Welcome back to the Healing Pain Podcast with Stuart McGill, PhD
We’re discussing the evaluation and treatment of lower back pain with Dr. Stuart McGill. Dr. McGill is a Professor Emeritus from the University of Waterloo where he has many years of experience. His laboratory and experimental research clinic investigated issues related to the cause and mechanisms of back pain, how to rehabilitate people living with pain, and how to enhance both injury resilience and performance. His advice is often sought by governments, corporations, legal experts, medical groups, and lead athletes and teams from around the world. His work produced over 240 peer-reviewed scientific journal papers, several textbooks and many international awards. On this episode, we’ll discuss some of the more common truths and myths about back pain, how to effectively assess low back pain, lessons you can apply treating lower back pain in the average person, as well as with high-performing athletes and whether or not surgery is indicated for people with lower back pain. Let’s get ready and let’s meet Professor Stuart McGill.
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How To Relieve Back Pain With Stuart McGill, Ph.D.
Dr. McGill, welcome to the show. It’s great to have you here. I’ve been looking forward to chatting with you about spinal biomechanics and low back pain. You have decades of evidence-based work in this area. Tell us first how you started to become interested in the biomechanics of the spine.
Joe, it’s a purely by chance story. I get asked to give career advice to student groups and I’m saying, “Please don’t pick me. I’m the world’s worst example.” It wasn’t supposed to even go to university. I went to play sports, believe it or not, and then became interested in biomechanics only because I was lost in the library one day. I saw a book that someone had left out on biomechanics. I thought, “This is interesting. It’s a little physics, a little mechanics, a little anatomy.” I found out where the biomechanics programs were. By that time, I went to a university for football. I was interested in cycling. I found out one of the best biomechanics schools was in Ottawa and they had the French Gatineau for cycling.
I went in and did that. I was playing hockey with the professor’s team at Ottawa. We played a university called the University of Waterloo. I had applied for my PhD in Systems Design Engineering, but I met one of the professors who was a professor at Waterloo. He said, “We’re starting a spine biomechanics lab, why don’t you drop by for a visit?” It was as dumb luck and happenstance is that. I always enjoyed certainly mechanics, engineering and had a performance injury resilience interest in all of this with my own. I don’t know if that’s similar to your story about how you became a therapist or not. Did you want to be a therapist when you were fifteen?
When I took my SATs as a junior in high school, you had to choose at that point on your SAT. There was a number that coded with certain careers. I put physical therapist on that. I was a junior in high school at that point. During my first two years of college, I was a Business major. Not too many people know that, but I studied Business for about two and a half years. After my second business law class, I was like, “I need to get the heck out of this class, course, and get back on track with healthcare.” That’s a little bit of my academic story.
You knew that you did have this basic interest in helping and healing.
Like yourself, I was an athlete, I was a competitive gymnast. I was always interested in the health of the body and in some ways the biomechanics of the body, so PT was a nice fit for that. Tell us how your research career has developed. I’d imagine a couple of decades ago, the spine biomechanics lab looks different than it does nowadays.
When I started my own lab as a newly minted assistant professor, I only had one question and it was how does the spine work? It was as simple as that. We would watch people move. We’d measure their muscle activation patterns and their different postures. We created at that time and maybe even still now, some of the most sophisticated and detailed three-dimensional computerized models. We would create a virtual spine of the individual, watch them move, activate their muscles according to the myoelectric signals that we recorded, etc. We learned all kinds of insights and things like everybody is different. People change when they get fatigued. They load different tissues.
When they’re learning new skills, they learn very differently. It’s a basic athleticism. Some of these people are touched by the hand of God and other people are related to snails. This was all very incredible to us to get that level of insight. I started a spine tissue lab where we took cadaveric spines, loaded them, and created the injuries. I developed the radiology suite. We got a one-to-one match between what were some of the non-optimal patterns that real people displayed. We would then apply those to cadaveric spines. We’d watch the injuries and tissue damage progress and form cascades. We’d go back to the person. Lo and behold, we look at the images and there we could see if we overloaded in compression first. This is long before any disc damage occurs.
The bone underneath the endplates, the Sharpey’s fibers would start to break a little bit and that would allow eventually the lamination and disc herniations to proceed. As a gymnast, if you hit the wrong landing, you could do a little bit of trabecular micro-damage you wouldn’t even know. That left a slight weakness for a cumulative cascade to start off if proper adaptation didn’t occur. The third bit of that whole development started many years ago. We started the research clinic. I wasn’t a formerly trained clinician. I wasn’t biased toward a certain school of medicine. I went from scratch. This will be particularly interesting to your audience.
I knew how important it was to listen to a person and have them tell their story. While they were doing that, we could do pattern recognition, observe their learning style, get them to do a few clandestine movements, and whatnot. I then knew what we needed to assess to reach some degree of precision in whatever was the pain mechanism. I started at that clinic with two-hour appointments. My medical colleagues said, “Are you nuts? No one does two-hour assessments.” Joe, within a year we turned that to three hours. Our medical colleagues are paid to perform procedures, so nowhere in there are they paid to perform a thorough, intensive investigation of why they have pain and this is a major impediment.
I get nailed as this strict biomechanist who only deals in the physical, yet when clinicians come and work with us and go through an assessment with a real patient for the first time, they’ll say, “Social media has you wrong. That was the most biopsychosocial rubric that we’ve ever seen.” We started that way many years ago. My real expertise is in mechanical processes. There’s no question. I remember writing an article years ago to tell a person they have degenerative disc disease. What a horrible thing to tell a person when it’s a lie. There’s no disease there. The cognitive dissonance that patients would come in, “Did you mean my spine is going to continue to degenerate?” I said, “No, I’ve got white hair and that’s not a degenerative disease.” It’s been a bit of fun, but maybe that gives a little bit of an overview of the process without getting question-specific.
I’ve seen a number of professionals, both those with high degrees and those who have never gone to college. Through working with people one-on-one, over and over through the years, develop a certain touch and charisma on how to help people with pain. I’ve seen that in Pilates instructors, yoga therapists, yoga instructors who’ve never gone to a university. I’ve seen an in professionals like yourself who have closely related but nonclinical degrees but also working with people to try to help them cope with pain and what’s happening in their life. You mentioned you spend 2 to 3 hours with someone when you’re first evaluating them or sometimes more, which is so interesting because the average person who has back pain probably winds up first at either a primary care physician or potentially an orthopedic surgeon. I would say they spend maybe ten minutes with them.
These are the tales of woe that I hear every week.
Through your lens, what does that say about how we’re training health professionals to evaluate low back pain?
I know there are all kinds of discussions at levels of government policymakers, etc., on what they’re going to do about this world. Some even use the word catastrophe in treating back pain. My answer to that question and to you is until the medical system creates the capacity to assess a person and get at what the mechanism of their pain is, we don’t have hope because there’s no such thing as nonspecific back pain in my world. It’s all highly specific. To give any nonspecific treatment to a nonspecific malady will always result in nothing works or everything works, etc.
Do we have such a thing as nonspecific head pain or nonspecific leg pain? People wouldn’t put up with that. I don’t know why we put up with this non-specificity in back pain. That can be specified in so many types of categories. In my world, we get right down to a category of one. That person is standalone in terms of their full psychosocial and physical pain provocation rubric. Their learning style matters, their family life matters as you know, their job matters, their mattress matters, how they stand matters and building capacity for an athlete to train again. Everything matters.
It’s a very true assessment of what’s happening in the world of pain care specifically with low back pain. We don’t have a good way to evaluate and treat it yet. We don’t have a good rubric or a good system. No one’s been able to systematize that yet in a way that’s been beneficial and a way that’s improved outcomes over other different types of treatments. It’s a good way to approach it. You mentioned mechanical processes and you mentioned the mechanisms. From a clinician’s perspective, when you’re evaluating someone, what are the mechanisms that you’re looking for with regard to lower back pain?
Can I go back to your statement that no one’s coming up with an approach? I’d like to discuss that with you. I’ve followed up with every patient I’ve seen through my entire career, 100%. I know exactly my clinical score. I know the subcategory that each patient was put into. I know whether or not they complied with our recommendations. I know how they would grade their success or failure. I don’t know of another clinical group that has done that. Within that three-hour time, when we start with a free-form interview, we tell them, “What is it that you’re seeking and what are your goals? Tell me your story.” Doing pattern recognition, we would then take them down here to the clinic and we would recreate the things that they listed that made their back pain worse or brought it on.
We would create an antidote to that. If they said, “When I sit down and I flex, I get back pain. When I flex my neck, my back pain goes away.” That’s the opposite of what every clinician has been taught in the slump test. If we do this and they say, “My left toe went on fire.” Right away there’s a classic under hooked nerve root if it’s going to the big toe. We’re looking at L5 unless there’s mechanical crosstalk to L4. There would be the start of a hypothesis that we can become very precise on. We then might do a laying decompression on their back and then repeat the test. They say, “My toe didn’t light up that time.” We strengthened the hypothesis.
We might try some neural dynamics and migrate the cord away from the under the hook and repeat it again. We would go back to the original offense and then I say, “I will bet I will find an open fissure disc bulge, posterolateral on the right at L5. Let’s look at your MRIs now. There it is.” I’m questioning this notion that we can’t reach a precise diagnosis with an awful lot of people. I would say the vast majority, it is possible. The issue being the clinician has to be savvy first of all interpreting the patterns that the patient provides. They have the clinical skills to know how to replicate them in specific provocative tests. They need knowledge of anatomy, pathomechanics and neural anatomy. They have to interpret how that person is describing their pain.
They certainly have to understand what they are seeing on the radiology scans. I will also tell you that most radiologists miss what’s right in front of them. They never get to see the patient. They don’t know the feature that they’re seeing on the scan is a wound that is fresh and causing pain or it’s an old scar caused 30 years ago and is now burned out. There’s no pain from it. Without seeing the patient, I don’t know how a radiologist could ever make any of those links, but I’m starting to put all of these things together.
The final piece of the puzzle is coaching skills. If the clinician can then describe with some precision and show the patient the mechanism of their pain in the full biopsychosocial rubric. Give them alternate strategies to avoid the pain immediately that the patient says, “I’m in control. Thank you first of all for explaining all this to me and not treating me like a five-year-old. I get it now.” That process I described was that a psychological, a social, a mechanical? It was all of the above. That’s what might occur in those three hours. I will argue that we can get to a fairly precise understanding and that precision gives us a fairly complete directive of how to advise that patient.
My clinician’s mind is starting to bleep a little bit here. Three hours can be a long time for a patient, a long time for someone with pain to endure during the evaluation. What do you do with people who are fatigued or maybe have some cognitive deficits that are difficult for them to maintain the three hours? How does that fit into the evaluation process?
I’ll take you on a tour of BackFitPro here, but to my left is a box of Kleenex and tears will flow. There’s a time to, “We’re going to take an interval now.” That’s all in this. We’re two hours north of Toronto airport. If they’ve flown from Europe, very rarely do we see a person who’s from Ontario, they almost all fly in. They have to drive a rental car up here or a limo or whatever it is. They get out of the car. They’re not ready for us to assess them. I’ll have to say, “I need some restored balance to your body. Would you go walk around the block please? We will start getting a true assessment of what your mechanism is.”
Once I’ve honed in on my impression, I tell them, “We’re taking a break. Go to the toilet or whatever it is you’re going to do. Here is a position of respite. Here’s a safe position for you to go.” That’s primary in every person who leaves here. They have to know where they can go to wind down the pain a little bit. It might be a prone lay, for example, for a person who’s flexing and toned. If they have a femoral root tension, we may have to bolster under the pelvis, for example. We work at showing them with precision where that safe place is. I go away and I go over all of the clinical notes that I’ve made from their history taking and them telling their story.
All of our provocative testing and that gives maybe a natural ten-minute break right there. There are several built-in breaks throughout that three hours. I did say sometimes I’ve had those go five hours, but I always invite the person to bring their clinicians with them. If they’re an athlete, they bring the team doc or the team physio or whoever it is. Some of the clients are very wealthy. They bring in entire medical teams. They might be royalty from another country. They all fly in. I’m not flying to them. It could be much longer even with another follow up the next morning, but we’re conscious of that for sure.
Think of the athletes that you worked with. They form patterns. There’s very little separation between the psychological and the physical. Think of every explosive athlete you’ve worked with. They have almost attention deficit disorder. In other words, their mind is binging and racing, but that’s the explosive neurology and their learning style. It’s a pattern. You’ve got maybe 40 seconds to coach them and make your point. You have to figure out a strategy. We’re going to float or we’re going to practice and then we’re going to give them the next versus someone who is more of an endurance, anaerobic athleticism, and that’s their base, natural athleticism.
You can coach them for a long time. It’s different. Figuring out the cues that people learn from a wrestler, a gymnast, perhaps I would be using hand cues, touch, and force. A sprinter, there it is sound. A linebacker, it’s a visual read. They’re watching the play form, etc. Your experience on how you handle people, athletes, and how that three hours is structured based on their psychology, which is their athleticism. They’re all one and the same when you form the patterns.
I appreciate you bringing up the concept of time with regard to devaluation because there are many different types of practice settings for most of our audience are physical therapists. There are other types of professionals also. It can vary between 30 minutes to 60. I would say much beyond 60 is probably a rarity in healthcare in the United States. I’d have thought about this more and more. Some patients depending on who the patient is and the population, that 90 or 120 minutes may be necessary. You’re working in rest breaks in there. As you’re coaching and counseling that involves some talking and is helpful with the therapeutic bond. In those moments when you’re coaching, you’re counseling and you’re talking to the client or the patient, I’m sure they have questions. What questions did they have? When you hear them, you can identify them as back myths that are persistent in our culture and our society that you try to address.
The person who has more of an anxious personality profile, you can usually nail them right off the bat because you’ll do a test or two and they say, “What is it? What are you finding?” I’m saying, “I’m still learning and I’m not going to give you any impressions until I’m quite sure.” When I deliver my opinion, I give it a percentage of certainty. I had patient and I said, “I’m 99.5% sure that this is what’s going on.” They were told they had a spondylolisthesis. I tested the integrity of the pars. I loaded them up. There was no pain on that. I looked at the MRIs. There was mild bone edema in the pars. What they had was a low-grade spina bifida. It is what it is but that wasn’t the driver of their pain.
As it turned out, it was two segments above. I touched the L3 and a shear test. Sure enough, it corresponded with the femoral root signs that they were describing around their thighs and down like that. If they ask me a question too soon on what’s going on, I have to say, “I’ll converge and I’ll give you that.” Some people have personalities that they are naturally precise and I’ll say, “Does that hurt more or less than the baseline pain I created?” They’ll give me a litany of ten sentences. I’ll say, “Better or worse,” there are only two answers. You know how it goes.
The next person, let’s say I might get some neural resonance. They’ve had some damage to T9. We’ve published a paper on six case studies where patients have had damaged to either T9 or T10. When we load T9 and T10, their abdominal wall goes into an 8 to 10 Hertz resonance. I was describing that at one of my assessment courses. One of the docs in the audience said, “I saw a patient like that. They had a T9, T10 disc herniation.” I ended up co-writing the paper with that person.
If that was the source of the question, why do I shake when I adopt a particular load, a posture, activity or whatever it happens to be. I don’t know if that helps. All of these models have been created by a company, which I have no business relationship at all. I’m telling you because they are the best biofidelic representations of what’s going on. They’re fabulous. Most of them have been based on some of the science that we’ve investigated over the years. A pelvis with three lumbar vertebrae considers L5-S1 as a normal disc. L3-L4 is a normal disc, but L4-L5 has lost its turgor.
It could have been a little bit of endplate damage or a fresh Schmorl’s node or a little delamination and a disc bulge. I’m going to stress it from the top. I’m going to twist the spine to see how most of the motion is occurring at the disc that lost its stiffness or turgor. That person will probably report varying symptoms of pain. At this point in time, it might be pain down the right side. At another point in time, that’s pain down the left side. An unstable pain pattern is highly correlated to an unstable joint. There is a true unstable joint for people who want to argue that spine stability is not important.
There are many interventions that a person could learn, say a pec major latissimus dorsi brace in certain activities to pull down to arrest that micro-movement and deal with their pain. Someone else might tune the abdominal activation to brace out that pain. I know who I’m talking to here, Joe. I know you’re well aware of all of these things, but all of these mechanisms have a tipping point. Loading is necessary for health. The problems come when a person crosses that biological tipping point and they create something like this that then becomes a pain generator or they’re the total opposite. They don’t stress their body enough and they never create adaptations. When I use the word anabolic, I don’t mean steroids. I mean the anabolic process of adapting the body. This is a very wonderful model for some central stenosis patients. I’ll bring this model out and I’ll have them pull the brass rod through the central canal and they feel that there’s no resistance.
In fact, if I let it go, the brass rod falls out. I’m going to add ever so slight extension and they can’t pull the brass rod out. It teaches them why a very slight pelvic tilt allows them to walk for ten minutes, but no one showed them that. That description and visual is so powerful in showing them why I might have them post on the wall and teach them how to find that magical spot that allows them to walk. For example, here is a typical example. I mentioned the word underhooked nerve root. A lot of people won’t know what that is. At the back of that disc is a little red mark that is some collagen delamination or a fissure through the end, as the end of my finger.
I’m going to flex and squeeze. You need a combination of both. I’m going to squeeze the disc and flex it forward. You see hydraulic effort creating a little bit of a bulge posterior through the open fissure. I’m going to change and direct the thrust line directly down through the spine vertically. I’m not going to allow deflection to occur. You can see the whole disc deforms but the hydraulic effort is now balanced and it doesn’t focus on the fissure and creating a bulge. You’re very aware of neurodynamics. That test I was describing as a person is sitting and they flex their neck and look down, but that migrates the whole spinal cord about a centimeter, 10 or 12 millimeters cranially.
If they were to look up, they get the opposite migration. An underhooked disc bulge looks like this. There’s the nerve root. There’s a physical offense when they look down with an underhook. That pulls the nerve root off the under hook. I’m going to have the person lookup and extend the neck and that migrates the nerve root into the offense. Most people are overhooked. That’s what the slump test reveals and exacerbates the dermatome or the myotome for that particular route. I’ve got many of these models that I pull out for the patient education part about the specific physical elements. I’m not suggesting that their job doesn’t play a role. Their avoidance of exercise doesn’t play a role.
The neighborhood that they live in, that they’re fearful to go out and walk-in at night doesn’t play a role in stopping them from going for the therapeutic walk that I’ve given them. We try and get into this and understand it. I’m the last guy that they see. They’ve been conditioned to fail. They’ve already seen 10 or 12 clinicians before. I need to know the impediments of why they failed all of those. In every case, except for maybe two in my career, there is a physical element. In almost every case, there is a social component to it. We all get this. That quote from Vince Lombardi came into mind when you asked me the question.
It was something to the effect that some clinicians are developing awareness and they get it. I think of Vince Lombardi when he asked, “What makes you such a good football coach? How did you learn about football?” I don’t think he was a player. Lombardi’s answer was, “I don’t know football, but I know men.” I thought that as a clinic. If you need to be taught how to read a person, I think you better find another job. You’re in the wrong business. I don’t care about your physical skills. We had a patient here won the PokerStars competition in Vegas. He’s got to sit there for many hours and his back pain was preventing him. He had to read people. I go to him, “How do you read cards?”
It was a fabulous lesson on reading people. We had one of the chiefs of Homeland Security here for the US as a patient. After the interview, he said to me, “I’m a professional interrogator. The tricks you used was textbook. How did you learn all of this stuff?” I said, “That’s what we study. I study criminals.” How do they know who the mark is? How do they know who’s psychologically weak or physically weak? They’re going to either rub their bank account or snatch their purse. Criminals didn’t go to university and didn’t know how to read people and patients. You must be smiling because I know at your institute, you teach this. What’s your thought on what I said?
I have a couple of questions and these are questions more that readers might be interested that you talk about and discuss. You’ve talked about mechanisms of back pain. You’ve talked about working with patients and evaluating, treating people with pain, and you’ve touched on some important parts of the biopsychosocial model of pain. Things like if you don’t have an environment where you can walk outside and get some healthy exercise is a social determinant of health there that all of us have to be aware of because that has implications on society and policy specifically and of course later on and how well our patients can take our recommendations and self-treat and cope with what’s happening. With regards to pain education and pain science, which I believe your work fits into. There are some evidence and some talk about not using models to describe mechanisms and the biomechanics of pain in the body. I’m wondering what your response is to that field of work and to people who have objections to that.
I was getting down to this idea of the subject and of one, and you read the person. If they are an educated person and they want to know the mechanism of pain. The models are very powerful and showing them the mechanism and then what they must do to create the adaptation so that mechanism is dealt with. I have a friend. His name is Mark Greenberg. He’s a pediatric cancer specialist. He’s done a fabulous TED Talk. In childhood cancer, most of his patients die. You have to speak to that child and you have to speak to their parents, tell them what’s going on, to have a genuine conversation. How do you do that? If you can get through it without bawling your eyes out, you’re better than I am. These are the things that we think about. There are people who appreciate those physical models and they say, “You’re the first guy who hasn’t treated us like a five-year-old. I understand. I get it now. I get why you’re coaching me this way.”
If they have that open fissure disc bulge, we will work to allow it to gristle. Here’s what you need to gristle, now you see it. Here’s where we’re going to operationalize it in your movements. Sit with a lumbar pillow, do all of these things and wind it down. I’ve proven this so many times because as I’ve had hundreds of athletes go back and compete in the Olympics, Major Leagues were certainly as hell not creating fragile people. We’re creating absolute warriors. To show them those adaptations that they must create, they get it. When I show them this model, they understand, “The last time I had sex, I blew my backup. They’ve been celibate for three months.” If you believe who that is, a determinant of health, there’s nothing more psychosocial than that.
When I show them, yes, that’s creating micro-movements, we did the first study on sexual technique for matching back pain triggers. We created an Atlas and we said, “If you’re motion intolerant, here are some ideas. If you’re extension intolerant, here are some ideas, here are things to avoid and here are things to do.” We can then show them on that Atlas. There’s nothing more cognitive-behavioral than that. Haven’t you had couples come to you and say, “We are now celibate because of the back pain we’ve experienced, guide us.” I don’t know how you coach that, but there are no guidelines that exist, Joe.
When we put together the models and the Atlases and show them, they are so grateful. We’ve even had couples who are here, “Can we get on this bed and show you? Will you show us please?” Some people will think this is rather funny. It’s deadly serious. It changes people’s lives. If people say those models don’t help them, that’s fine. Maybe it doesn’t work for them because as a clinician, they’re a subject den of one. We all have different skills that we bring to the table, but I can assure you for the people who are at the end of the line that I see, they are essential.
The flip side of that is, do you think we’ve gone too far with the psychosocial part of the cognitive-behavioral part of treating people with low back pain, and has that maybe potentially gone awry for some people?
There’s no question for some clinicians. I’m going to tell you a story. I had a patient who came to see me and said, “I’ve seen 4 or 5 physical therapists. I’ve been to a surgeon. The surgeon wanted to amputate my foot.” I said, “What happens?” He says, “Sometimes my back crunches and clicks. It feels like someone’s opening up my hamstrings with a shard of glass. My foot goes on fire. I can’t even stand the weight of a summer bedsheet on my toes. They were going to amputate my foot. I went to the pain clinic and they loaded me up on Demerol and I’m hooked on it. The psychologists have told me I’m magnifying my pain and that perhaps I want to be a woman.” I’m listening to this and I’m on the edge of tears. He says to me, “Doc, if the pain is something that I’m magnifying, it means I’m crazy. I don’t deserve to live if I’m crazy. I hear you’re different, but if you can’t help me, I’m putting into it next week. You’ve got one week.” There’s my clinical world. Welcome to it.
I said, “What causes this pain? Because clearly, you don’t have it now.” He said, “I have to do a certain movement and this raging blade that opens up my leg hits me.” I said, “Could you show me this movement?” He says, “What? You want me to create the pain?” I said, “Yes, it’s the only chance I have to understand it. You’ve been to a dozen different clinicians here, has no one ever asked you to show them your pain?” He says, “No. You’re the first guy who’s ever touched me.” I thought, “What an indictment of clinical practice.” That’s the full mechanists, the full pain scientists, everyone said their shot, the drugs and everything else. No one has touched him and not one has given him an assessment.
I put my instrumentation on. It’s full 3D reconstruction. He whines himself around like this. He comes around the top dead center, creates this raging trap down his leg. I heard a clunk as if the spine cavitated when this happened. I laid him on the plinth, gave him a little decompression, and got him tuned down a little bit. There was nothing more I could do. I said, “You’ve got to trust me on this. I’ve got a good start on this. Don’t do anything stupid. Will you promise to give me a few days?” He said, “Yes, I promise.” I phoned him up that night, “How are you doing?” “Okay.” I called him the next day and I said, “Will you come in tomorrow?” This is day three and he’d calm down. He came on day three. What I had measured was he had this micro-movement as I’m describing here.
What happened when he wound himself around, the muscle that was required for the movements and postures created sufficient stiffness and control. As he came through the top dead center, he shut his muscles right down. I saw the precise instant he hit dead center. We saw the instability occur and we saw all the muscles drop to about 3% or 4% activation. It was at a precise time, the joint clunked like we see traps in whiplash patients on fluoroscopy. It was exactly that. I said, “Come on in.” I instrumented him again. I said, “This time, push my fingers out laterally. No, that’s too much, just there. Keep talking to me. Let’s go around the circle one more time.” He came around the circle, he started to come up through the top dead center and you could see the fear in his eyes. The trap was gone. We had stiffened it out. I said, “Do it again.” The same thing. We empowered him 100% confidence that he engineered out that pain trigger.
You’re creating some stability through a Valsalva or contraction of the abdominals in some way. That’s creating stability in the spine. He’s not getting the instability as he moves through that one direction.
Now, it has to be tuned. Talk about coaching. He laid drain tiles in a farmer’s fields as a living. He owned the company, but he was on the crew doing it. It’s a very physical job. Right away, my number one job was I had to stop lead poisoning. That cognitive dissonance that had driven him to suicide was instantly gone through him psychologically taking that control and realizing that he had full control over this. I said, “From now on, pain is only your tutor. It means you failed to do what I’ve shown you to do.”
That was about a few years ago. He brought his daughter to me because she’s a heavy field athlete and on scholarship in the US. She’s got a disc bulge. I said to him, “How’s your back these days?” He says, “100%.” I said, “Did you ever have more of those episodes?” He said, “I never ever had another episode opening up my hamstrings again.” I brought him back after four months to assess him again and reevaluate and he got the motor patterns. He’d honed them and zero trap that he was creating at that instant of you call it instability, I call it insufficient stiffness in true mechanical terms. Does that answer the question a little bit, Joe?
It does. There were a couple of things from your story there that I appreciate. One is asking someone, “Show me your pain.” Often when people are going to a physician or any type of practitioner, practitioners are looking for pain where patients want to be heard and by asking the patient, “Can you physically show me what causes your pain?” is a nice way of validating someone and letting them know that you’re interested and you’re helping them with their pain. The other thing about your story is there’s a movement to bringing back more multidisciplinary pain treatment centers, which I’m supportive of.
There are people out there with multiple comorbidities that oftentimes need the services of many different types of health professionals and we need more of that. We don’t have that in the United States of America. Although in your case, what you’re demonstrating is that a well-trained clinician or well-trained professional who has an understanding of both the biomechanical and the psychosocial aspects can effectively, safely, and efficiently treat people. What’s important about that is it saves assisted money. This person potentially could have wound up in a multidisciplinary setting and turn their wheels there for weeks or months, potentially and wasted a whole bunch of our healthcare dollars, and still not found a positive outcome.
There’s one part of that story that does perk my ears up a little bit, but everyone should pay attention to that if the rates of suicide are higher in people with chronic pain. If someone says if they don’t find a solution, they’re going to put a gun to their head. There may be a trigger there for a mental health consultation. I want to bring that in for our audiences. The moral of your story is that there are ways to effectively treat people’s pain without bringing in ten different types of professionals into the mix.
I have two comments about that. Did I treat him? I like to think I educated him to heal himself. Yes, he had already been to a multidisciplinary pain clinic. It’s they didn’t have our expertise there. The multidisciplinary clinic maybe doesn’t have the right makeup of expertise always. Having said that, I’m going to play the other side of the coin as well. I have a broad network of professional colleagues that I refer to and they refer back to me. If an athlete comes in with a tear, we can document it. You can see the contraction dynamics. In ultrasound, if the muscle knits together, there’s a tear. That’s now out of my wheelhouse. If they can do their magic with PRP and all the rest of it, there you go.
When someone comes in and they’re crushed by their weight or they can’t move and get enough capacity to do the exercise programs, which are essential for desensitizing their pain. I have a person to help with that. Like you, I’m sure you have your Rolodex. I’m old-fashioned. I have my Rolodex of people around the world that I refer back and forth. I do stay within my wheelhouse, but that is biased biomechanical. It’s about reading the person as well. All of these other things for sure I’m working back and forth with my colleagues. Here’s another comment for the younger people that might be reading this. They’re struggling to get their careers going and they’re trying to build their clientele and all the rest of it. That referral network pays you back in spades. As you work with your colleagues, they feed it all back to you. I would suggest you get back more than you refer to on that.
Can you tell us about your company, BackFitPro, and what your aim is there?
BackFitPro was essentially a forum to sell my books and inform people of the educational courses that we put on. I’ve retired from university a few years ago. I’ve got my teaching colleagues that do most of the teaching. I do put on a master assessment course in my hometown here for two days, a few times a year. It gives people with back pain and clinicians some thoughts on some of the scientific foundation. The first book I wrote, Low Back Disorders, I wrote that for clinicians. The next one, Ultimate Back Fitness, I wrote that for coaches and athletes. The Gift of Injury was the story of a heavy athlete, a world record holder in two different weight divisions in powerlifting. When I say he had a catastrophic injury, I don’t know if you’ve seen that book, but the MRIs of Brian Carroll, when he came to me, he’d split his sacrum front to back. He crushed L5 and that’s not an exaggeration of the word. The discs were heavily damaged.
We did bone callousing for a year, rebuilt him and created the tissue adaptations for him to come back and squat over 1,100 pounds once again. It’s a bit of a testament to the power of mechanostimulation. A company from New York came to me and said, “Would you write a book for the lay public? We’ve read some of your scientific ones.” I said, “No, I don’t know how to.” The hardest book I ever wrote was Back Mechanic, which I wrote for the lay public. The company book agent said, “It has to have a title, Fix Back Pain in Five Easy Steps or something like that.” I said, “I can’t do that. That’s a lie.” As this show has demonstrated, it’s complicated but not impossible.
I ended up self-publishing the thing and it’s seventeen chapters. I start by describing some of the mechanisms, pathways and cascades that caused people to have a disabling back pain. I’m not talking a little ache and pain here. I’m talking about disabling back pain that is inhibiting their work and their life. As we discussed, it’s very difficult to find a competent assessment provider. Chapter 6 guides the person through a self-assessment. We have them sit in different postures, lay in different postures, and hold loads in different positions. It gets them to realize certain things trigger their pain and certain things don’t. From there, we show them movement hacks or spine hygiene. If this causes your pain, think about brushing your teeth this way or tying your shoes this particular way.
We show them how to build strategic mobility and stability. Treat your ball-and-socket joints like ball-and-socket joints. Create power, have fun, that’s your shoulders and hips. The spine isn’t a set of ball-and-socket joints. It’s an adaptable fabric. The collagen fibers are like fibers on your shirt. Repeated stress-strain reversals are okay. If you want to be a gymnast, great, you can train spine mobility. However, if you think you’re going to tolerate heavy loads, you are mistaken unless you’ve been touched by the hand of God. If you want to be a powerlifter, forget about mobility and being a gymnast. In life, there’s no free lunch. You can only have it one way in terms of tissue adaptation. We take them through that and then we show them, there’s no question you have to walk. Short interval walkings are, as we all know now, good for a lot of things in your body, but to have optimal spine health, quadratus, lumborum, latissimus obliques, etc., it’s non-negotiable and we get into the special conditions. We mentioned stenosis and some of those other things.
That’s the book. You don’t have to buy it. I’ve told you about it. There’s a chapter on there on if you’ve tried all the different clinical approaches, you’ve tried chiro, physical therapy and whatever else, Cognitive Behavioral Therapy and you’ve been to the surgeon, etc. Now you still have pain and someone has told you the last resort is surgery. There is a chapter to help a person navigate through that. There’s no question. Surgery is needed and helpful sometimes, but much more rarely than most people think. If they would try what we call virtual surgery, which is to pretend you’ve had surgery now.
Tomorrow you’re not going to the fitness center and writing the elliptical for twenty minutes, that’s not going to happen. You’re going to rest and you’re going to get up and have short little interval walks. It guarantees a slow adaptation, which you’ve never done before. You’ve been addicted to exercise or whatever the reason is. Surgery works because it’s forced rest in a lot of people. You might think, I’m talking through my hat of the patients who’ve come to us over my entire career and I said I’ve kept score so I know exactly what the score is. Of all of those who’ve been told, “The last resort for you now is surgery.” Those who did virtual surgery and we guided them through the process, 95% avoided surgery and we’re happy that they did and I can stand by that statistic.
It says a lot about visualization and then a lot about the rehabilitation process after because a lot of people who get better from back surgery, it’s because they’re forced into a rehabilitation program. They’re forced to comply with that rehabilitation program.
I can play both sides of that. I’ll agree with you. There were those who say they’ve got a posterior lateral disc bulge at L5 and then they re-herniate. They re-herniated because of the negligence of the rehab program to show them what caused it in the first place. Had they shown them that with models and whatever else, and then given them a strategy not to recreate the offense, the chance that they would have re-herniated have been dropped right down. What happens, maybe they didn’t re herniate there, now they come back two years later and they’ve got exactly the same location of the bulge but the level above, now it’s at L4. You must have had patients where now they’ve had three discs surgeries all on the same side, different levels. They come into your clinic and you say, “I know why you’re getting these. Has no one ever showed you this?” The rehab failed to remove the cause which, in my view, is the very first element of rehab. Remove the cause and then rebuild the base foundation and get them moving, playing, and doing whatever it is they want to do in life.
I’ve been speaking with Dr. Stuart McGill. You can learn about all his great books and programs and products. Dr. McGill, let us know again where we can find you.
It’s from BackFitPro.com. Joe, I’m not on social media. I don’t even know how to sign on. Apparently, my daughter does it but go to the website.
If you’d like to follow Dr. McGill’s work, you can go to www.BackFitPro.com. You can find all his books, products and programs there. His courses are great. He’s been around a long time providing good information on biomechanics for people with low back pain. At the end of every episode, I asked you to share this information with your friends and family on social media and stay tuned. Make sure you subscribe to the show so I can send you the latest episode right to your email inbox each week. We’ll see you next time.
Thank you so much for all you do at the Integrative Pain Science Institute. It’s fabulous the education that you put on and deal with all of the issues that we discussed. Thank you.
Thanks, Dr. McGill.
- Dr. Stuart McGill
- Low Back Disorders
- Ultimate Back Fitness
- Gift of Injury
- Back Mechanic
- TED Talk – Mark Greenberg
About Stuart McGill, PhD
Stuart McGill is Professor Emeritus (after 32 years at the University of Waterloo, Canada) who authored over 240 scientific journal papers, 4 books, and mentored over 40 graduate students during this scientific journey. Investigations in the laboratory, training center and research clinic probed back injury and pain mechanisms, rehabilitation approaches, and performance training. As a consultant, he has provided expertise on low back injury to various government agencies, many corporations and legal firms and hundreds of professional/international athletes and teams worldwide. He is regularly referred to special patient cases from the international medical community for opinion.
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