffness strategy, they eliminated their pain immediately. Some of the doctor are very surprised to hear this, but once they understood the micro-movement story, they got it. Now I can answer with that background this idea of super stiffness.

01:00:56: There was a time a few years ago where some of the therapists were believing the story that, "Oh, work on transverse abdominis; this will help your back pain." Well, when we measured that, it didn't create sufficient stiffness to reduce pain. Of course, after a while, the efficacy studies showed full super stiffening kinds of pattern were much more efficacious. But nonetheless, there's a little bit of a start on super stiffness. They are strategies to create proximal stiffness sufficient to engineer out the micro-movements and tuning the stiffness to allow purposeful spine movement but then adding sufficient stiffness to allow it to bear load successfully.

Greg Potter - 01:01:41: Stu, as you're discussing the girl on the neurological world there, one of the things that you mentioned was side-to-side imbalances in some capacities, and this seemed to be somewhat predictive of subsequent back pain. How do you recommend addressing imbalances in movements like the side plank? Is it the question of just doing more strengthening exercise for the weaker side?

Stu McGill - 01:02:02: I wouldn't start there at all. Walking is non-negotiable for people with back pain. But we start with short interval walks, and we get them to stand tall, walk swinging the arms about the shoulders. Now, think of the usual weight room activities of things like bench press, power cleans, squats and deadlifts, these are all activities with both legs on the ground. They're fabulous for building sagittal plane athleticism. That's in the front and the back of your body. But not one of those exercises had the individual stand on one leg. Well, I've already described this. Standing on one leg creates frontal athleticism, side-to-side athleticism, which is so important for people with back pain, but also so important for people like rugby players and strong men, people who spend time loaded on one leg. It's non-negotiable. Walking is the start of building that side-to-side athleticism.

01:03:05: Then we progress to things like carries. We might do a farmer's walk, which is holding a weight in either hand and simply walking. Then we go to a suitcase carry where load is just in one hand; then we might go to a bottoms up kettlebell carry, which really adds much more challenge to the stabilizing element of the spine. So it starts out so simple, and then the sky is the limit. But you must have a balance of athleticism in all three planes of your spine to extend this resilience to pain-free movement. Once again, I criticize those so heavily who say, "Oh, just exercise." No, it's much more expert than that. Balance up and tune the back and make it resilient for all kinds of things. They just leave so much potential on the floor and it's very troublesome.

Greg Potter - 01:03:57: One of the effects of the Big Three is this acute reduction in micro-movements. Do you ever use them as part of a warm up as a protective measure?

Stu McGill - 01:04:05: Oh, absolutely. We did several studies. This was in my twilight years as a professor. The grad student who led this was one of my master's students called Ben Lee. Now, Ben was a Muay Thai fighter. I tried to talk him out of it. He'd quite scrambled and damaged. He eventually retired, but he was a fabulous character, in that he really wanted to study Muay Thai and I wanted to study spine stability. So we met in the middle and we did trials of training, normal graduate students, which generally are not very athletic, and then populations of Muay Thai fighters with the Big Three. What was so interesting was we measured stiffness in the spine, and I've already said appropriate stiffness in motor control engineers out the pain for all micro-movements.

01:04:56: When you do the Big Three exercises, some patients say, " I feel really good for the next two hours." I say yes. We measure a residual stiffness. So doing a round of the Big Three, when the person stands up, they feel in control, a little bit stiffer and less pain. Now, in some people, that stiffness lasts for 20 minutes, in other people it lasts for two hours. Well, now, let's go to some of the top athletes in the world and let me go to one I've worked with recently. He's mentioned this on the internet. Most of my patients, obviously, I can't discuss because it's a medical confidentiality issue. But Blaine Sumner is probably the strongest power lifter in the world right now. He holds the Wilks record, which is the highest combination of squat, bench press, and dead lift.

01:05:49: He starts every training session with the Big Three as a warm up to get that residual stiffness going because the stiffer the core, the more the motor control system unleashes the hips and you become a better power lifter when you can use the hips to drive a stiffened [derrick 01:06:09], which is the spine. There are NFL football teams that start every training session with the Big Three. I've worked with pretty much all of the coaches of the NFL for the last two years in spine athleticism for the players. Going back to our Muay Thai fighters, they hit harder and faster, both with foot strikes and arm strikes after training the Big Three. Adding this stiffness in a warm up enhances both resilience and performance.

Greg Potter - 01:06:42: I think I'm going to include them in my next training cycle in the warm up.

Stu McGill - 01:06:45: I hope so. For those patients who say, "Yeah, I feel better after doing the Big Three," then the programming changes. They should do half of the volume of the Big Three mid-morning and get themselves a little bit of time of pain respite and then repeat mid-afternoon. Now, you're programming two times of the day to get a little bit of pain relief. So there's all sorts of strategies. We can't do it now in the podcast, but all of these sorts of hints and expert level hacking your low back pain is in my book Back Mechanic.

Greg Potter - 01:07:20: You mentioned the morning mess, Stu. Many people wake up with stiff backs and they probably have the intuition to stretch their backs to overcome this. Can you explain why that might be misguided?

Stu McGill - 01:07:31: There are several potential mechanisms there. First of all, we measured this. We put people to bed for 36 hours. They discs of the spine are hydrophilic. They naturally suck up fluids throughout the night, and as people move throughout the day, the fluids are hydrostatically squeezed out. So at night, you're actually shorter than when you get up in the morning. But when you get up in the morning, some people, the discs are actually swollen and the pressure is higher. So if they have a disc pressure mechanism to their pain, the best thing that they can do is just get up and go for a walk. That's probably the most efficacious thing to do.

01:08:13: If the person says, "I roll over in bed and I get sharp pains," that's indicative more of a micro-movement type of pain trigger. Simply doing the Big Three during the day, practicing spine hygiene quite often settles down those micro-movements. By the way, they will slowly gristle over time and that mechanism will go away anyway. You don't hear of too many older people complaining about the micro-movement subcategory. But, can I just talk about sleep and mattress choice here for a minute as well?

Greg Potter - 01:08:47: Yeah, please do.

Stu McGill - 01:08:48: We did a study where we had people, night after night, sleep on a bed and we would video them in infrared so we knew how many times they shifted position and then they rated every mattress. We just set them up in the residence at the University, so each night they would sleep at a different room with a different bed. It was so interesting how bodies are different from both an orthopedic perspective and from a neurologic perspective.

01:09:17: The heavy male who snores, typically they do well sleeping on their back and they don't change position very much. When they slept on their back, a lot of them preferred the kind of memory foam mattress. The heat of their body cause them to depress down into the mattress and as long as they didn't move position, they found that most comfortable. But now we take a person's who's built more like you and me perhaps, or a bit more angular. In other words, we have high hips and shoulders and a little bit of a narrower waist. Typically, we change position in beds throughout the night. We don't do well in the memory foam beds because people sink down into the beds. When they change position, they actually have to work to climb up out of the depression. We will do much better with a firm mattress and a softer pillow top to mitigate the stress points under places like the hips and shoulders and put a pillow between the knees.

01:10:20: There are other people who spine position matters a lot, and then when they lay in bed and the bed is a little bit sloppy or unsupportive of their spine, they get pain triggers through that deviation. Let's take a person who lays on their back and they get low back pain. They might have large buttocks, for example. Have the person place their hands palms down under their low back. If that provides relief, we would then say place a folded towel under your low back and chances are you will wake up with less pain. We actually have a product called the PropAir, which is made for sleeping that people inflate and tune to neutralize the stress deviations on their back while they're sleeping.

01:11:05: Another thought just came to mind. As we go around the world, we'll find beds change based on culture. For example, if you go to certain regions of Asia, in Japan, for example, where the futon is very popular. It's very characteristic of the Japanese spine to not have much lordosis. It's a much flatter back, same in Korea, for example. But if you take the average Caucasian, which naturally has a lot more lordotic curve and more protruding buttocks, when you sleep on a hard surface, the low back is bridged up in the air and it's no longer supported. So generally speaking, they will report that the futon is not very comfortable for them. The book that is quite educational on all of this is a book by Bart Haex, H-A-E-X, and it's on the Ergonomics of Sleep, I believe. But he goes around the world and create some of these very interesting contrasts.

Greg Potter - 01:12:06: I'm impressed by your ability to identify which mattress I do best on just over Skype.

Stu McGill - 01:12:12: You know, that's why I get the big bucks. It's understanding the details. You can see why I get a little bit nixed sometimes when I hear people say it's in the head. It isn't. It is so precise.

Greg Potter - 01:12:26: This is not a seamless transition, but I'm going to ask you about your concepts of job coaching and what it is.

Stu McGill - 01:12:33: Well, that's interesting. We coined that term a number of years ago. Let me start with a concept called ergonomics. Ergonomics is changing the job to fit the person. It's very helpful for people who do factory work where they're repeatedly manufacturing the same part or they work in an office and the chair type and the layout of their computer and whatnot determines the migration of stress in their body. So ergonomics can be helpful for these kinds of people. However, it was only ever half of the equation.

01:13:10: Let's take someone who is a construction trade worker, a fisherman, a lumberman, a plumber, a police officer, someone in the Army, they can't use ergonomics. The only thing they have is how they move their own body. So job coaching, for us, became this blend of ergonomics plus coaching of the individual's movements to minimize stress points and manage their biological tipping points. We've done this with several groups to measure the efficacy. We did a study at a tire manufacturing plant. We put in two of our people and they became job coaches. They worked with the public health nurse at the factory.

01:13:54: Now, historically, the factory was spending about one and a quarter million dollars a year on back pain claims. After we put in job coaching, so a little bit of engineering of the job, and then personal training of the person's movement patterns, the cost of subsequent back injuries in the years dropped to about a quarter of a million. Interestingly, it cost us a quarter of a million dollars a year to put in the program. So it cost a quarter of a million to save one million. It was a four times payback. We've done the same thing with fire departments where the average cost of a firefighter's back injury per fireman's incident was about $40,000. That dropped back to $10,000 after we put in job coaching.

01:14:46: So I can give several examples of that, but that's what job coaching is and a little bit on its efficacy.

Greg Potter - 01:14:54: Very impressive numbers. Stu, can you speak a little bit about wearing belts at work to support the spine and whether it's appropriate?

Stu McGill - 01:15:02: Yes. We've actually done several studies on belts, not only in athletic situations, but also in occupational settings. You remember Home Depot years ago, it was a mandatory condition for employment that the workers wear belts. Well, I was actually involved in the debate on that many years ago, and you'll notice now that, of course, they don't wear belts. Well, let's look at some of the potential benefits of wearing a belt. There is some evidence that wearing a belt acts like a strong around the finger and it reminds people to use movement competency or good mechanics while they're doing physical work. We also know that with elite lifters, you can lift a little bit more load if you're wearing a belt. It adds more proximal stiffness to the core.

01:15:50: But then when we look at the downsides, for example, when you do study of workers who wear a belt and then they stop wearing a belt … this was a study done at American Airlines. The incidence of back injury was elevated once they stopped wearing a belt, leading this to conclude that there's some element of dependency on the belt. Then we got into other issues. I mean you're not made to wear a belt and create high pressure down that low for long periods of time. There is concerns about elevated incidence of varicose veins in the testicles and these sorts of syndrome associated with long-term belt-wearing.

01:16:33: But I was then asked by some different branches of different governments and also large corporations to write a policy statement on belt-wearing prescription. In a nutshell, it was this: if you get an individual who needs a little bit of stiffness for a temporary period of time, prescribe a belt. But no one gets a belt unless they've been thoroughly assessed, they've been coached on job coaching on how to do their job more safely. They've committed to an appropriate exercise program to start building some athletic resilience in their back and that they slowly wean from the belt. But we're dead against universal prescription, say, in a workplace. It's not the answer for back pain.

Greg Potter - 01:17:21: Lifters are always interested in being able to lift more weight and will do anything to that end. Should they just save belt use then for maximal efforts?

Stu McGill - 01:17:31: That's probably a pretty good guideline, yes. If you want to win, wear a belt.

Greg Potter - 01:17:37: Okay. Not a very good transition, even though it's so important, you're one of few people who studied sex. Can you tell us about The Economist report on your work and some of the key takeaways for people with a back pain during sex?

Stu McGill - 01:17:50: Yes, we did the first study on couples having sex in the clinic and it made the front page of The Economist. I can remember the title; it was Brokeback Mounting: Sex and Backache, which was a cheeky term. Anyway, that study became the most successful media release in the history of our university. Of course, it had to be highly managed from the university's point of view. We made front page of newspapers in countries around the world, and when you added up the readership of those newspapers, it was well over two billion people.

01:18:27: But let me now give the background to the study. Every frontline clinician will tell you that they have couples who come to them and say, "The last time we had sex, we knackered our back so badly. We are now fearful and we abstain from sex. It's not worth it." The clinicians have no guidelines at all to guide what they're going to do for that patient. So our objective was to create an atlas and guidelines for the clinicians to advise couples who come in with that issue. So that was the motivation to create the atlas.

01:19:06: So as you can imagine, we went through a couple of years of the ethics process and it turned out we couldn't recruit anybody from the university community. We had to recruit all outside and I went to some of my family doc friends and asked them to refer couples who had reported this. But I even lost a good friend who was a family physician who was quite taken aback with all of this, if you can believe it. But most of them were very onboard and said, "Yes, this is exactly what we need."

01:19:34: So we had couples. They came into the lab and we coached them to have sex in several different styles, and we measured spine motions, muscle activations, and then we did stress mapping. Then in the end we found what the best advice was to create the atlas. So the general principles are that the person on top is responsible for the movement and the person on the bottom is responsible for buttressing their back into a very comfortable position, and then they basically stay in that position. Then the atlas shows them various options for doing that. Then the clinician quantifies the pain trigger.

01:20:16: So let's say you have a male who is spine flexion intolerant. The typical missionary position would not be the position of choice. I didn't even know what spooning was, but I do now. As it turns out, spooning would be terrible advise for that male. However, if they learned to hip hinge and not spine bend, the quadruped position or doggy style is the preferred position for the male with that particular category. But not for extension intolerant driven pain. So, anyway, we created that atlas. That's still being published. There's various American and European journals that force you to parse all of this up. What are the male effects? What are the female effects, etc.?

Greg Potter - 01:21:01: It's very important work, and congratulations on all the media attention. Sex seems like a good notes when done. Before I ask where people can find you, is there a question that I should have asked but have skipped?

Stu McGill - 01:21:13: You mentioned at the very beginning that our approaches have helped you but also some of the meditation that you do, which is quite interesting. Meditation is not my area of expertise, but I certainly won't dismiss it. But where I do get concerned is those who say, "I only do meditation for my back pain." Meditation is never a replacement for the mechanical approaches that precisely address the pain trigger. They certainly can augment the person's state of relaxation, and some of the evidence that I'll give is there's some very nice work done by my colleague, Bill Marras, at Ohio State University where he created a link between personality type and certain types of back pain via the reaction.

01:22:01: In other words, he would bring in people. They were workers doing factory jobs. Then he did a personality profile of each worker. Then he had another person, the workers never knew this, but it was a boss who came in and yelled at the workers. Well, he had instrumentation measuring the workers. When the timid personality was yelled at by the boss, they had a visceral response to that stress. They clamped up their body. The muscles contracted. They loaded their joints. In other words, there's no distinction between psychological elements of pain and body reaction and the physical. They're all one. So interestingly enough, they stressed their backs because of their personality.

01:22:49: The next personality type would be a more overt type of personality. When they were yelled at, it didn't create that visceral reaction. I know I have a very dark side that I have to keep control of, and I will have a visceral reaction to certain types of stresses well, and it's the meditation or the philosophical approach that mitigates the physical reaction to that stress, be it mental, be it a social stress, etc. So as I said, it's not my area but I know enough about it that we don't dismiss it, not at all.

Greg Potter - 01:23:27: So it's potentially used for adjunct treatment.

Stu McGill - 01:23:29: Oh, of course, but you know the answer is: it depends. It will be quite important for some and they're relevant for others. But, at least, doing the assessment, when we do an assessment, we have a few check off boxes where I'm recording their personality type. I will stress them with certain questions. I want to see the reaction. Again, people think all we do is a physical assessment. Not at all. We're reading the person the whole time.

Greg Potter - 01:23:54: Finally, Stu, what's the best place for people to find your work?

Stu McGill - 01:23:58: Well, they can go to the medical literature, but they're going to be a long time synthesizing all the parts of it. That's why I wrote by books. I wrote clinical texts for doctors and then I wrote my book, Back Mechanic, for the lay public. I wrote Gift of Injury for the strength athlete recovering from back injury. I wrote that with world class powerlifter Brian Carroll. So for those books, we have a few videos as well. If they go to BackFitPro.com, and it's just how it sounds, BackFitPro. com, they will see the various books and resources. For the clinicians and trainers who are listening, we have different courses as well. So if they click on the Courses tab, they can see what course are being offered and what locations in the world, and there's a certification process that trains people to obtain the skills so they can converge on a precise understanding of the client's pain mechanism and really direct the most appropriate intervention. Of course, books are also sold on the various Amazon sites around the world.

Greg Potter - 01:25:06: You've been hugely generous. Thanks so much for your time. It's been a great pleasure to speak to you.

Stu McGill - 01:25:11: Greg, you're very good at what you do. I've enjoyed your questions and they were very insightful and quite penetrating, so good for you.

Kendall Kendrick - 01:25:22: Thanks for listening, and come visit us soon at humanOS.me.