How to Fix Your Back Pain with Dr. Stuart McGill

welcome my friends to the Bob and Brad podcast my name is Mike Keenan and today I'm interviewing Dr Stuart McGill who is an expert on back pain his laboratory and experimental research Clinic investigated issues related to Casual mechanisms of back pain how to rehabilitate back pain people and enhance both injury resilience and performance so without further Ado here is Dr Stuart McGill welcome back to the program Stuart McGill thank you for joining us today good morning Mike today we're going to be talking about back pain but before we get going would you mind giving our

audience a brief story of your background no pun intended there I was a professor for over 30 years at the University of Waterloo uh when I started uh uh I only had one question and it was to investigate how does the spine work and we developed techniques to measure stress concentrations in the various parts of the back and it was interesting that the pain that individuals reported was almost always related to where the stress concentration was in their back and we learned that if they moved into a certain posture that would increase the stress and

their pain and moving away from it decreased their their pain and stress then we created a uh a cadaver lab where we would take spines and then apply the stresses to various parts to see what kind of injuries uh occurred and that helped us complete the loop in studying real people and then cadaveric spines and then we started an experimental research Clinic which was rather unique because uh we started with two hour assessments and my medical colleagues said to me what are you going to do for two hours and I said we're going to first

of all listen to their story do pattern recognition try and understand all of the variables that were leading them to be disabled with pain and then assess them very thoroughly to get a precise understanding of the pain pathway and then address it either by eliminating the pain causing mechanism or changing something in their life to address that once the pain was wound down we could then build them from the ground up to regain athleticism the other unique part Mike was we followed up with every patient we ever saw in the history of the clinic it's

the only clinic in the world that I know that has done that so we know our clinical score depending on the various subcategories of pain that the person had so that was the story of well 40 years now so where can people find out more information about you and your books well there's no need to find information about me it's about them and uh I've written uh several clinical textbooks for my medical colleagues but I wrote a book for the lay public who are suffering uh with back pain it's called back mechanic it guides them

through a self-assessment of their pain and then gives them thoughts on how to wind down that pain and then rebuild as I described earlier uh it's available on our website which is backfitpro.com just as it sounds if they're looking for a clinician who's trained in our techniques they are listed on that website as well um or they can buy the book from Amazon as well everything's on Amazon now I'm afraid most of it is okay we're gonna get into the back pain question so the first question is how does stress affect back pain I'm assuming

you're talking about mental stress yeah I suppose there's physical stress too we're going to talk about mental stress all right I don't see a great dichotomy or a separation between mental and physical stress the way many people do and the reason I say that uh is this my colleague another spine professor at Ohio State University Bill Maris has done some really interesting studies where he took groups of workers uh now before he started he did personality profiling on them then they would work at their Factory job and it was a ruse one of his graduate

students would come in and pretend to be doing a scientific experiment then he would come in and really berate the graduate student create a lot of mental stress a very stressful situation and then he he measured the response of the worker then the the graduate student said oh we've got to repeat this experiment and then they re-measured the physical stresses on their body as it turns out people who have a very uh shall I say a timid uh subservient kind of personality the mental stress was manifested in their body they began to crush their joints

with more uh over activation of their muscles as they tensed up those who had a more overt outgoing kind of personality it was like water off a duck's back they didn't change the physical stresses so how a person handles mental stress uh is personality linked as one variable in the example I'm using now so the next question is uh all biological systems thrive on stress whether it's mental or physical no stress you have a weak very unrobust fragile system stress causes adaptations that make it more robust but every system is governed by a Tipping Point

if the stress is below the Tipping Point it's building it's anabolic it makes the person more robust if it crosses the Tipping Point then uh things happen to the various systems that cause them to break down if it's a tissue then the tissue eventually will become injured being physically fit there's a psychological and a physical robustness profile that goes along with that when a person comes in and they say you know the last time I sneezed or I tied my shoe I had an acute attack in my back if we teach them a movement hack

so if it turns out they sneeze put you down this way and they have a type of a disc bulge that that is triggered by a loaded flexion pulse then we show them that that was their mechanism after we've attested and established that and we show them sneeze up a chew and they have now uh bulletproofed themselves from future attacks so the physicality and the movement pack gave them mental uh confidence or they might say oh I threw my back out when I tied my shoe well we might again establish their mechanism to be flexing

and bending forward if we show them you know they could tie their shoe this way which uh doesn't give them confidence and it might trigger their back pain but if we showed them to put their foot up push the knee ahead take the hips down to the Target being the heel of the foot and then tie the shoe move the hips out of it they didn't go near their physical pain trigger and now the mental anxiety evaporates so mental and physical stresses go together our interventions are always targeting both that's that's a lot of thought

put into that it's a good answer well hopefully that's what we do all right our next question is does sitting too much cause back pain well every question you ask me I have to pause and and put thought into it because these are not simple questions the epidemiological studies that study the incidence and prevalence of back pain in the population show that in general those who sit more and longer have more back pain they also have other uh illnesses my my friend uh Kelly Starrett for example I think his book is called sitting is the

new smoking there's a whole host of cardiovascular concerns with prolonged sitting uh back pain Etc but now I'm going to give you the other side of the coin let's take someone getting to my age now when they were younger sitting caused their back pain going for a walk was relieving but then when they get older the spine becomes a little bit more stenotic a little bit more arthritic and then they will say you know what going for a walk hurts my back and sitting provides the relief so if I did an epidemial logical uh study

on the broad population it would show no effect but if we study young people and then older people you get a differential story an impression on sitting now let me add to uh this story a little bit more and talk about uh young people if a person sits slouched for eight hours at the computer they are stressing the posterior part of the annulus of the disc which in of itself may not be that problematic if they have an open fish or disc bulge which I can show there you can see is as I'm bending this

joint forward the collagen fibers split and delaminate um and the nucleus creates a little uh bubble or a small bulge but if I posture the spine upright and squeeze you see the whole disc uh change shape but it doesn't drive the Bulge posteriorly so it's a hydraulic uh effect well I said uh this has to be combined with something else so let's say the person then goes to the gym for one hour at night or 45 minutes and lifts with very poor form they're not relieving the eight hours of stress on that annulus from sitting

they're actually compounding it by moving poorly under load at the gym and now they think it's so unfair they sit for eight hours they get back pain they go to the gym and they get even more uh back pain when they sit had they been conscious to move better and not stress the uh annulus in the gym that would have built uh robustness so sometimes it's very difficult to ferret out the links between these various things like sitting uh and anything else but the the the bottom line message to all of this is uh if

they're at the gym and they sit for eight hours as part of their job it's more important to use the hips when they're at the gym using uh hip hinging for example to pick up a load rather than uh their spine uh and that kind of thing be careful with uh exercises that put the spine under load and big uh movements uh and and rotations so there's a little bit of a an essay I suppose on becoming more resilient and the the sitting cause pain oh I should also mention rest breaks say a person uh

sits at a computer the rest break shouldn't be sitting in the lunchroom it should be going for a walk it's the mechanical opposite to relieve the stress but let's take someone else who's a uh uh they walk for their job I guess in the old days it would be a postman there aren't very many postmen left anymore but say they're a carpenter or a plumber then sitting down could be their rest break so there's a lot of moving parts to your your question but I hope that little essay gives some guidance as to uh does

sitting too much cause back pain it may and it may not yeah I used to work in the clinics a lot more in therapy and like I typically walk three miles a day around these large facilities in the last few years I've been sitting down a lot more and I figured out that I need like every hour I need to get up and move around or stretch or do something because it's just gets old sitting in that long of time on your back well that would be part and parcel of our uh very thorough assessment

that we do we find the thresholds that cause pain in the thresholds that produce relief so if if uh walking once every hour works for you that's fabulous and other people it might be every 30 minutes just go for a three minute walk or I think we're going to talk about stretching later but I could also give some specific stretches that combat the cumulative stresses of sitting in some people sure all right we'll go on to our next question so how does obesity contribute to back pain that is a fabulous question I've been involved in

several uh lawsuits as an expert witness actually around this issue so it's it's a very very interesting we recognize that there are many different Pathways to back pain consider the obese person with the kind of obesity where the belly comes down and hangs right on the thighs we would consider that a massive hydraulic jack so if a person has spine instability and I'm going to use this model to demonstrate what exactly that is this disc is normal it's not injured and this disc is normal it's not injured this one is injured it's lost stiffness and

stability so if I apply a general movement torque to the top of the spine you can see how most of the movement is occurring at the Joint that is lost controlling stiffness those are called micro movements in a sheer mode those trigger off shots of pain and clinically the purse person says oh no I move this way and my right toe goes numb I move that way and the pain flashes into my gluteals now it's on the left side of my back a person that reports that kind of migrating uh pain uh is usually has

some joint instability well that obese person that we were talking about doesn't have that migrating type of of pain profile very often it's very rare then uh they uh have a concerted effort to lose a lot of weight so interesting once they've lost the weight they now have unstable pain patterns in their back so they've now increased their pain because they lost the weight um some of the lawsuits I've been involved in is uh surgeons for example who will say to a woman who has a large chest that is causing your back pain we're going

to surgically reduce the size and the mass and therefore uh reduce your back pain and it wasn't working out very well and there was a lawsuit and I was asked would I offer some uh expertise every single one of these women was in the obese category whether they had a breast reduction or not the effect on their spine was so minimal that it it really wasn't changing their back pain but if you take a non-obese woman uh who is considering a breast reduction then you do the test and the test is simply this um stand

and put your fingers and your thumb on the erector spinae and you will find the switch point if I my chin forward and poke it you will feel the erector spine a become active and that activity adds compressive load to the spine can I bring my hips forward and retract my chin to shut those muscles off if I can I can now stand in a very relaxed Manner and those muscles aren't chronically contracted into a muscle cramp but a woman who has more mass anteriorly they have great difficulty in shutting off those back muscles so

in the non-obese you see it becomes more of an issue and quite possibly that is the mechanism of their chronic uh fatigue muscle um ache anyway there's a little bit of a an essay I suppose weight can also just as it loads knees and feet and ankles and causes chronic pain it can also cause that in the back but a very thorough assessment will lead the person and their clinician towards the right intervention for that particular subcategory of back pain that they have but it's not as clear-cut as people think so if someone loses weight

and you work with them and they sell back pain do you just work on core stability or well we don't just do anything we we refine the mechanism with some Precision through uh uh the assessment and then we allow the results of the assessment to guide us as to what they need generally speaking if they now have joint instability in the micro movements triggering pain we will give them stabilization exercise we will change uh say they are doing full end range stretching that is causing the laxity to continue or something else in their life that

we can intervene on and and make a difference um so it might be a core stabilization maybe they have a stiff hip or well you know it could be anything you know Mike yeah there's no right correct answer for everyone exactly so our next question is how does smoking affect back pain ah smoking is such an interesting uh variable because it has a delayed effect on health you know there are people right now who are saying oh posture doesn't matter in terms of back pain well if you studied a group of young people who smoked

you you wouldn't find the link with cancer because it takes a long time of exposure to smoke to uh create the cancer the same with posture and the same with all of these other things it's a very delayed effect and you know you go back into history and look at the smoking uh the the smoking Lobby in the 60s 70s and 80s and how effective they were at delaying legislation that would help prevent uh cancer so it's a it's a fascinating um topic we studied smokers who were now end stage they developed uh COPD chronic

obstructive pulmonary disease I guess their lungs had lost elasticity a healthy lung uses the diaphragm to contract and suck air in uh and then the elasticity allows the air to expire people who've smoked and now have COPD have lost the elasticity and they breathe with their spine what we would measure was they would Inspire with spine extension and then expire with spine flexion so every breath was a load on their spine and now we could measure why they had back pain so there was an example of how smoking over time led to uh their back

pain and we would call that a disease of choice because smoking was a choice but it's a very horrible situation to be in at the end of life there are many other uh Pathways that have been proposed that we haven't directly measured but those who measure uh smokers and smokers cough for example the coughing mechanism uh if a person has a cold they'll say if they're susceptible to this oh after I had my cold I I had real problems with my foot going numb as I've been forth and that would have obviously been stress on

the disc so coughing uh they're again a different Fitness profile than smokers versus non-smokers all of these things have been suggested although we haven't directly investigated them sure I like your uh mustache coffee mug there yeah I ke's gifts and and this one it's it's kind of fun you have to guess whose mustache it was based on the code and the answers on the bottom of the mug I think I'm close to uh uh nine and uh oh uh oh Friedrich nietzke and uh who is uh nothing yes and number 12 Leon Trotsky I I

know he was a Russian I don't know any more about that I was gonna say I don't know half of those names okay next question I guess object here specific sleeping positions for back pain relief may I introduce some mechanics of sleep to give a perspective on the spine and then that will allow me to give a reasonable answer sure okay the discs of the spine are avascular they have no blood supply so the discs receive nutrition every day and wash out the waste metabolites by a diurnal variation throughout the day you squeeze the spine

with hydrostatic compression from daily activity which squeezes fluids out of the disc and during the day night you with osmotic pressure suck up fluids through the end plate of the disc through the top and bottom so that diurnal flow is a requirement for a healthy spine well now we're going back to the end of the former Soviet regime and this is kind of an interesting story uh the former Soviet Bloc had a conference in Poland and I happen to be the Canadian delegate who is invited to review the Soviet Cosmonaut science that Nolan had ever

ever seen before and as you know when you go into space the concern is becoming osteoporotic there's not load to stimulate bone and you lose it while their data suggested that you lose bone throughout your body except in two places your spine and your skull and when you go into space your lymphatics on Earth are are milking Against Gravity pulling fluid up as soon as you go into space and you lose gravity your face swells you get what's called a puffy face syndrome but your brain swells so much that it pushes puts pressure on the

skull and actually builds mineral content but the discs also swell and put the spine under stress the American astronaut data coupled with the Cosmonaut data show that a lot of astronauts and cosmonauts are actually on the painkillers for spine pain being because of the extra expansion it can be two inches in uh some Spaceman so what is the equivalent on Earth and I'm sorry for that background but it motivated a study that we did with students where we put them to bed for 36 hours and measured their spines swelling uh their spines kept growing even

after eight hours of bed rest until they went into stress you can imagine having the flu and laying in bed all day chances are you will have spine pain because uh of the swollen discs the optimal amount of bed rest time for most people is about eight hours if you stay in bed longer than that they continue to swell and you actually create uh more back pain so now let's talk about uh sleeping positions when people wake up in the morning some say you know I've got back pain I said good describe the character to

me and they say it's an ache and it's right and they can put their thumb right where that back pain is and I'll say ah um lay on your other side or take a folded pillow and put it under your waist in that position or lay and push one heel away in other words change the micro posture just a little bit does that change your pain and if they say yes we then measure to see if they have joint instability and it almost always is so they lay on their side and the joint off a

little bit to one side causes the ache and the familiar symptom in a single location and yet when they adjust that that very specific ache goes away or it might be a numbness in their toe uh for example um but the next person doesn't have that they might have a swollen disc in that particular disc might have a disc bulge in it or a fractured end plate or something a micro fracture and their kind of pain is just a general stiffness uh in their back so what they might do is pull their knees to their

chest to try and alleviate that um that can be problematic because when they pull their knees to their chest they fire off a stretch reflex which their brain interprets as an analgesia the analgesia lasts 15 minutes and then they have that ache and the want to stretch uh all over again so this was studied uh through the Liberty Mutual Insurance Company uh Professor snook LED that study and uh he asked those people to avoid pulling their knees to their chest and forward bending just in the morning and that particular subcategory of pain uh resolved so

you asked me about uh positions there is no position for uh all people just like everything else in back pain do a thorough assessment figure out the cause and then lead the person to their sleeping posture that migrates the stress away from the pain mechanism at disc bulge certain types of disc bulges the person might get relief by sleeping on their tummy a person who has a little bit more of an arthritic trigger that would be poison terrible position um can I finish off talking about mattress types yeah go ahead there's a little bit of

a science that's been established uh on this and we started it actually with our study putting students to bed we we then were asked to do a contract on different mattress types and measure the mechanics and we created the fidget index and all these kinds of things we would watch people sleep with infrared uh cameras and count the fidgets and measure the spine stress and that kind of thing um you've heard of a memory foam style of uh mattress uh the body heat causes the person to create their own mold down into the mattress those

seem to suit heavier men that snore it sounds like a funny category but typically they're heavier they lay on their back and they don't change position and those are the people who report great comfort with a memory foam you take someone who's a bit more fidgety and they're changing sides throughout the night the memory foam turns into a problem because their body sinks down into the memory shape and they have to do work to climb up out of the depression and roll over onto the other side so for those people we found that a stiffer

mattress foundation with a very generous pillow top because generally they are are not so heavy and they have uh bony or hips and shoulders and that kind of thing so a firmer foundation with a generous pillow top was a preferable mattress for that particular body type and sleeping style so there you go there's a little bit of an essay on uh astronauts all the way through to choosing a mattress I'm learning about so many variety of studies in this podcast it's all fascinating to me well that was that was what we did our questions throughout

my career as a scientist we would listen to clinicians and uh ask you know what what do you need answers to and they would give us the questions and if we couldn't answer them well that became the topic of our next study so that was our uh Mo for 30 some odd years this was Waterloo that's in Canada I'm guessing right yes University of Waterloo yeah there's a Waterloo Iowa but you tell me you're from Canada so I got confused for a minute yeah it was uh University of Waterloo in Ontario Canada all right next

question gets a little long here are there any alternative therapies for back pain relief that you endorse and for our audience I'm referring stuff like acupuncture Chiropractic Care massage therapy and mindfulness techniques right I don't endorse or condemn any single thing there's always been someone somewhere who has been helped and hurt by every single one of those things that you uh mentioned so again I have to go to Scientific principles to create a logical uh answer and a uh logical application to help the individual so the first tenant there is let's take Chiropractic since since

you mentioned it if you went with the same person to three different chiropractors would the experience be identical and I think the answer is no so the going to see a chiropractor is is very dependent on who you go and see many of the clinicians who are in our back fit Pro family of clinicians or chiropractors and they will not manipulate a person they are are very Savvy and a broad spectrum of uh interventions so they match it to the individual um take a person who has joint in stability which I showed uh with the

model uh it doesn't make sense to apply a chiropractic manipulation to that it would probably make them worse and yet I could tell a story uh we had a uh an Olympian who competed both at the Winter Olympics and the Summer Olympics uh they had a particular uh type of back pain we were able to address it we changed their training they got rid of the acute pain triggers but they still had a little nag and it turned out to be in the quadratus lumborum just on one side I couldn't get that one muscle to

quieten down I sent them to one of our Chiropractic colleagues and with three manipulations over three days it was gone so we've also measured by the way and investigated the mechanics of Chiropractic sometimes they quieten down local muscle spasms sometimes they induce local muscle spasms so do you see no one can can endorse or condemn any uh one of these things I think of uh I I did the keynote lecture at the international fashion meetings this this past fall and our experience with uh fascial pain and some of the myofascial syndromes is uh someone who

has pain triggered throughout their body with a specific movement they've been traumatized in other words the brain is perceiving that fascial stress as pain and if they draw their pain map they show oh they get a headache they get pain in their swirling around their shoulders and swirling around the hips it's a very swirly kind of expression of the pain and uh you know now it's time to have a a little bit of a psychological intervention a little bit of Confidence from graded exposure to the movement that is causing that particular kind of pain trigger

um there are some massage therapists and Rovers who just generally massage and and they might cause more pain sensitivity in a person with joint laxity but less in someone with the situation I was just describing in fascia you go to the next massage person and they're very targeted they leave a lot of the tissues alone and they just might release a psoas for example for someone who is sitting a long period of time getting out of the chair and having a problem getting back to Upright because of what we would measure not guess measure to

be a tonic Tone If you will in their psoas specifically so there's a little bit of an essay I suppose um a thorough assessment once again I sound like a broken record gives the understanding of the specificity of the pain pathway of that particular person and will guide the appropriate intervention that could involve any of those things I have colleagues around the world in all of those professions who I would refer individuals to at certain points in time I heard you reference once on a different podcast you did that people often think of back pain

as one thing and then you said do you ever say I have leg pain no you say I have ankle knee hip pain when you say back pain he's like there's so many nuances and I just I don't think a lot of people realize that yeah you know this term oh you've got non-specific back pain and scientists will study people with non-specific back pain I've never read a single study in my life of someone who has non-specific head pain it doesn't exist I think it's an excuse by clinicians who are either time constrained and they

don't have time to assess a person to really get a specific cause of their back pain or they don't have the skills and know how to do it so they say you know it's their get out of jail card uh you know you've got non-specific pain it doesn't help anybody in fact it ends up with a lot of physical and mental anguish sure all right I don't have any opinions do I ah next question uh pretty basic one is stretching good for back pain ah yeah well you know how my answer is going to start

on that and it's adjustment will always show uh whether stretching will uh help or hurt I've mentioned how uh certain stretches fire a stretch reflects and give the person 15 minutes of analgesia so they think the stretch was a good thing to do not realizing that they just increased the underlying mechanism so it triggers um uh easier in the future uh so let's take a person for example who we measure uh a flexion and tolerance we might have them on a stool and we'll say sit upright grab the stool and pull up 10 pounds with

each arm does that cause your pain no no it doesn't good just put your hands in your lap and slouch does that cause your pain yeah a little bit there it is now bring your chin to your chest oh yeah my toe just went numb so bending forward we just proved triggered their back pain and yet their therapist might have said before you get out of bed every morning pull your knees to your chest and interestingly enough that will uh cause 15 minutes of analgesia and they think they did the right thing and yet pulling

the knees to the chest if they had this particular kind of uh delamination in the annulus caused the disc bulge to grow uh and by the way we measured this I'm not talking through my hat we can watch that disc bulge uh on MRI we would take a person and flex them for a while put them in the MRI and see their disc bulge touching the nerve root and then 15 minutes we we get them out of the MRI they might lay on their tummy they might sit with a lot of lumbar support they might

stand and push their arms overhead to the ceiling and deeply inhale and then we re-measure the size of the disc bulge 15 minutes later and it is now uh reduced so we would then say stop stretching don't listen to the 15 minutes of analgesia and in about a week they start to say you know I don't have that need to feed the stretch reflex and my back pain now is generally less throughout the day so that is a little bit of a start on is stretching good or bad I've given you some bad but now

let's talk about the good let's take a person who sits a lot uh throughout the day and in some people not all but in some there is a neurological facilitation it's called neogenic facilitation of now many people will say the hip flexors And yet when we measure it it isn't the hip flexors it's purely psoas so when they stand up they feel this tightness in the front of their hip and it's hard for them to get upright and pull their hips through so they can stand it ease and relax so we might prove to them

we'll show them where their psoas tendon is now you can palpate it we ask them to stretch the hip flexors with a lunge but they can feel that there is tension there but it's not in the psoas and then we show them when they put the arm overhead and strictly push to the ceiling and lean away just a little bit off now they've just stretched the psoas tendon and when they stand up they say you know all of that is gone or I'm just going to move back so you can see me now uh they

might have a very strong fascial connection with psoas so if you follow the work of Tom Myers for example in anatomy trains this is wonderful wonderful work where uh we would take his particular science identify that anterior fascial chain feel the psoas tension and then as the arm is stretched to the ceiling internally and externally rotate the shoulder and one rotation winds up the fascia and you can feel it in the psoas by palpating it with your fingers and the other way it releases it so their particular psoa stretch would be involving winding up and

releasing the fascia to have an effect very distally uh in the uh in the body others I know Bob and Brad did one of our thoracic spinach extension stretches for older folks that was on a few weeks ago uh we might do a standing stretch for office workers you said uh at the beginning of the podcast you like to get up and go for a walk sitting at your computer every hour well if you stand up just let the discs equilibrate for maybe 10 or 15 seconds put the arms overhead wait another 10 or 15

seconds lean back and push strictly more overhead and then finish off with the Deep inhalation jacking the diaphragm up off the pelvic floor and then release and when you re-measure the tension in the extensor fascia and tissues you will find that it is now relieved allowing the person to stand with less stress so again there's a a bit of an essay on is stretching good can be very good or very not so good the assessment will always guide the way yeah I think each circumstance is very individual for a question like that obviously all right

next question if someone has strong back muscles can it help with back pain sometimes the science doesn't show a strong relation which surprises a lot of people in fact many people hurt their back in an effort to increase the strength thinking that that's going to relieve their back pain what the science shows actually is if you separate strength from endurance endurance is much more protective for future back pain than uh strength is and this science started off in Denmark when I was a young scientist and we saw this many times throughout my career I remember

we were studying men who chromed uh car bumpers for Chrysler the car bumpers weighed uh 80 some odd pounds 40 kilo perhaps and we had something like 76 workers all doing the same job so the physical exposure was controlled 26 of them I and I might be off on my numbers this is going back quite a few years uh but 20 some odd had an acute attack sufficient for them to miss work every year and the rest of them never had disabling back pain what do you think that and and we spent half a day

measuring the health profile of every worker what do you think the differences were between those who had an acute attack every year and they missed work otherwise they were fine versus those who never had a back issue do you think they had stronger backs or weaker backs they probably had stronger backs but they're probably doing it with improper form so the ones who had stronger backs lifted with their backs and they lifted less with their hips and legs so they would bend over and pick up the bumpers with their uh back and those were the

ones who uh had less muscle endurance but they were using their backs their backs were stronger but they were disabled uh at work the ones who were much more robust had less back strength but more muscle endurance and they would bend using a hip hinge and their hips and their legs pulling their hips through walking with appropriate control Etc in other words they moved better and had better form so you you hit the nail on the head uh you know it's an epidemic that's occurring right now with patients coming to see us and probably coming

to see you how many of them have been injured by therapists and trainers doing deadlifts believing that strength will reduce their their back pain um there are athletic competitions where they will take Olympic lifts and who can do the most of them in a certain period of time or something like that well the Curious Thing is in the Olympics they never left more than once so endurance isn't part of the equation strength is part of it but they lift perfectly they never break form and in fact if an Olympic lifter gets hurt it's because they

broke form and then these athletic events that are bastardizations of Olympic lifts they will lift multiple times they break form which in this in this expression of endurance strength uh that that's a problem in terms of uh injury so always if you are building strength and you know we build athletes we're all about building strength but we make sure we build an endurance and a pristine form underneath the movement so that they can build strength with uh uh several some robustness um another thought that comes to mind with muscle strength on the pro side is

that having bigger muscles reduces load on joints and I'm going to talk about our experience with Elite bodybuilders consider my skinny arm here for a second and let's say the biceps Flex the arm if I had a oh let me talk a little bit more about the mechanics if I had an object in my hand that weighed five pounds the bicep connects to the Bone uh 1 15 of the distance of the lever of the mass so in other words for me to hold five pounds at this distance from my elbow requires 75 pounds of

force in the bicep because of the mechanical disadvantage to lift five so the joint pays a penalty now of 75 pounds just to live five pounds but if I had a bigger bicep and double the moment arm I would now be down to 37 and a half pounds of force in other words double the moment arm of my muscle I just half the load on the joint and this is exactly what we see in bodybuilders massive uh uh bulk in the erector spine in fact I one of my my uh patience is a Mr Olympia

competitor when I measure the erector spinae bulk in his back it's twice mine which is uh astounding so when he lifts uh just say uh I don't know 400 pounds uh his back is only seeing half of the spine load of what I would see because my muscles have half the wrench handle distance to extend my back so having big muscles spares your joints now here's the interesting thing bodybuilders put a lot of mileage on their bodies but they're so massful and stiff that the stiffness and the mass holds their joints together but you know

if you damage an acl ligament in your knee you get joint laxity typically their joints are getting lacks but just like our discussion of obese people their Mass holds their joints together then as a consultant I will work with them as they return to civilian life they lose a hundred pounds of muscle they lose the stiffness in the moment arms now the joints that were loose but were previously held together with muscle mass the muscle's gone now they ache their knees ache their spine aches and when we measure it it's the uncontrolled micro movements so

my message to them is if they are going to do that to their bodies and put that much mileage on the joints for a long period of time they as they return to civilian life they're still going to have to train a little bit to keep the ache out of their body and then over time again when they reach my age nature will stiffen the joints and uh all that looseness will uh reduce and go away but if if they retire in their 30s or early 40s say they're going to have to lift and train

at a more moderate level for the next 20 years if they want to remain pain-free but in any way we'll just finish off the strength if you're a trainer and you're listening to this there are so many better ways to train back strength than doing deadlifts for the average client if they're a power lifter you've got no option of course but uh you know if I just simply did a air squat push one hand into the other overhead push the hands activate the back muscles squat back and as deep as I like as long as

I'm containing most of the motion to the uh hips uh I can maintain sufficient strength for the average person to avoid back pain and still be very robust for life but anyway there seems to be a disconnect between getting someone out of back pain doing stabilization exercise and then when they're out of pain the trainer will say okay well now we can start doing deadlifts there is a lot of transition exercise before you get through to uh to uh deadlifts now that's in my book ultimate back Fitness and performance by the way I'll put a

plug in there on the way to transition through to uh before you get into the heavy performance strength endurance power type of exercises how does someone build endurance for their back then because you mentioned that earlier great question we investigated that in several different populations of ordinary people police firefighters different athletic groups Etc and most of the time the science kept showing uh what we call the big three uh is probably the wisest way to spare the spine and build endurance so it's those exercises built on a Russian descending pyramid of programming so I can

explain both those things first of all we have a spine which is a flexible rod and no engineer would stack a bunch of oranges and put a load on top and expect it to Bear load so the role of the muscles first and foremost is to stiffen that stack of oranges or stack of vertebrae and allow it to stiffen up and bare load so you need guy wires in the front of the spine in the sides and in the back so uh in the back uh exercise for most people to start would be a bird

dog we would do that all in all fours on the ground if they're hip replaced they might do it standing at a table uh there's all forms of uh back uh bird dog exercises those are contained in back mechanic my book for the lay public for the side we would do a various family of side planks we might start simply on a wall for someone who's just a beginner can you see me um where they are side planking on a wall and then slowly they will move uh supporting the side plank with the elbow and

knees and then the elbow and feet and then we'll do a rolling uh for example uh on the floor I I don't know if I can get on the floor because you won't see me but if I did a front plank and then just tap the elbow and then come back very quickly I will start to create great rotational power as well but it's driven by the shoulders and hips and not through the spine itself so to create in fact the person who I've measured in the world to have the strongest rotational core does doesn't

do a lot of rotational exercises they lock their back and they might do a land mine pivoting around the toes um I'll tell you who it is it's Pablo satsolin the chairman of strong first uh incredible rotational strength but he does it through drive he converts hip power to rotational strength Mike Tyson would be another example who he doesn't do a lot of spine twisting it is footwork it might be a drop step rotate hook the lever come around you know what I mean it's footwork through the hips and uh converting the hip rotational power

through a very solid core and then expresses it the the shoulder the front of the core mechanism the abdominals we might start with a modified curl up which is very little spine bending if you look at the book you will see how we would de-stress the spine by putting the hands onto the lumbar spine bending one knee to take some tension out of the neural uh pathway the sciatic root and the femoral root and then they just begin stiffening the core with a lateral flare don't suck in don't push out just push the fingers out

laterally like that and then lifting the head neck and shoulders very small amount off the floor other people we might lay them on the floor opposite arm opposite leg hover them up to uh sorry that was the same side opposite arm opposite leg hover them up to 30 degrees and just tap the arm and foot on the ground every five seconds or so um a few more programming notes hold those 10 seconds for the average person is it going to get you to the Olympics no uh will it help with back pain 95 percent of

the time and we've measured that it will help um if you were to do three 10 second holds of the bird dog on the right three ten second holds on the left brief rest then it's a descending pyramid and set design so then it would be two on the right two on the left one on the right and one on the left and repeat those for the side plank and whatever you're doing for the abdominals and then you might go to a four two one or a six four two or whatever but keep it as

a descending pyramid as long as there is a motivation for uh back pain uh oh the final thing is never doing exercise every day there's very few things in the health rubric that you should do every day I mean I recommend breathing you should continue to do that every day uh you should drink water every day but everything else I would suggest say for the big three just do them six days a week always take that one day to allow complete rest and the adaptations that you've been stimulating through the week have to occur and

some people fail because they never create the adaptation so don't do anything seven days a week except breathe and drink water maybe sleep too yeah yeah but you know I suppose you could go a day without and and you'd still uh live but uh no I agree but let's add sleep to that uh list anyway I don't know if that answers the question it's a bit of a long I'm sorry I write essays or not you're just thorough the I I hope I am the people who come and see us no one gets back pain

and they say oh we'll go to backfit Pro or see Miguel or one of the clinicians every one of them has already seen several clinicians and they've failed you know please go see your clinicians and I hope you get better but if you don't those are the people that we see so we have to be thorough I should say for our listening audience this is on video on YouTube where Dr McGill was demonstrating all these things he's talking about so you can visually actually see it all right my next question is what is more important

spine stability or Mobility yeah I know there are some people who say oh it's always more important to have Mobility first or stability first and the answer is we're talking about a balance here and it depends if you have sufficient stability then you would probably do well by getting more Mobility uh if if you have sufficient Mobility then you probably would do better with uh stability and the the other uh beginning question would be do you have pain or not um so if they have back pain the assessment will show what is needed either stability

uh or mobility and it might be uh not back Mobility it might be Mobility at the hip uh for example you'll see someone with a pre-arthritic hip and they can't sit with full hip flexion so when they sit down uh they run out of room because of the arthritis right here and any more hip flexion occurs by turning the pelvis and the spine so if they sit in a low couch for example they have put their spine in distress and if that is their particular pain trigger they've got back pain so what can you do

about mobility in that pre-arthritic hip and the answer is not too much you might be able to get a little bit of Life uh left out of it with some gluteal activation exercise sometimes but for those people the hip replacement and by the way I'm one of them back pain disappears after they've allowed Mobility to return in the hip with a fake hip a prosthetic um hip but going back to our science uh one of my I think he was my last PhD student uh Professor Jordan Cannon who's now a professor of at my old

alma mater at University of Waterloo um it was so interesting when you looked at the work done by Tim Hewitt on ACL injury so knee ligament injury uh women in the NCAA basketball have six times the ACL injury rate than men and he wondered why um well he found it was a combination of things but lack of core stability not Mobility lack of course stability was one of the major predictors and he uh devised experiments where he would put the women on a box and they would jump off the box and land on the ground

and if they landed on the ground and the knee hinge ankle hinge and hip hinge were in line that was a very protective motor control pattern then the ones who were at risk of getting ACL injury when they landed the knees would Buckle inward just a little bit what he found was doing our big three coupled with hip external rotation cured that flawed mechanic so when they land the core stiffness allowed the gluteal muscles to pull the knees out and they would land with a resilient pattern because the knee tracks where the hip tells it

to go because of the gluteal muscles drive internal external rotation which affect knee valgus and Mobility the knee goes where the hip drives it to go and the ankle allows it to go so talk about stability and Mobility uh it depends on what the person was lacking in their particular mechanism as to what was most important but he did trials for ACL injury with the core stability uh exercises and and the hip mobility and he brought the injury rates of females which were formerly six times right in line with the uh males we found exactly

the same thing uh with back injury uh generally speaking as well so uh there's a a little bit of a start uh I can go on with more uh essays if you like in terms of transitioning out of back pain and then moving on to Performance uh because we live in a linkage the skeleton requires proximal stability to create distal Mobility let me give you an example in the shoulder and then I'll move to the hip and spine say I could bench press 300 pounds if I bench press 300 pounds and then I stand up

say I'm on the on the offensive line in the uh in a football game American football and I can bench press that much if I don't have proximal stability the pec muscle the bench press muscle distal to the shoulder joint creates the effect the pushing or the punch but proximal to the shoulder joint that same muscle bends my shoulder away so if all I use is the bench press muscle boxing on the NFL I simply collapse but if I arrest all the proximal movement with core stability 100 percent of that muscle activity is now directed

distally so you see with that principle all distal athleticism comes from core stability you have to fire a cannon out of a battleship not out of a canoe you've heard that expression I'm sure many times so in terms of hip power if I was running I extend using my gluteal and hamstring muscles but if the core is not stiffened and controlling motion the spine bends because of the gluteal activity and you leak energy you can't Sprint as fast you can't replant and cut very uh very quickly so you're more apt to injure because of the

stress concentration of the spine Bend and the performance goes down as well so what do you need first core stability or hip mobility it all depends on whether there's pain or not what the activity is what the person currently has the assessment will show what is needed and it will also guide the best way to get that person there given their age their injury history their body segment proportions etc etc I wish it was easy it was easy everybody could do it all right next question so one of your goals for people is to stop

picking the scab can you explain what that means when we started our scientific investigations four decades ago we found that pain end injury comes from stress concentrations but you change where the stress concentration is by moving and changing posture if you don't believe me go to Jujitsu class so if you put someone in a submission hold and you don't have the angle right you don't create the stress concentration and the pain doesn't occur but if you change the angle ever so slightly and migrate that stress concentration the person Taps out think of laying in bed

a very benign activity if you lay in bed and don't change posture you will become uncomfortable you will create stress concentrations if you ignore that discomfort alarm shall we say uh those stress concentrations turn from discomfort to pain and if you ignore that alarm shall we say of pain you will become injured and it's called the bedsor so there is an example of prolonged stress leading to uh an injury so we use this concept of migrating stress away from where the concentration is to stop picking the scab consider stubbing your toe if I stub my

toe once it'll hurt but if I do it every day after a few days I just lightly touch my toe and it will scream it's highly sensitized am I going to do exercises and strengthen my toe to get rid of the pain no I'm going to stop stubbing my toe so this is what we do in terms of stop picking the scab and we use this entity or technique called spine hygiene and you can think of spine hygiene as a collection of movement hacks simply educating the person on how to move in a way that

migrates the stress away from the thing that's causing pain there are general principles what is poor posture what is posture that causes pain well consider holding a joint Against Gravity if I sat at the computer Shrugged my upper trapezius will become very painful and in fact people become disabled with this because of the stress due to that posture if we relieve that posture migrate the stress away the uh medical situation uh disappears so there was a principle holding a body part Against Gravity is is something that can be addressed with a movement hack or appropriate

spine uh hygiene allowing appropriate rest after a stimulating bout of loathe would be another principle reducing Shear loading so I could do a a paloff press for example which is a Shear load on my spine or I could do a side plank which is a three-point Bend which is just a Bend through my spine but there's no sheer load uh so that's what a lot of uh movement hacks are trying to do they're trying to eliminate the sheer load compression is stabilizing to a joint uh if you load a joint in compression it becomes stiff

the the neutral zone as it's known as it disappears as you load a spine and compression it's all held together there is no neutral zone so all of these things are all core principles pardon the pun um keeping the thrust lines so if I was to pull a cable and I pull it off center of my spine I've creating not only a Shear but a twisting torque which is very expensive for something like the spine but if I pull through the core through the spine there is no twisting torque if I combine it with a

drop step and pull now I'm creating a very uh athletic highly transferable movement hack to pulling open a door to pulling an opponent uh in a comeback cage all of these things enhance athleticism and uh reduce stress concentration so that's what we mean by stopping picking the scab using movement hacks or spine hygiene to rebuild that person to enjoy life be robust Etc I like the term spine hygiene I've never heard that it's very easy to understand the meaning all right next question do you recommend using an elastic wearable back support I'm curious now what

do you think my short answer is depends yes not that I'm trying to avoid the answer I'll give you an answer but it's not a singular answer it always says context so there's been a lot of studies on this over the years and actually I've been highly involved in this 20 years ago again as an expert witness in legal cases you'll go back are you old enough to remember going to Home Depot and when you went in there every employee had to wear an elastic stretch belt around the waist in fact it was a mandatory

condition for employment do you remember that I don't I'm 35 I don't know if I remember that okay well it was before your time and uh there was there were studies done that suggested wearing an elastic Stretch Belt reduced the risk of injury well I I became involved in this and really investigated the science and the context of it all and at the end of the day it wasn't the people out on the floor getting hurt anyway it was the cashiers so uh you know uh picking something up moving along the the belt what turned

out to be more stressful than being on the floor but to you know we we looked at studies of uh men and women who loaded the cargo Bays of airplanes both wearing belts and not wearing belts we looked at effect on blood pressure uh varicose veins in the testicles was another the varicocele as it's known was another uh side effect reported uh in one study some studies showed there was a a dependence on the belt and if you wore a belt for a while and stopped wearing the belt that was a time of a higher

uh incidence of uh acute back injury so I was then asked to write the guidelines for the Canadian occupational uh health and safety uh group I did it for several companies I did it in the U.S and the guidelines in a nutshell were this we cannot find justifiable science on balance that would say wearing a belt at work all day long prevents back injury but if an individual gets relief they would get a belt if they've been assessed for cardiovascular concerns because we know belts um affect that uh has there been an ergonomic assessment and

a spine hygiene assessment done uh at their job I mean I don't care what term you use a movement hack or or ergonomics or or whatever it happens to be but make sure that has been done for their particular job that they do exercises which create the very best natural abdominal belt and support that they could possibly have and that the goal is not to hook them on the Belt but to get them over a rough spot and then wean them off the belt um now last year or was it this past winter the winter

before I had two people show up at the doorstep here at backfit Pro who had slept on ice and really cracked their pelvic ring so the whole pelvic ring was loose they went to a chiropractor who manipulated them explain that to me if someone has had a traumatic impact to their pelvis and someone thought it appropriate to manipulate them one came on crutches and one came in a wheelchair both had fractured pelvic rings they wore a intertrochanteric elastic belt that we gave them for about four or six weeks and then it allowed them to hold

together and heal um I've had uh a couple of rackets players that come to mind One tennis star and uh won uh National squash champion who had way over trained deep loaded split squats lunges and they'd loosened up the pelvic ring and they wore a stretch uh belt uh between the trochanters and the iliac crests for a while as they stiffened up uh to pull it all together so there you go there uh systematic widespread use in a company no it's it's not justifiable for individuals there are uh occasions sure all right my last question

is you often talk about the importance of walking for back pain would you care to elaborate on that I've already said how when you map the course of a person's Orthopedic life the walking issue quite often changes when they're young sitting if they have a open Fisher disc bulge sitting will cause their pain and walking will give it relief as they get older and a little bit more arthritis around that unstable joint has now grown and uh some some Spurs and uh uh gnarly labrums of the vertebral body Etc causes them to get pain from

walking we would measure changes in disc bulges from standing and walking as a reliever in the younger person and sitting causing the disc bulge to grow so if we have a younger person and they have a little bit of joint instability with that kind of disc bulge and walking gives them relief we now have two things can we optimize the style of walking together with the exposure and as it turns out they might we ask them well how far can you walk without getting pain and they say well I can walk for an hour but

if I walk for over an hour I get more pain I say good never walk more than an hour or they might say oh walking after 10 minutes I get pain good you every time you walk for 10 minutes you've guaranteed failure we can't do that walk for eight minutes but do it three or four times a day now you've interval trained guaranteeing uh success we were I believe the first to measure the role of arm swing so if you don't walk with sufficient arm swing and it's the Hallmark of people who have chronic back

pain they walk usually slightly flexed with frozen shoulders and this is their gait pattern which causes more static chronic load on their spine but if they transfer we'll say to them swing your arms and invariably they swing the arms about the elbows spill with frozen shoulders the problem is not addressed we show them how to Jazz arms Jazz knees and swing the arms from the shoulders storing and recovering elastic energy in a crisscross fashion as their right leg and hip flexes the um left shoulder flexes creating an elastic stretch which then is recovered elastically as

they walk it's so interesting that if you go back to the Roman Scrolls of over 2000 years ago Caesar General Julius Caesar wrote in his battle plan they would encamp 30 they know that their enemy was encamped 30 miles away Nightfall came Caesar would March his Legions 30 miles through the night and create a surprise attack because the per the the opposite side the enemy couldn't conceive that anyone would March 30 miles through the night and they falsely thought that they were safe but he taught exactly the mechanics that we found in our scientific investigation

posture matters it matters incredibly ears over the shoulders loosen up Heel To Toe walking swinging the arms about the shoulders taking full advantage of the storage and recovery of elastic energy eliminating chronic stress concentrations reducing pain and enhancing performance and that was part of his battle strategy so uh there's a little bit of a start but by the way another thought just came to mind we might take a younger person who says you know I I can I can walk but they're slightly intelligent your chest is forward their chin is poking we might give them

a backpack with say eight kilos of load low in the backpack what that does is it acts like an erector spinae muscle with a bigger mechanical advantage it Jacks them up and then we'll say go for a walk over a golf course or a slowly undulating surface and they'll say oh doctor magical you that that was the secret sauce you just cured my back pain and uh well you know I didn't do anything to cure their back pain except give them an understanding of the mechanics and the best tool to use to create the adaptation

that they need to get them on their way anyway there's a little start on the mechanics of walking well you have gave us a wealth of knowledge today and thank you for that so I'll mention your website again which is bat fitpro.com and you have how many books do you have out uh too many to count no no I've got two in the works oh I I I've got four I I will say our uh are out uh that that are there's there's low back disorders which I wrote for clinicians it's fully referenced and uh

uh covers all of the issues that we talked today from a very scientific essay uh style trying to present both sides of when to consider the issue from this perspective and when to consider it from the alternate um I wrote a book for the lay public called back mechanic which guides the person through a self-assessment and then based on that what they should do to wind down their pain and then build themselves back up again uh the next book is called ultimate back Fitness and performance which was designed for Savvy lay people people who like

to train but they don't get the transition right between getting out of pain and they go back to their old training and they break down and repeat the pain cycle again so it's how to transition then into uh training all the way through to high performance training and I give many examples of some world records that I've been involved with uh Championship performance in many many different sports and uh let's see oh gift of injury that was a book I wrote with uh the man who has squatted the highest amount of load in human history

1 306 pounds uh he came to me as a very painful injured athlete in 2013 and when he came I said you know I I don't know if I can get you out of pain but here's my suggestion for you and he just looked at me and he said good when I'm out of pain I want my old record back I want my world record back and I said well if you can do that we'll write a book together about it so he did it and I ended up writing a book and it turns out

he was a wonderful writer and he's become one of my best friends Brian Carroll with uh so that was his story of uh not only the very emotional story but it was how he got back to squatting 1300 and the six pounds from uh very substantial uh fracture and disc herniations that's a ridiculous load it is when you can think of getting even under a thousand pounds and what that feels like for your body and to play a trick on your mind to control the thrust lines if you're out one millimeter you've lost the lift

and you can't correct it that's the other thing that's going to crush me so and and you know what another you might want to get him on your your podcast one time to tell you the mental process of having a thought which is what strength is it begins as a thought and then convert that thought into a very very dense pulse train down through the nerves only a very few people can do that create that density of neural drive and then organize the body to receive that activate the muscles and by the way that that

lift is on YouTube he made it look easy and yeah I said you know many people have said to him can you do it again he says no I did one perfect lift and that was it and you know I I used to uh with my uh students I would say um you know who knows how to bench press everybody puts up their hand and we we then do a one-hour bench press Workshop it turns out no one has a clue how to bench press they thought it was lowering the weight and pushing it back

up again uh and and we would add you know substantial proportions of load with more safety and resilience to most of them once we taught them the mechanics and the mental process of of how to do it so all of these things are highly Technical and if if you think you know how to deadlift or or squat um you know that they should hang out with with some of the people I do like you know World's Strongest Man how do you do that and you will get the most wonderful three-hour lesson how to do a

single little thing and you thought you knew something about it yeah these people they are special in World champs for a reason yeah well thank you for joining us today yeah thanks so much Mike and uh as you know I've been on Bob and Brad before I love them both so please uh extend my uh best wishes uh to them and uh hopefully we'll see you again yeah [Music] thank you