Dhru Purohit Show - Exploring the Root Causes of Chronic Back Pain and What to Do About It with Dr. Stuart McGill

Episode Date: May 8, 2024

This episode is brought to you by Birch, Plunge, and AquaTru.  Back pain is a common affliction exacerbated by our modern and sedentary lifestyles. This discomfort frequently hinders work and daily activities. Our guest today delves into the back's anatomy, identifying movements—or lack thereof—that contribute to pain and discussing factors contributing to its increasing prevalence. Today, on The Dhru Purohit Show, Dhru and Dr. Stuart McGill delve deep into back pain. Dr. McGill shares insights into why back pain is so prevalent, dispels myths surrounding it, and discusses the types of repetitive stress and strain that can lead to chronic pain. He also outlines his approach to treating back pain and highlights the limitations clinicians face in treating their patients. Dr. Stuart McGill is a distinguished professor emeritus at the University of Waterloo and the chief scientific officer at Backfitpro Inc. McGill has written more than 300 scientific publications on the topics of lumbar function, low back injury mechanisms, investigation of tissue loading during rehabilitation programs, and the formulation of work-related injury avoidance strategies. He has received several awards for his work, including the Volvo Bioengineering Award for Low Back Pain Research from Sweden.   In this episode, Dhru and Dr. McGill dive into (audio version / Apple Subscriber version): The prevalence of back pain (00:00:36 / 00:00:36)  Drivers of back pain in our modern world (3:17 / 3:17) Repetitive stress and strain that leads to back pain (12:00 / 8:36) Types of training and how to choose what is best (22:00 / 17:50) Dr. McGill’s Origin story (34:00 / 28:00) The myth of non-specific back pain (49:00 / 43:50) How to find an appropriate clinician (57:00 / 52:17) The Big Three principles to prevent back pain (1:04:00 / 59:06) Ancestors ability to engage in a variety of movements (1:15:00 / 1:10:10) Training in cycles (1:23:00 / 1:18:27) Advice for Dhru’s pain (1:33:00 / 1:28:00) Dr. McGill’s Seven-Day Approach (1:37:00 / 1:32:30) Strengthen what is weak and stretch what is tight (1:47:00 /1:52:30) Also mentioned in this episode: Dr. McGill’s book, Back Mechanic BackFitPro.com Spine Models For more on Dr. McGill, follow him on Instagram or his website.  To get 25% off your Birch Living mattress plus two free eco-rest pillows, head over to birchliving.com/dhru today. Right now, Plunge is offering my community $150 off cold plunges and their core products. Just go to plunge.com/dhru or enter code DHRU to revolutionize your wellness journey today.  AquaTru is a countertop reverse osmosis purifier with a four-stage filtration system that removes 15x more contaminants than the bestselling water filters out there. Go to dhrupurohit.com/filter/ and get $100 off when you try AquaTru for yourself.  Learn more about your ad choices. Visit megaphone.fm/adchoices

Stuart, such a pleasure to have you here. You know, today we're talking about getting to the root of back pain and some of the top myths that people have around this topic that you are most known for dispelling. And most importantly, we're going to be talking about what people can do to address it or potentially prevent it if they don't have it. Knock on wood, I hope they don't have it right now, but a lot of people do. And on that note, I'd love to start off a little bit big picture about something shocking that I heard you share. And maybe I'm just not in the know, but I didn't know this statistic. So I'm

going to share your quote. You just make sure that I got it right and then we'll talk about it. So I heard you share that up to 80% of people in their life today will suffer from some form of debilitating back pain. So number one, did I get that right? And number two, what the heck is going on in this modern world that we live in that 80% of people are going through this? The word debilitating. is interesting. I was a professor throughout my life, and I could have quite severe back pain, but it wouldn't prevent me from standing in front of a lecture hall and giving a lecture. If I had a physical job, say I worked as a fisherman or a car mechanic or a construction worker, the same level of pain absolutely was debilitating. So the definition is it's a severe impact on

work, severe impact on the person's occupation and on their enjoyment of life, whatever that might be in their current stage of life. Picking up a child, being a grandmother, would be such an example. So the often quoted rate of incidents and prevalence is about 80%. So to build on a little bit further, I feel like you were kind of going. there, but just, you know, just to understand how vast the problem of back pain is, especially, you know, I'm 40 years old, maybe some people that are in my age demographic or younger, think that as I thought that this was kind of like a rare thing, people have injuries, but as you age and you talk to people, you actually find out that just because somebody is not on disability,

just because somebody hasn't stopped working at their job, just because they aren't showing up in the world, doesn't mean that they aren't struggling. with what still would be classified as debilitating pain. And that's partly what I feel like I'm hearing you say. Yeah. Again, it depends on what the person does throughout the day. If they are a computer operator and they are unable to concentrate because of the pain, they're unable to sleep because of the pain,

they're gaining weight because of the inability to move. And it's a major health compromise. You know, Stuart, on that note, the second part of the question was really sort of thinking about it a little bit bigger picture. And I'll, you know, feel free to chime in. I know you're very precise with your language, which is a big reason why we wanted to have you on, is that many individuals like myself are asking, what's going on in our modern world that is a big driver of this? And to the best of your ability, do you think that this has always been the case? or is this a trend that's heading in a worse direction? Do you have any thoughts on that?

I do. Let me go for the first part of that question. Now, again, yeah, I need some specificity sometimes for my professor's mind to be on cue. Think of every system in biology requires stress, whether it's a cognitive psychological system, your endocrine system, your musculoskeletal. system, which we're talking about here. If you don't stress your body, it's weak, not very resilient to life, but if you over-stress it and cross what's known as the tipping point, more excessive load is catabolic for the system. Micro trauma accumulates, pain occurs, micro-injury that eventually goes to full-blown injury. So an example, of that and then people might not really get this idea of mechanostimulation. Consider laying in bed.

Well, that's not stressful. However, if you lay in bed for a long period of time and don't move, you get uncomfortable. And if you ignore that discomfort and you don't move, you will eventually become injured. And it's called a bed sore. So there's an example of something where you cross the tipping point because not of high load, but of duration of load. So, load has a magnitude. Everyone understands if you pick up a very excessive heavy load, there's a chance you will create a stress concentration and that tissue will damage or become injured. But I've given you an example now of duration, which might be sitting at a computer. Another one is repetition. A, another one is repetition. Another one is, well, all of those are mitigated by rest.

So the key to all of this is variety of stress to make sure that you're below the tipping point, moving stress through different locations in your body by posture change and changing activities, being well-rounded if you want to think of that, and not doing too much of any one thing. So you can imagine, you can get away by splitting your firewood or whatever you boys down in L.A. do. I'm not quite sure. That's all we're doing all day. We're splitting firewood here in Los Angeles. I'm just going to give an example of something where I live that would be a common seasonal activity. Well, if you split wood on Monday, you've built up a little bit of micro trauma. However, if you rest on Tuesday, your body responds to that and rebuilds those micro traumas into something that is now more robust and more resilient.

Do it again on Wednesday, and now you've added a little bit more stimulus with very, very micro trauma. However, that's what the body thrives on. But if you split wood today, tomorrow, and the next day, there is a good chance. that if you're crossing the tipping point every day, the micro traumas are accumulating and eventually I can give you many pathways specific for spine injury. I know you mentioned myths. One myth is you may have heard people being told, oh, you have non-specific low back pain. Well, that to me is a myth. There's no such thing as nonspecific back pain. pain. It's all very, very specific. But it requires a fairly thorough assessment to figure out

what the specific pain pathway is, and then we know what caused it. And it's usually a violation of this principle of mechanostimulation that I was describing earlier. They've crossed the tipping point in whatever form it was. And now the key is to not go back to building that cumulative trauma and figuring out the pathway to give the antidote to keep feeding this system through mechanostimulation to create resilience and robustness and pain-free abilities. So I don't know if I've avoided your question or I've answered it, but there's a little bit of a start on the scientific principle of why the widespread complaint, symptom of back pain is. But if we can talk about specific individuals, we can certainly get into why

person A has pain, why person B has pain, and there are two totally different pathways. So would it be fair to say that if we look at our modern world, we have, especially since the advent of computers, but really office work in general, we have a lot of repetitive type of stress or strain that we're putting on the body, even driving cars. And a lot of these things, not just that sitting as one component of it, we stand in the same way. We do a lot of the same things. And as a society, that could be one of the reasons. It's not the whole reason as to why we see a lot of individuals who have some of the pain

that they do long term with back pain because generally there's not enough variation and there's not enough equal distribution of different types of stress and strain. I don't know if I got the languaging right, but is that partly what I'm understanding? Yeah, consider someone who sits at the computer for however many hours a day, but let's choose seven hours and then they go home at night and watch television sitting once again, and they wonder why their back is giving them signals of back pain. Now, interestingly enough, when we take, say, a cadaverick spine, a young one, and expose it to the stresses of sitting, we don't measure stresses building to the point of injury. But here's what happens.

if that person were to go to the gym and lift excessively, and that's the key word, lift excessively and cross their tipping point, and then they come home and they think, oh, I've got even more back pain. Now it's so unfair. I sat all day. And then I went to the gym, and now I have even more pain. If they sat less and trained more with less magnitude, shall we say, chances are they would say, oh, my back pain has now gone away. So what happened in the gym?

If I could give an example, say a person lifts excessive load, moving their spine while they're under load. Well, the ball and socket joints of the hips and the shoulders are made to create power. It's a ball inside a socket, full motion, high load. That's what they're made for. But the disc of a spine, which is the joint of the motion unit, is made of collagen fibers. Consider it to be a fabric. So my shirt is a fabric made of fibers.

If I wanted to delaminate the fibers, I would create stress strain reversals back and forth like this. And eventually I would work a hole in my shirt at the region of stress strain reversals. Collagen fibers running at different angles back and forth form concentric rings like a onion skin. And if you now, if you just move the spine back and forth, say you were a belly dancer, we don't measure delaminating stresses because there isn't very high imposed load. However, if you squeeze the spine and then do repetitive motion, the delaminating stresses between the fibers build. But here's the realm. Inside the nucleus, which is the middle of the disc, it's a gel composition. So a gooey, phlegmy fluid. If you then squeeze the spine and bend it and allow some of those fibers to

delaminate, the pressurized nucleus from behind will find and seek where the delamination is, and that's one of the major pathways, not the only one, but one of the major pathways to a disc bulge. So you can see the red mark in the collagen fibers at the end of my finger, can you? Yep. And remember now, inside the nucleus of the disc is a gel. So I can bend the spine back and forth, and I'm not going to create the hydraulic pressure stresses of the fluid working through the delamination because I'm not applying load. But now I'm going to flex the spine over and over again under load, create the delaminating stresses. Now I've created a weak spot, so to speak. Now I'm going to squeeze the spine and flex it or bend forward under load, which would be considered poor form lifting.

Now, I'm going to squeeze and just watch. You see the fibers delaminating and opening up, and then the pressurized gel working through the delaminated collagen. Now, I'm going to change the hydraulics. I'm going to stack the spine nice and tall, and I'm going to squeeze. You see the whole disc squeezing down, but the hydraulic effort of the pressurized nucleus is equalized. It's pushing all the way around, and it's not focused where the delamination is posteriorly. So you could imagine if you had an orange seed and you squeezed it between your thumb and your finger, it just locks the seed if you create a thrust line right through the middle of the seed. But if you bias it one way, The seed goes out one way every single time. Do you follow?

So there is one very potent mechanism. So if a person has a disc bulge and they come into the clinic, you can find that mechanism in their past history almost every time, but not always. And I can give some other examples. Now, let's take a person who doesn't do heavy lifting in the gym with poor form. And again, I don't want to be misquoted here. Lifting with good form is important, as I just showed. And I'm all about that. So I don't want to create the impression that I'm anti-exercise or anti-training.

I'm the polar opposite. But it's the way that the people train that get them into trouble. Now let's take another person's spine, and this person doesn't lift heavy, but every day they go to yoga class or some sort of mobility training, or maybe it is that they just play pickleball, and that's all they do. So a lot of bending, but they don't do heavy strength type of training. These collagen fibers will adapt. they become a little bit looser to allow you to have more mobility. So if you keep stretching one way, stretching the other way, you get a little bit of mobility and laxity, shall we say, between these fibers.

That's the adaptation that occurs. And I should also point out, I'm not against yoga, not at all. What I'm advising people is choose one. because the laws of mechanostimulation mean that there is always a trade-off. So if you adapt your body to lift heavy, back off on the spine mobility a little bit. If you want a lot of mobility in your spine, probably better to back off heavy load type of strength training. So a golfer, for example. You know, we went through an era 12, 15 years ago where some prominent players got into heavy lifting.

A, they didn't hit the ball any further. And B, they ended up with some of them quite disabling injuries. Although now you'll notice that the golf top players generally have backed off on the heavy load. So there's an example of the specificity. a little bit of mechanostimulation. So here we have a disc. Can I ask one clarifying question about that? Yeah, sure.

Just as you're kind of going through. So you're saying pick one or the other. A lot of people, as they're thinking about what really leads to, you know, most of my audience is not trying to be Olympic level athletes or even perform in competitions, even if they are into resistance training. And a lot more of my audience is now into resistance training since we've been talking about the importance of muscle when it comes to metabolic health, when it comes to glucose regulation, as well as the protective element and leading to ultimately improve grip

strength, et cetera, et cetera. So when you say pick one of the other, I imagine that immediately the audience's ears are perked up and they're like, well, does that really mean like if I am not competing at a heavier level that I, who resistance trains, you know, three times a week to, keep my body strong for my future years. Does that mean that I should be doing no yoga at all? To what degree do we have to be careful of keeping in mind the sort of guidelines that you just shared with us? Right. I really appreciate you making that clarifying point. So I wasn't clear enough. You're correct. Most people want to be generalists. They want to be able to play a round of golf. They want to pick up their grandchild or child. So they want a little bit of strength and load-bearing ability. They want

sufficient mobility. So now we're talking about the middle of the road person. My message to them... Would you put yourself in that category as well? Are you in that category or are you in one way or another? Just so I can get an approximation. It's changed throughout my lifetime. As a younger man, I was all about strength. God gave me enough mobility I didn't need anymore. I wanted strength and speed. Now I want, don't let me get away from that previous question though because it's very important. I got you. Don't worry. I got your back. But now I want, if I walk in the woods and trip on a something that catches my boot, I need to recover that fall because it hurts more now. It's going to hurt my shoulders a bit more, etc. In other words, the risks to me,

have really changed. I'm in my late 60s now. So I work on hip power. Get my leg out in front of me if I stumble to arrest that fall. I do, well, I can tell you about my whole program now, if you like. But anyway, my point is I've really changed. And now I'm, do you want to talk about my training program right now? We might come back to that, just so you can finish your other point about, people who are in the middle of the road and you've mentioning that you have changed you used to be more about strength and power now it's more about what i'm hearing is you're more focused on longevity as you get into your later 60s 70s etc it's not just about power for power strength you know

it's not just about you know strength for just the purpose of strength you're really focusing on making sure that you can live a long and healthy life that's what i'm hearing right exactly i don't want to lose anymore. And obviously, each decade, you're not 16 again. You do lose a bit of resilience and athleticism. And you accumulate miles on your body, and we all have injuries that we have to manage. So again, what works for me might not work for someone else. And just to give some insight into this, you know, I'm hip replaced. My knees aren't what they used to be. I've got a lot of things. But I don't know anyone at this stage who's had a good life that doesn't have to manage something. We're not 16 anymore.

But going back to that previous issue, which again, I appreciate you pointing this out, the more extreme a person wants in their athleticism, the more the tradeoffs are against other things. So if we go into a physiologic realm, and again, I'm a spine guy. but I'm just going to use a physiologic one because the audience might resonate with that a little bit more. It's very hard to be an explosive athlete and have a high VO2 max. They are competing metabolisms. One's a fast-twitch metabolism. And then the VO-2 max comes from a slow twitch and durable.

So do you see how those, if you really train one hard, if you really have a high VO-2 max, you lose a little bit of your explosiveness and vice versa. You can't have it all. And I know everybody wants to have it all. So training in a... And just one clarification on that, just as we go through, and my apologies for the interruptions, you can always feel free to say, hey, actually, let me just finish my thought. But just one clarification on that, you know, my audience is not even the CrossFit audience. You know, they'll be working out of the gym. They'll be practicing regular resistance training. A lot of them are just getting into that. So when you talk about having a high V-O-2 max, you mean at an athlete level. Is that correct? Like you're not just talking about high-figure age group.

It could be, but we know that having the higher the V-O-2 max is as you progress through the decades of life, chances are you going to live longer and have a longer what's known as a health span, free of injury and debilitating disease. You're living better longer. So that is a health metric that's been established. But I've already pointed out that I also want a little bit of explosive power to recover from a stumble. It's nice to dance gracefully. It's nice to split my firewood. But I don't need to, I'm not on the gridiron banging again, you know, like we like we used to or in a hockey rink. And I don't need that athleticism that in order to train to that level now, I would have to give certain things up.

You can't have it all. So these systems compete with one another. The more extreme you want to be, the more tradeoffs there are. But most of us want to be middle of the road. So my message in all of that is accept a level of sufficient strength, sufficient mobility, sufficient endurance, et cetera, et cetera, et cetera. And I think people will have a happier final decade, shall we say. So going back to that analogy that led to this sort of clarification we had there for somebody

who has a level of moderate resistance training, let's say that's that. That's two to three times a week where they're in particular probably working with either bands in my audience maybe or weights with a trainer potentially at a gym or at their home gym. If this individual also wanted to benefit from having some mobility, pliability, you know, in their life and they're thinking about, hey, is it okay for me to be doing yoga? one or two times a week, I feel good, it makes me feel happy. Is that problematic or I know it's so person dependent, but we're obviously talking about on a podcast. We're talking about broad strokes. So for the middle of the road person who's working out two to three times a week, no debilitating back pain at the moment, but maybe some slight signs and cues because a lot of individuals have that, even if they are pretty healthy, that something is going on that they need to address. Would that, and yoga a couple

times a week, would that be problematic in your eyes? What are your thoughts about that? I wish I could give you a very clean answer on this, but people are different, so I can't. But an assessment would reveal the answer for that individual person. There's a book. It's called Your Yoga, Your Spine. And it's written by a fellow named Bernie Clark. He's a yogi. He's taken our courses. And he wrote it. another book, Your Body, Your Yoga. And the point of his books are to tell someone to do a general yoga program who has a bit of pain somewhere in their body is, it's driven by luck, not by science. Say they have a right hip labrum sensitivity or joint capsule sensitivity. And then they do a certain

pose or an asana, and it pushes that injury and irritates it a little bit. But what Bernie does is he takes them through a few movement tests, and he will identify some of these sensitivities and say, your yoga program should do this and not that. So you're tuning this broad category of yoga to suit the person, because some exercises will help, and some won't. They will probably do the opposite. So as a spine clinician, that's exactly what we do. We do an assessment to figure out what is the pathway to the person's current back pain. It's not non-specific. It's highly specific. But every single person is a bit different. So we eliminate what is the pathway to their pain, and it might be an activity,

It might be their postures. It might be an excessive load in training, or it might be an underload. In other words, if they sat too much, we need to get them interval walking throughout the day to break up the stress concentration of sitting. So it's a matter of tweaking that mechanostimulation to achieve the goal. But everybody is slightly different. and every person who comes through these doors has back pain. And, you know, sometimes the assessment is quite extensive.

When I, John and hear where that assessment came from and how it evolved. Yeah, absolutely. Let's talk about your origin story. And just before we get into that, just so that people are aware, you have an incredible book. I've been going through it over the last, you know, a couple weeks in preparation of this podcast. I want to show it here for those that are looking on YouTube. it's called the back mechanic and the secrets to a healthy spine your doctor isn't telling you

about and also too you're going to get into your story but you know you live in Canada you're not really at the place where like everybody who's going to be able to be listening to this podcast could see you but you've trained a whole group of people in your methodology and not only you're known for working with some of the top athletes that are out there in the world you work with a lot of everyday individuals and everything that you've learned from the athletes is completely applicable to the everyday individual. So I just wanted to add that into context here as people are listening. There's a lot of resources that are there for us to go into the specifics because as people

will see that so much of this depends on their unique situation. But let's talk to talk about how this methodology was developed. I think you were going to get into a little bit of your origin story about the assessment. Right. I started my PhD in 1982. So that's 42 years ago. we've been working on this and it's it's been evolving i started with just one question drew and it was simple how does the spine work so we would investigate and measure people doing different things and

measuring how they activated their their muscles and how they organized their posture uh and then i created a very sophisticated anatomically sophisticated model of their spine based on their their MRI scans documenting their internal architecture and that kind of thing. And then we would measure with electrodes their own movement strategies. And then we would watch their computer, we called it their virtual spine move. And then we would measure the loads on the different tissues inside, the stress concentrations. And then we would measure things like stability and that kind of investigation. As it turned out, most of the time, not always, but most of the time, the pain came from stress

concentrations, either because of the way they chose to move and maybe they were moving in a certain way because they had a sore hip and they had to stress their spine bending off kilter, so to speak, as they squatted down or maybe the volume was just too much and crossing the tipping point, etc. After a few years, I realized I don't know enough about the mechanics of the parts, about the disc, the vertebra, the nerves, the muscles, etc. So we created a cadaver lab where we took mostly animal spines, but of course we had to calibrate the findings up to humans. And we would load the spines with the stress concentrations that we were measuring in pained people to see what the reaction was in terms of, well, is the bone cracking, is the nerve becoming irritated,

is the disc bulging up, etc. And then we did epidemiological studies because stress concentrations form from common exposure. So a certain job or an occupation would have a common exposure. and we would look at the clustering of types of pain pathways. Sports are the same. You know, why do gymnasts? When a clinician thinks of a gymnast, they will think, well, there are characteristic back pain mechanisms. For example, a spondylolisthesis.

If I said to a clinician, who gets that? And they would say, gymnasts. So, you know, it's because of these common exposures. And then the dean came to me and said, okay, hot shot. Well, he didn't use that word. But he said, why don't you put your money where your mouth is? And let's start an experimental research clinic. Well, I didn't really know how to do that because I hadn't been formally trained in medical school.

But around this time, I was being asked to present our new findings in biomechanics to various medical meetings. And after I finished my lecture, medics would have. ask, could you come and see a patient with us who's resistant to whatever the intervention was? And I'd say, well, no, I'm not a trained clinician. And I slowly learned from them what their skills were. And I realized I saw the world from a different perspective. It was much more from an engineering perspective. And if a person had pain, I would probe it.

we would stress it. We would try and make it worse. We would try and do the antidote to make it better. We would play with loads, postures, motions, loads, study the commonalities of the mechanostimulation from like activities. And that's how we came at all of this. And then when we started to see patients in the clinic, I set aside two hours to see a back pain to patient. And my medical colleagues would say, two hours, what are you going to do? You know, Drew, after the first year, I changed that to three hours.

And then when a patient came in, of course, they brought their imaging with them and all the rest of it. And I didn't say too much. I welcomed them. And I said, tell me your story. That's all I would say. And some people would give away why they have back pain. And then after 15 or 20 minutes, I might ask a little follow. up question and then they'll say, you know, Doc, I've never told this to anyone before, but

then it just pours out of them why they have back pain. And, you know, I learned that genetics, the type of spine that they have loads the gun. Exposure to a certain stress or demand pulls the trigger and then the psychosocial milieu around them influences their pain behavior. It affects their job and their family life. And then the next person is water off a duck's back. But when you understand and probe all of these things and the stories I could tell you about people for the first time they reveal to you because no one came to the University the experimental research clinic with fresh back pain. They were the failures. They'd already been to 10

different clinicians. They'd been conditioned to fail. We had to do a thorough investigation to find out what were the impediments that caused the failure of the previous nine attempts or 10 attempts. So it was very different from anything in the medical milieu. It wasn't paid for by medical insurance. There's no code in medical insurance to pay for a thorough spine exam. What clinicians are trained to do so? There isn't a profession that trains such a clinician. So, you know, I had to study techniques of interrogation, orthopedics, neurology, base anatomy, pain. Anyway, so it's it's taken a long time to hone down that assessment that starts with, tell me your story.

And then we follow up with key questions. They might say, you know, I was reaching a certain way and I felt I had a little catch in my back. That is an indicator of spine instability usually. And I'll just show one here. Now, here's the pelvis, the sacrum, L5, L5. L4, L3, and there's three discs there. This disc is normal, L5, and L3 is normal. L4 has been damaged.

It's lost a little bit of disc height. You know when you let the little air out of your car tire, it bulges on the road, and it's a bit sloppy to drive. Watch. Now, I'm going to drive the car or load their spine. Watch the twist. You see how the twisting motion applied from the top is creating micro movements at the joint that's been damaged. So that's called a joint instability. So if that person was laying in bed,

there's a chance that that one joint, you see how it's going to shift off in a sheer mode, just a tiny bit? And then when they say, you know, when I lay on my one side, I get an ache just to the left of my spine right here. And they put their thumb on it, right there. And then they shift to the other side and the pain changes because now they have a little shift. in that micro movement. Does that show on an MRI? No. Does it show on any medical image? No, but it requires a thorough listening to the character of the pain, and now I can come up to them in the clinic. I can hold one Iliac crest in their pelvis. I can put my shoulder over, leather shoulder into my armpit. I give them a little squeeze. There's your pain. Yep,

that's the pain, doc. You found it. Do you see how that would never show on a medical image? And then I'll say, all right, we've just identified the pain mechanism. I can see that joint is a little bit flat on a scan. Now I poke my fingers laterally into their oblique muscles. And I say, push my fingers out and now fight me just a little bit. And I repeat the test. And that musculature around their back and their sides and their agamilals in the front form a three-dimensional muscular girdle. Now when I probe them, I've arrested that micro-moving. They say,

oh, Doc, you just took my pain away. Okay. So there is an example of a test that's quite an untraditional test, but it's very specific. It identified their pain pathway. And even better yet, it gave us a clue as to the antidote to arrest that pain mechanism. Now it's nuanced. They just found that a little bracing engineered out that sheer emotion. And then some people will react like a robot. They're stiffening, going around, and not realizing that is way too much. And then they end up getting a backache because if you stiffen, you're actually adding compressive load to the spine and you're crossing the tipping point in yet another mechanism now.

So now back off a little bit. And so you see the the the first of all the coach the clinician has to be aware of remember that word I used being sufficient. Not too much. Absolutely. Not too little. It's a nuance. And it's funny. Then personality comes into it.

And I'll say to one person and you know their personality is a warrior. They're going to beat this out of their back by doing more exercise and whatever you give them. They're going to do even harder. And those are the ones where you have. to say you're not going to beat this out of your spine, you're going to romance it out of your spine. So let's back off now and I'll just teach them a standing hover. Very quiet, relaxed. Now, I give them a target and I'll say reach and touch me. Good. Now I'm going to stress them a little bit more. I might give them a bit of load. And then they have to keep tuning that amount of

control so that they don't break to pain. Now they're building a movement repertoire. or a wisdom, perhaps, a catalog of movement techniques that they can now call upon, and with more experience, they just flow from one to another. And, well, it's just wonderful to watch an athlete on the television, for example, competing in sport. And they were a client sitting in my waiting room two years ago in debilitating pain. And now I'm just watching all the patterns flowing together. What's fabulous is, you know, these combat athletes in the UFC and whatnot and just watch them flow. You know, beautiful, drop step, pull, flow, pull into the naval, exactly as I told them.

And they were avoiding the stress concentration, which is really just the efficient movement. And that's... That all came from that assessment. Oh, by the way, I retired from the university eight years ago, and they won't let me retire. I still wake up every morning. You know, Drew, there's nowhere, and you've never been able to find, get an appointment with Dr. McGill, call this, or, you know, do that. It doesn't exist. It never has done.

And yet I wake up to these emails. would you see me as a client? And some mornings I just have tears in my eyes, reading through these. And such heartfelt stories and misery that people, you know, I've done this, I've done that. And, you know, well, no wonder is what's going through my mind. I wouldn't say that to them, obviously. But anyway, sorry, that was a long diatriar. No, no, it was great.

It was great to give the origin story, but also you led up to what has been the combination, the unique combination. You know, why is it that a well-trained surgeon might still be holding on to some of these myths about back pain and how they approach surgery? Or why is it that a PT, who's well-intentioned, would be missing something? or why would a MRI scan that somebody's gotten not showcase or help them get to the root of why they may be facing debilitating back pain? And really this example that you've shared is helping the audience understand that there had to be

these unique things that all came together, the cadaver work that you guys were doing, the spinal models that were there, the fact that you had an outsider approach by being an engineer and sort of probing people's pain to see if you could recreate it versus, holding on to ideas that might be something that beholds that clinician or physical therapist or whatever to not questioning certain things. And the combination of all those unique things that have led you to be able to get results and help people who have been suffering and ultimately the people that you ended up training, they have led to, and it's one of my favorite parts of your book, they've led to questioning all the

these different myths that people have had. And we hinted at some of them. You know, you mentioned the first big one, which was that you don't believe in non-specific back pain, that everything is a specific pain. Just pulling that thread a little bit more. You know, I'm not sure if everybody in our audience fully understands what that means. So who's out there arguing that some of the pain that people have? Or what is the advice that people might be hearing from people that might be well-intentioned, but is misguided that, hey, your back pain is nonspecific and therefore we're going to treat you this way. Who's arguing for that and what are the implications for it? If you would take, you know, help us contrast it. Well, I don't think it's anyone's fault. I think it is subject to the politics of

medicine. Clinicians now are terribly overworked and they're given time. allocated per patient, which means you've got to see three patients per hour or some limit like that. And that might be insurance driven. It might be hospital driven or facility driven. But they don't get a chance to thoroughly assess a patient. So that's one limitation right there. And it's a systematic problem. No single person's fault. So they just have had 10 patients. They didn't have the opportunity to get right down to investigating their specific cause. So it's easy to say, oh, well, we couldn't find a cause.

Therefore, you've got nonspecific low back pain. And it's just a byproduct of them getting older or you're too stressed out in your life. They're just saying things like that. This is a cop-out. This shouldn't happen. They're dismissing people. people. I know I had a thought and it was it was just escaping me. The other, and I think you started to allude to this yourself. Say a clinician has been trained in a specific procedure

and they have an insurance code to pay for that specific procedure. So every single back pain patient that comes in, they get that specific procedure. So it's dumb luck whether that one's going to help them or not. And you can choose any procedure you like. There needs to be someone up front who can be thoroughly trained enough in all of these various aspects of assessment and then say, okay, with that particular mechanism, you will do better with this particular intervention. And there are some surgical groups that are forming around the world that are multidisciplinary that are doing quite well at that. And they are their own entity and they bill for time and that kind of thing.

So there isn't a pressure to apply a specific billable code, shall we say. So the patient shows up, they get a thorough assessment, and then that assessment will direct them onto a person who, look, what you really have to do is avoid the cause in the way that you're moving. It's the way that you're moving that's creating a stress concentration. So let's go to a person who understands how to coach you in pain-free movement. The next person comes in, and I'm just picking on real live examples now, the patient came in, and I said, tell me your story, and they said, well, it's driving. I can't stand to drive. I get this terrible pain down my leg, and it actually sometimes moves up my spine in the middle as well. And I said, okay, and I did the typical physical therapy slump test, which is where the patient sits on a chair and,

They slouch forward and they pull their knee into extension, which pulls the whole spinal cord and neural tract like this. And if they have nerve tension issues, that will reveal that. But here was the person who they did a slump test and there was no pain triggered. and they were deemed as having, well, non-specific back pain, meaning the clinician couldn't find their pain. But I don't accept that, and we keep going, okay, you said in your interview that driving is your problem. Well, what is peculiar about driving? It is, the head is now up. It's not in a slope test, but you extend the knee so that the foot can touch the accelerator pedal.

That triggered the pain. What is it? In that particular person, see, the spinal cord and all the nerve rootlets, they're like a rope. They're all connected. And they slide up and down based on head and neck posture and where your legs are and that kind of thing. So when they looked up, it released the nerve root and allowed it to drift down. And then as they extended their knee, it drifted down even more. And then I tried to floss the nerves, and that was very minor irritant, but there was something very peculiar about that.

Now, they said the pain went to their little toes. If that's the fifth Lumbar 5 root, that goes to the big toe. It's not that one. L4 goes to the little toes. So now I'm informed. I'm informed to look at the radiology, the MR. and there's something on that particular nerve root when it's pulled that way that causes their symptoms. Now I go back to the MRI and I find what's called a Tarloff cyst,

a nasty little cyst that was on the nerve root just outside the foramen. I found it. I was informed by listening to the person. I reproduced the pain clinically. And then I went to the MR and found it. So the radiologist, without that information, probably would miss the Tarlov cyst because, like you said earlier, in school they're taught. In many schools, Tarlov cysts don't cause pain. Well, I can absolutely promise you 100% in some people they do.

They can cause very miserable lives. But anyway, so with my skills, I can't do anything about a Tarlov cyst. The typical surgical intervention is to put a needle in and drain the fluid. but they usually grow back. So there's a surgeon who I refer people with Tarloffsus to who's developed a technique where they rat the nerve. And he has as about as good as any success rate than any other. So do you see, I will refer out as well. But it was that approach and dogged, don't give up.

If I can't find it, it's my fault. It's not the patient's fault. And I say that to my students regularly. You miss their pain. Go back and look again. You miss something. We don't give up. And no, I can't fix everything and nor can some people.

However, there's just another example that came to mind that it took several layers, one and forming the other. So a radiologist on their own, in their own silo, go to the radiologist in heaven. NMR, they have no chance to find it. Did you see it had to be informed one after another? So teams that are put together. It's precise. It's precision work. It is. Yeah. It is. And what are the, you know, because of course, you know, and this is partly why I'm sure, you know, the university, you're such a wealth of knowledge. And you don't want this to just be, you know, your knowledge. You've written about it, but you also train people just a quick little teaser

if we could, if somebody wanted to find somebody who you've trained that can help them go through this precision assessment so they can get to the root of it and then find the appropriate referral, where do they go or what type of practitioner or coach are they looking for? Well, the ones that I've trained, and again, Drew, I didn't want to do this. I was asked, would we create a certification system? So if you go to our website, backfitpro.com, if you look under the tab master clinicians, those are the clinicians that have been formally trained in their home discipline, and then they come and work with me and we see patients together and I train them to do the type of assessment and treatment regimen that I'm describing.

There's also a second category on there of certified clinicians because I just don't, it takes long time to train a master clinician. It's a big commitment on my part as well. And I can imagine. We have two other teaching master clinicians that greatly assist on all of this. But we have limited time. But we also have the certified clinicians. Now, they've taken a 50-hour course with me, which is more than many clinicians get on back pain in their entire medical training. For sure. And then after those 50 hours of listening to me online talking, then they come to my home here and we study together for three days and that's the day that we work on hands-on skills techniques and really develop them sorry those of them they can then challenge

the certification exam and now I don't work with them personally with patients but they do the 50 hours plus three days together here. They challenge a written exam, and then they have to get a patient, and this is usually online, sometimes it's live, and they have to assess the person, and then in front of the examiner's program what the intervention is going to be, and then carry it out, which is usually a very specific exercise program. So those are the certified clinicians, not as elite as the master class. clinicians who I've worked with personally. So I, again, I was asked to do it. Yeah, no, it's an incredible

resource. I mean, at the end of the day, if you've developed a precision program, having people who know and can carry on that legacy, because ultimately, the more people that are trained in that, the more people that will end up getting resolution. And as we know, from the statistics that we share in the beginning, a lot of people are in pain. You know, Stuart, when I've heard your podcast and I've heard you talk about your various degrees of work and education that's out there. From my landscape, I've seen it as, okay, there might be individuals that are suffering to some higher degree. As you mentioned, a lot of your methodology came out of helping people who had had many failed attempts of being helped. And then finally, through this precision approach, this assessment,

then potentially a referral, some stabilizing exercises, et cetera, they were able to get, you know, resolution and ultimately reclaim their life. And then there's another part of your work, also in your books and also in your education, that is focused on people who might have these signals. And if we all continue to get older, even at, you know, in our 30s, 40s, 50s, we might start to see some of these signals that our body is sending us. Now, it may not even be close to debilitating, but we can start to notice that there's something maybe sticky, as I like to call it, that's going on in the body. And you have methodologies and exercises that are for that person to incorporate, in addition to your big picture principles, to hopefully knock on wood, help them avoid being

that person that long term might be some of those treatment resistant individuals that end up in your clinic. Is that a fair way of me sort of talking about some of the landscape of your education and your work? Well, that's certainly the goal. I don't want to give the impression that we have 100% success rate because we certainly don't. I can give you our success rates based on the specific pain mechanism of the individual. Some things were very successful and uniquely successful with and some things were not. Got it. No, that makes sense. So I'd actually love to shift for a second.

And we may come back to, we'll put a pin on sort of where the conversation's been so far. I want to shift a little bit to make sure we give some love and attention to individuals who are listening who are very fascinated. But they might be listening today because like me, they don't have anything maybe major going on in their life, but they're trying to make sure that they're aging and taking care of their spine and their back in the right way. So when somebody comes to you and says, okay, hey, Stuart, I really get the big picture methodology to the degree that I can as somebody who's a layperson who's listening to you. you and I understand the importance of how, of why it's so key to be taking care of my back and my spine as we age. I understand the statistics of people who end up in problems when they, they don't. What are some of the things that you would have me incorporate into my world and

my life, exercises, et cetera, things that I'd incorporate in my schedule that would help me best take care of my spine as I age? What would you recommend? to that individual who's listening to them? For me to be best in offering an opinion, I would need to understand you. And I would need to understand your pain history, your injury history, your age, your current level of fitness, your fitness goals, your jobs, other demands in your life. And then I can start to give good advice. So you're asking for a generic answer that doesn't exist. You will get a very middle of the road,

probably an effective program doing that. So if I were to ask you some questions, I would hone in on that. But there is an algorithm that converges on the most healthful practice for your spine. No, that makes complete sense. And maybe we could go down that route even with me with some of the questions. Right. But let me take a step back. One of the things that your work is known for is you coming up with these big three. Can you just talk about those for a second? Yeah. What the big three are and why somebody might want to be incorporating these movements into their life.

Okay. Now you've given me something a little bit more specific. We. Thank you for bearing with it. I have to start with a little bit of an essay on. Please. Where all this comes from and what. why it's important. So we are a mechanical linkage. We have segments with joints, the joints

of different architectures, and the muscles are all designed based on the particular joint. So it's not a just coincidence that we have a ball and socket joint at either end of your core. So my first principle of a linkage moving well is proximal stiffness and control to unleash distal athleticism. You're familiar with a backhoe, which is a tractor, an arm out the back with a bucket. The first thing the operator does is put down stabilizers to lock the tractor into the ground. Proximal stiffness, which now allows the arm to move and grab dirt and pull. Failure to do that means you just pull the tractor all around. So if I was going to open a door and I failed to create proximal stiffness, it would just yank my back. But I do. But I do.

don't. I'm very strategic now in that I can walk up to the door, use a hip-hens reach for the door. Now watch my fist, grabbing the door. I'm going to pull the door into my navel. The most spine-conserving athletic way and powerful way to do it is I drew a drop step. I pull it back and I walk through the door. So people will say, well, I don't have to do that on my bedroom door. That's a walk in the park. I said, all right. But you told me in your story, you hurt your back pulling on the church door or a door in the shopping mall. So do you see how they're giving me clues as to where the flaws were and why they ended up with disabling that pain? So let's establish that principle just a little bit further. Assume I'm going to create a very effective, efficient push. So people will say, well,

I'm going to do bench press, and they may build up to, I can bench press 300 pounds. Could. If I'm in a standing posture, I can only bench press half my body weight in a push, and then I knock my own self over. Consider the bench press muscle. It's the peck major, connects the rib cage, crosses the ball and socket joint of the shoulder, and connects onto the humerus of my arm. Distal, outside of my shoulder joint, the peck major, creates the push, the desired athleticism. But look what happens on the proximal side. On the rib cage, it collapses my shoulder. You see what happened on the inside of my joint? So half of the muscle is

collapsing the athleticism. The other half is repelling it. But I arrest the collapse by creating core stability. I lock my core. Now, 100% of that peck major bench breast muscle goes to the the athleticism. So this is called an energy leak in an engineering sense or an unwanted eccentric contraction if you're a muscle physiologist. So do you see why now you have to have proximal stability? And this works out joint by joint to give distal athleticism. So if I want a push, punch, kick, run, pull, carry my shopping bags. It all goes back to the mother. of all proximal in your body linkage, which is your core. So that's principle number one. What is the most effective pattern to ensure core stability? Well, you contract all of the muscles

appropriately, not too much and not too little, just so you can navigate, open the car door, get into the car, etc. Freeing your hipsy shoulders. But, you know, if you watch someone run without a sufficient core, you'll see a little hitch every time they run and then they wonder why when you run in a marathon or partial marathon or something that, no, it may be a hip impairment that's causing a little hitch going into their back. Hip asymmetry, as an example, is much more predictive of back pain when you run long before something like having tight hamstrings, believe it or not. It's the asymmetries that turn out to be more important.

So, what are the best exercises for training that core girdle that I'm talking about to create proximal stability? We measured all kinds of exercises and those that were claimed to create core stability. But the ones when we measured it, remember, we had the virtual spine that allowed us to do all of this, was the bird dog, a form of the side plank, and some form of abdominal exercise, whether it's a walking out plank, a push-up is a form of a front plank, or a modified curl-up, not one that bends the spine repeatedly under load, but more of an isometric style, etc. So they spared the spine of compressive load. Remember, these people already have some compromise. to their back. That's why they're a back pained person. But we're guaranteeing that, do you know what an N-gram is or muscle memory? A muscle memory, a wise way to activate those muscles. And then the final bit is to transfer them to real life. How do you know what you're

doing in the gym transfers to picking up your child? So it checked the boxes. Those exercises were the most superior for most people. So that's where they came from. If I can give, I've already mentioned the second type of stability requirement, and that is a joint that has been damaged or injured in the spine needs a little bit more control. And again, the big three was fulfilling that requirement. And the third example is something that I can show with this model. Here is a mock column, and it's held together with stiffness. Now, some people hear the word stiffness, and they think, oh, that's a bad thing. Not necessarily.

I can stand here without muscle, just having a little bit of stiffness. I don't need any muscle. Did you follow what I mean? So rights have stiffness, your car tire when it's inflated with air. air has stiffness. If you let air out, it goes wonky. So here is a column of the spine. Let me put a nice little orotic low back curve into it. There's the thoracic curve. It can stand upright so I can sit and talk to you without any severe muscular control requirements, but now I'm going to take the stiffness away and it collapses.

But I needed to release the stiffness to tie my shoe, to get dressed in the morning. So do you see it's a little bit of a game where you're all the time modifying mobility with stiffness and control. Now I have to pick up my child out of the crib, gather the child with a hip hinge, organize the curve of my back that doesn't create a stress concentration, not humped up like a camel, but not to sway back or extend. end it, and then just middle of the road, which is the less stress, shall we say, slide the child to the crib, hold them so they don't fall, pull the hips through, and now you've executed a very efficient movement. But it was a dance. It was a blend between sufficient muscular

control, but not too much. It was appropriate. But now when you pick up the groceries or a wheelbarrow full of yard, earth, or something much more demanding. You might be in the gym. You need much more stiffness to control the spine and make sure it doesn't develop a stress concentration. I mean, years ago, we were videofluoroscopy monitoring power lifters, and we measured an injury. We saw an actual injury occur, and just at one level of the spine, it bent forward a little bit to pick up the load, and then just at a single joint, it suddenly kinked, if you know what I mean. So it was an instability.

The lifter didn't have enough stiffness and control, and that's when the injury occurred. So, you know, I can go at this from a tissue perspective. I can go at this from external load perspective, but it keeps coming back to that idea of sufficient control and then dialing in just the right amount. So those exercises, the big three, start off the training, and then I think it's a little bit of a myth. Oh, McGill's approach is just the big three. There's a lot more to it than that, as you know, there's the efficiency of moving. There's training patterns in pushing, pulling, lifting, carrying things, applying force through long levers. You know, amazes and pulls.

So the awkward things in life. But anyway, does that give a little bit of background as to where those exercises came from, why they were converged on and how we might start to train them. It does. And the way that I understand it is that, you know, you have these big three and I might have you just repeat them one more time, right? These things, you know, when I zoom out a little bit more, right, we're zoomed in a little bit. When I zoom out, we live in our modern lives.

We're so far removed from a lot of the sort of regular training that we would have just happen from living, picking up water, fetching water, fetching wood, doing this, doing that, all the things that we'd be doing that, even from a young age, and spending time largely outdoors, squatting, sitting, you know, squatting, getting up, a lot of those things, it's not that our ancestors were necessarily, who knows what they were doing or not doing, but I don't think that they were training in the way that we are. Obviously, we know that to be true. But because their lives were so dependent on being outdoors and moving in this way. They didn't have to study the technicalities. It's just that they adapted those because they had a lot more of that healthier

level of being in the middle of the stress and strain where they understood how to engage their core, how they understood to create the pressure that was there because life demanded of it. Now because we've been removed from a lot of those things and we sit a lot of more. We have to actually go out of our way to train these things uniquely because our modern lifestyle is not necessarily baked into training it into us. Do you think that that's a correct understanding that I have? I do. And the evidence I would use is when we interview patients and we'll get into discussions, what activities make your pain? What activities actually make you feel better and are restorative? How do you feel at the end of Friday night after

sitting at your job for five days versus Sunday night when you got out and had a lot of fun and moved your body. How did you feel after the last two-week vacation? These are things that reveal patterns and you can then relate the exposures to them. And that when you do that often enough, I think you'll strongly agree with yourself. A variety of movements means you're continually migrating stress concentrations. Yep. So to your point, I think some wisdom was there. Would you mind just repeating those exercises?

And what we'll do is on YouTube, for those that are watching, we'll link to, you have a lot of these videos that are available for that people can watch where you've demonstrated how to do these exercises correctly. I don't actually. I don't. Okay. I thought they were. There's a lot of people on YouTube who've, who,

have no clue and it's very rare to see a reasonable bird dog. Now my colleague Brian Carroll has done a fabulous job with a YouTube video on them. But may I just mention the bird dog for just a moment? Please, please. So a bird dog, I've just noticed the lunge that I did and now I'm on all fours. I'm going to extend one leg, the other arm, and there's a bird dog. Now here we're we're my patient this morning who came in and said bird dogs hurt my back and I said would you show me one and this is what they did now do you see how they can they were freeing their hip only to this point and then their hip ran out of room and they lifted their leg by extending their back and when i sat them on a chair and they said what causes your pain and they said moving back so do you see they exactly created

their spine trigger unbeknownst to them with lifting past the point of what their hip would take them. They lift with their back, raise their leg, they just went right to their pain driver. So my cue was, lower the leg and push your heel away, and all of a sudden they said, oh, my pain's gone. They've controlled their core. The gluteals and hamstrings are now doing the most. movement and the spine is, the musculature in the spine is stopping the movement. Now we've got exactly what we want, a stable core unleashing the hip, and now the next one is

squeeze the fist, really get some radiation of these muscles into the upper back. So there might be just a little bit of a start, and then what I learned from I have to credit the Americans won't like this, but I had to credit the Russians here. And have you heard of Strong First, my good colleague, Pavel Satsulene, who runs. I haven't. No, I'm not familiar. Well, Pavel taught me some of the original Russian science. And the American way to build endurance is to hold the posture. or repeat it for reps in a long period of time and you get tired.

The Russian way is to hold that for 10 seconds. Touch the floor with your hand and knee, excuse me, and then hold another 10 seconds. In other words, you're building up endurance without getting tired through repeated 10 second bouts. That was so clever because now it became tolerable for back pained patients. So we find when I did epidemiological, surveys of groups of workers all doing the same job.

Say they were in a manufacturing facility, all doing the same job. Those who had repeated acute episodes of debilitating pain every year, in other words, they had to take four or five days off. But the rest of the time their back was okay. What do you think the difference was between the ones who had repeated back injuries and the ones who never did in terms of mobility, strength, endurance, etc. Well, most people would say, oh, they were weak. No. The ones who were more strong had more acute bouts of back pain. And here was what happened. The ones who were more strong

lifted with their back. The ones who were less strong in their back lifted with their hips. And they just stiffened and controlled their back without a lot of back motion. So they were using their legs and hips. The difference was endurance. The ones who got hurt were stronger that had less endurance. They broke form soon. They got a bit tired. They then stopped using their hips. And then after that, I just used their backs over and over again. And it was so blatant when you saw it. We had a patient just for a bit of fun who was an athlete. And we always say to the athletes, Would you bring, most of the good ones are on YouTube, but we study them playing their sport before they ever show up here,

whether they know it or not. But this person sent their game films, and we watched their opponents who were just moving so efficiently without stress concentrations, and our client was moving because they didn't have sufficient endurance. When they got a bit tired, back pain. So are we going to, now we've identified, identified the specific variable that gives them resilience.

It wasn't strength. It was endurance. Now, that's not always the case, but I'm just giving you some examples where, knowing that, we are now going to program that bird dog on a endurance, but not an American, typically an American profile, but more of an Eastern European Russian. And that was one of the keys for prescribing it in a way that was more suitable for back pain people needing endurance. It's a bit of an essay. I'm sorry, it's a bit of a long thing.

No, no, no, it's super helpful. So on that note of prescribing it, how often, and I thought that was very helpful, again, for those that are watching on YouTube, you can see the demonstration by Stewart. I thought it was very helpful to talk about that example of doing it correctly, incorrectly. So how often would somebody be incorporating that into their weekly routine? Is that something that you do? Yeah, how often? If I said to you, what's the answer? Just what would you say? I'm curious. It depends. Yes, thank you. It depends. And here's why it depends. for a start. Let me give you a generic start. We need to train in cycles because remember my opening little mini essay on mechanostimulation. So let's work with biology here and we're going to train in cycles. The first cycle is two weeks long. So you said how often? In the first two weeks, let's go for week one, do the bird dog six days out of seven.

Why the seventh day off? That's the day where you just allow adaptation to occur. Don't allow any nagling snag or anything to grow. Do it again for the next six days, cycle number one. And then before you go into cycle number two, take three or four days off. That's the delode just to let everything settle out again. Now start off. You might repeat that same cycle.

Or the next one, we might add more exercise or different loading or whatever. So that's the science to begin to answer your question. Most people do it every day. Now, let's have a client here, and we show them the bird dog, the side plank, and a modified curl up. And they do two reps, either side of each of those exercises, and then they stand up. And I say, compared to five minutes ago, before you started that, right now, are you you better, worse, or no different? You'd be amazed at how many people say, my pain is gone. Or, I feel better. Good. Your programming is going to do half the exercises mid-morning,

do the other half mid-afternoon, now you've guaranteed two periods of respite in the day where you have less pain. The next person is struggling, and we might have to say, Let's say they had a funky hip or a knee replacement or something like that. Stand at the kitchen counter and do a bird dog like this. And, you know, we'll just keep modifying it as required to try and engineer out. What is limiting their ability to get what we need from that particular mechanostimulation tool? So does that help you a little bit? It depends. I've given you one example, training in cycles, another example of twice a day.

And then there will come a time when that person is so robust, we move on now. And I know you know this, but some of the people who've now gone back to set world records in various strength things. winning golf tournaments, winning weight divisions in combat sports, or many, many Olympic sports. So they then get quite beyond doing a bird dog, obviously, and the level of mechanostimulation that they need, A, to perform, and B, to be resilient will change. But that's the beginning of it in any case. Does that help with the programming? It's a science.

It's a science for sure. Then there's a lot of specificities and unique things that are there. So generally speaking, the big three, they're going to be things that are going to be helping people get back into activating certain parts of their body. And then you might graduate from that if you have an appropriate training routine that still incorporates the different. and goals that those things are doing, but for what load and stress and strain you want to handle based on your unique goals. Is that correct? Absolutely. Yep. So for somebody like me, who is, you know, going to the gym, probably three to four days a week doing resistance training, you know, plays pick a ball probably like once a week, goes, you know, on a, you know,

two one hour hikes every week, has a, you know, moderate level of activity in my life. life and averages about 10,000 steps a day. I don't have any knock on wood, you know, pain that would be in this classification that you've expanded on that is debilitating. And I work with a trainer and he's very technical. Would you say that I could potentially be benefiting from incorporating these big three into my life? Or is that maybe not what's going to be, appropriate for for me and my main focus is again just healthy longevity uh continuing to maintain a good VO2 max on on the benchmark that i've had so far in terms of like my long-term fitness goals and i still want to add in because i was you know grew up vegetarian i under ate on protein i didn't

resistance strain and when i turned 40 i finally like woke up and realize like how i've been doing it wrong, even though I've not been vegetarian since I was 26, I want to add probably at least about another 10 to 12 pounds of muscle in my early 40s because I know that I'm going to be losing that over a period of time and I know that I'm under muscle. So that's why a lot of my resistance training and dietary focus is focused on prioritizing sort of lean muscle mass. So yeah, you know, should I be thinking about incorporating these big three in my routine? Any thoughts on that? I'm doing pattern recognition as I'm listening to your story. True, it sounds as though you've got it dialed in.

Now that might surprise you. So you don't have any goal that you're not currently meeting. You have some overarching philosophies that you're trying to satisfy, and you don't have any pain. Sounds pretty good to me. Now, if you came to me with pain, pain would guide me. as to, I have to find out what the mechanism is, and then we would do things to reduce the pain and retune your body to get back to a pain-free state, if possible.

But if you came to me with specific goals, which you didn't really give me there in terms of performance, I'd really like to do this. Then I would say, okay, what are the demands of that activity? I want to surf. There's a good L.A. example for you. I want to surf. Okay, well, I know on a surf board, you need a certain amount of extensor endurance and core endurance to paddle the board out. Then you need hip mobility and speed and balance and flexion to pop up on the surfboard, and after that you need flipwork, a sense of balance, and all the rest of it. So do you see how I'm defining in physical terms the demand of the sport?

Okay. Now I'll take you and I measure you. Do you have the hips that will allow you to pop up on a surfboard? Or are you, you've got back pain, flexion driven back pain? Is it possible for you to use your hex and spare your back? Because if you can't, I can guarantee you that more surfing will only cause you more pain. So do you see, that's where we're going to go. We're either going to make your spine more resilient, your hips more mobile, or hopefully both. So now that we're measuring what you currently have, we know what the demand is. We train difference. So now that's the program. If in the program we just described, we'll try some hip mobility. I'm pretty good at that, but I might bring in a hip mobility expert. There's a good one in L.A. by the way. and then I would say probably the big three will help you with your back pain to get the pop up

and the ability to paddle out surfing. Does that answer your question? So for you in that example, I need to know the demand. I need to know where you are. And I know what the pain mechanism is. Now I can start going and choosing my tools because exercises to me, are specific tools. One's a hammer, one's a screwdriver, one's a bolt extractor,

etc. For specific things. I don't tell with this generic exercise if there's pain. Now, you don't have pain, and it sounds to me as though you got it dialed in. So I'm going to keep my opinions to myself on you. That might surprise you. Let me add a little bit more to that

because I think this could be helpful for the audience, even though it's my unique story, is that I've had periods where I've had a little bit of pain. So under my left shoulder, after, let's say in particular, maybe like a strenuous time period of lifting weights, just being in my normal routine, but sort of increasing my load, I've felt periods of time where there's a deep sense of tightness and pull and through a combination of taking a little bit of a break and also getting some chiropractic as well as

some massage and doing some, you know, facial release exercises that were taught to me. I've seen an improvement that's there. And to the best degree that I can, I didn't have any imaging or anything else done. It wasn't that bad, but it was enough that it was annoying. I couldn't sleep on that side. I couldn't sleep on my left side of my shoulder. I would feel some pain in the evening. I saw that, wow, okay, as I progress in sort of the load that I'm bearing,

in my, you know, three times a week, you know, workouts with my trainer at the gym, yes, I'm getting stronger and I'm adding lean muscle mass, but something I'm doing is causing some sort of, you know, pain that sort of a specific section. And I've never been able to get to the root of it. I just know that whenever it pops up and it's pretty mild, I take a break, I kind of go a little bit lighter. And I get to the way. some, you know, worked on or I'm paying more attention to it or more stretching that's there. You know, the thing that comes up for me is that watching some of your content, seeing your conversations with other people, even though I'm working with a trainer who I feel is very

technical and pays attention, you know, very precisely to my form, I'm thinking about, oh, okay, as I progress and I'm doing things like squats and dead lifts once a week, not anything more than that time period, with proper performance. form with my trainer, should I be worried about these activities as I continue, you know, into my mid-40s and then 50s and 60s and, you know, beyond? So I guess the question there would be is that I have a routine that I'm working on to continue to become stronger. I don't have any benchmark of exactly, you know, what type of strength goals that I'm trying to do. I'm sure I could break it down per activities. But should I be, you know, yeah,

what would you be thinking about? You know, is it worthwhile for me to be working with one of these practitioners or master, you know, clinicians that you have to look at and sort of identify what am I uniquely doing or do I have some proper incorrect form that is causing this situation to flare up so that it doesn't become a bigger issue later on down the line? Well, I have two thoughts listening to that. The first one is understand what the stress concentration is that's leading to the symptom. and hack your way around it.

It's either an inappropriate exercise with an inappropriate volume or an inappropriate technique for the, and it might not be the exercise, it just might be the way that you're performing that exercise that's leading to the stress concentration. So if you can have that done for you, that is an avoidance of the cause thing. But then the second part of the logic is knowing what the mechanism is now, is there something that we can do in a pre-upstream sense to build more resilience? So what is it about that stress concentration? Is there a muscular weakness?

Is there existing damage to the joint? It could be some people have a fascia complex around the muscles that if it was addressed, they would have more resilience. Or, believe it or not, some people are too loose. They've stretched too much. And if they tightened it up, it's like putting a tenser bandage around that area of the body. That can sometimes add more resilience. So figure out the mechanism and through mechanostimulation, you make it more robust.

Oh, that's super helpful. You know, when we did our pre-call and we were chatting a little bit about, you know, topics to cover today and how to make sure we, you know, covered all the things that I thought my community would be interested in, you talking about sort of things from your perspective. One of the things that you mentioned that I found really interesting that I want to go into now, and you hinted at the beginning of the interview, was you were talking about your sort of approach at the stage that you are at in your life. And you talked about this sort of essentially like this biblical approach, right? the seven-day approach that you have now, now that you've updated your plan for your unique goals

and focus on in life. Could you walk our audience through that knowing that this is your situation? This is not necessarily going to be the thing that applies to everybody else. But I think the methodology of how you've created it and why you've created it for you would be helpful for people who are thinking big picture. How do I design a movement routine in my life that supports my goals for? for longevity, which is a lot of our audience today. That was a really nice preamble. A lot of base notions in there.

So appreciate that, Drew. When I was younger, as I mentioned a few minutes ago, all I wanted was strength and speed. I was a Canadian kid. I liked playing hockey and American football. And that's what it was all about. But you build up miles on your body. And when I started as a professor, computers hadn't even been invented yet.

So the job rapidly changed through the 90s and the 2000s, and I became a sedentary worker, which is something I never signed onto. It's not in my makeup. So my professor's job became sitting at a computer. And even in the end, students didn't want to come to office hours. They wanted to do it on Zoom. And I said, no, you come down here because we're going to do some demonstrations to think around this whole thing about optimal movement.

Anyway, I retired in pain. I retired when I was 60. I was not healthy and in pain. I worked hard at night and on weekends. But that sitting job just didn't suit my physiology. So I got back to the rural life. We, for the most part, heat our house with wood, do a lot of wood splitting and preparing firewood and carrying it in.

And, you know, just living life. All that sitting pain went away. And then I worked on optimizing the variables. And it goes like this. I called my week now the biblical training week. This wouldn't have worked when I was in my late teens and 20s when I was heavy into sport performance. Every major religion of the world has one day per week off the Sabbath.

When you think of it from a mechanostimulation point of view, it's valid. It's perfect. You take that one day just to delode and allow all your systems to dispel a cumulative stress. So that leaves six days a week to work. Two days a week, I strength train. And I very strategically strength train. I work on things like core stability. I train in patterns.

I have push patterns, pole patterns, a lift pattern, a carry pattern. And then I have all the unzilleries. I do wrist work with an iron bar. It's called sword blade just to keep the hands and grippers in good shape. I'll do things like one-legged, rear-leg elevated, split squats and things like that from my posterior chain. And by the way, I'm hip replaced. You know, I have a few things I have to manage. Years ago, I broke my neck.

It requires a certain amount of maintenance strength, two days a week. Another two days a week I do mobility training, which I never did. when I was younger, but my hips need work, my neck needs work, my shoulders need mobility work, and my thoracic spine needs a little bit of work as well. If I don't, reaching overhead hurts, but with thoracic mobility, all of a sudden I can manage those patterns. Two days a week, I work on my ticker, cardiovascular training. So living where I live now, In the winter, I cross-country ski, in the summer I ride a bike, swim, et cetera. So, say, let's go back to that splitting wood example.

That checks all three boxes. I'm picking up 100-pound bucked-up logs, oak logs, putting them on the splitter. I might be using the splitting mall, acceleration speed, etc. I check the boxes on all of those. So I don't need to train that day. I've done it. but the next day comes along and I'll say, oh, no, I need more mobility. Okay, that's my mobility.

The next day, I'm not doing mobility. It has to be either strength or cardiovascular. The next rule is don't do two things. Sorry, don't do the same thing two days in a row. So if I split wood Monday, if I do it Tuesday, I'm getting a little bit sore by Wednesday. So I back off and I allow that to enact. So those are some of the things about what I call the biblical training week. And I'll tell you, Drew, I feel fabulous.

I'm obviously the oldest I've ever been. But I've been the most pain-free and generally healthy than I have been for decades because of what the computer did to my profession. It's not a computer's fault, obviously. But anyway, does that, so if, for your older audience, give that a thought. And I think they will converge on what is very doable and will result in a really nice, pain-free, able, resilient life. that's great i'm look i'm listening to that approach and i'm thinking you know that could that could potentially be working for me too i don't see anything inside of that routine does it do you see anything

that you're doing there that couldn't be something that i could maybe bar from and how i approach stuff because i'm not at the stage of my life where i'm super focused on strength at all cost or speed or you know explosive performance at all costs i want to be healthy mobile flexible pliable, but also strong in that sort of middle of the road to just support like a healthy life. Could I borrow from that routine that you have? I'll go along with you if you use the word sufficient. Sufficiently strong, sufficiently mobile, etc. Because sufficiently, yeah.

What comes through the door here are people your age and even people my age and they say, oh, you know, I want to set my next personal best in deadlift or in bench press or, you know, I want to run the marathon. And I'll look at them and I'll say, okay, can you explain to me why? Who's paying you $2 million to go out and run the marathon when your feet are really arthritic? You know, the cartilage of your right hip doesn't have that much resilience left in it. You know, and they'll look at me. And I'm the first person who isn't encouraging them.

go for their next personal best because the stresses that they would have to go through will probably shorten their athletic career, not lengthen it. So I'll say to them, let's discuss the goal of, you know, you want to be able to pick up your grandchild without pain. How does that grab you? And they'll say, yeah, yeah, that's my goal. I don't know why I didn't quite think of that before. So, you know, it's okay to set personal bests, but there's only so many really in your body if you want to hang on to that and meet your objective of having a really nice last decade, in my opinion. And I base that on being quite familiar with the scientific literature, but also being around. this game long enough now. I've watched people over 40 years to see who has met that end goal successfully and who hasn't. And there's no guarantee in life. But on average, you're stacking the

deck in your favor. This is probably outside of your world, but because you are in this unique place and you have such a view of how all these things come together, my audience is very interested in things like other factors like diet and, you know, hydration, et cetera, beyond the sort of typical guidelines that you might see out there of people saying generally steer towards whole foods, stay away from processed foods, make sure you're adequately hydrated. Is there any unique viewpoints that you have of how our diet or supplementation has any impact on some of these factors that you deal with, with pain, avoiding pain, building resilience inside of the body? I will say this. You're getting outside of my area of expertise. And at this point,

I will get to the spine-specific part, but let me just start generically. That's why I listen to people like yourself, Peter Atia, Cuberman, etc. Because they, I really have. I really have. made conscious effort for my own behavior change and I'm feeling better for it. When I worked, I drank far too much. And I look back and I think I would have recovered from jet lag faster. I would have slept better. And even though I knew what I knew, I didn't change my behavior. So hats off to people like yourself and Dr. Atia and Dr. Huberman who've motivated all of us to just use common sense, but it isn't so common to, I mean, this is really low-hanging fruit when you think about it. Have you read the book The Comfort Crisis? I have.

Yeah. Have you ever interviewed Michael Easter? I have. He came on the podcast. I've known Michael for years. He used to interview me quite often for men's health. And I think he's really onto something else. It shouldn't be comfortable. There should be a certain discipline in life that you have to meet,

and you just can't go and eat all the great food that tastes wonderful, but it is just, to use a euphemism, crap for your body. So that's my generic answer. But when we get down to back pain and are there supplements and certain nutritional rules that will help people, let me put it this way. If you're not moving well and exercising appropriately, you won't overcome any of those deficiencies through diet. So eat well, exercise well, move well, think well. think well

be a good person all of these things I can tell you at this stage of life matter some people will say well if I lose weight will that help my back pain what's the answer it depends

and I can give some examples where you know I've had some people with a heavy torso and they lose weight and now all of a sudden they have these symptoms of spine instability. They've got movement catches. So when they were heavy, the gut acted like a pneumatic cushion to stabilize their spine. So when they lost the weight, the guy wires shrunk, so to speak, and the spine instability existed all the time, but now it's become clinical.

Do you see what I mean? We'll see sometimes massive professional bodybuilders, and they put a lot of miles on their joints. And then when they retire, return their bodies back to civilian life, and they lose all that mass, now they ache, and they wonder why their joints are aching. And now, because they have a little bit of laxity and micro-movements. So to them, I'll say, this will surprise you, but if we get a little bit of muscle back on your torso, that will actually reduce the specific symptoms you're showing me that are due to the instability. So that's a surprising thing for some people, and yet other people, they are just crushing their spine. So when we measure their particular mechanism, it is a compressive

intolerance to their back. That's a difficult one to get away with if you're heavy. So losing weight will help them. So do you see why there's two contrasting cases where losing weight will help one and not the other? And that's primarily diet. Is there a supplement? Again, nothing is coming to mind that's magical. We'll have some intransigent cases where the pattern doesn't fit. And I'll say to them, we need to investigate this further, but it's not me who's going to do it. Have you had a really thorough blood workup?

And then I encourage them to go and do that. I might even refer them. And then it turns out they have Lyme. disease. That was the cause of not only their back pain, but their achy neck and knees and everything else. So, you know, but deficiencies, it may be just eating craft. But again, that's not the primary intervention for their back pain. Does that absolutely. Yeah, no, that's super helpful. Yeah, real amazing that I am not the nutrition expert. Yeah. You know, Stuart, both in this interview and previously as I've gotten more and more familiar with your work and having

had the pleasure to meet you. And thank you again for coming on the podcast today. The way that I'm looking at this is that, you know, like a lot of my listeners, I want to be in optimal health compared to the population. And you know, the population right now, especially if we talk about North America, but in particular the United States, you know, most people are overweight and obese. Most people have metabolic health issues. Most people are not fit. They're living a sedentary lifestyle, et cetera. And if we go back to these core aspects, because of our modern world, which has come with a lot of beautiful things and has put us in this place where we are in this comfort crisis, nobody's ever really taught us how to lift properly. Nobody has taught us how to

sit properly. Nobody's taught us how to take care of our spine. I'm looking at your work. And because in a beautiful way, so many of your answers are contextualized based on, well, what is your unique situation and circumstance, I'm like, I don't want to end up in a category where I'm one of the 80% who has debilitating back pain in the future. Is it worthwhile for me to just preemptively meet with one of your practitioners or one of the people that you've trained as a master clinician and just do an audit? You know, I am somebody, probably again, like a decent amount of listeners, there's some disposable income, but more importantly, there's reprioritized income. Instead of spending money on this luxury good in one way or another. I know like a lot of my audiences like

me, well, I'd rather like to be proactive about things like my spine, which is going to be a huge part of how I age. So is it, I'm thinking after this interview, I'm motivated to do a little bit of an audit and what little pain I've been dealing with, at least work with one of the practitioners that are there and get a sense of, am I heading in the right direction? Is there anything that I need to be thinking about or correcting based on my unique situation so that I, I'm going to, you know, I can knock on wood continue to age in the direction that I want to. I understand that not everything is available to everybody. There's location.

There's finances. There's other things. But generally, my audience has some resources that are there. Is it a bad idea to be proactive and go and find somebody that's been trained in your methodology and at least take the step in the right direction of seeing, am I moving and am I treating my spy in a way that's going to be beneficial in the future or am I heading in the wrong direction? What are your thoughts in that? My answer might surprise you. I'm not the type of person who tries to make everybody the same. And sometimes that is that person's movement signature. And there might

be a reason for it. And I'm not an over-correcter if you know what I mean by that. Oh, you are, you've had no pain history. You're 40 years old. You're having a lot of fun. There's no symptoms yet. But I see this and you and you should fix this. I might surprise you and I'll say I'm more tending just to let it be. Now, I'm going to give you some science.

We had a PhD student, Joan Scannell, who was a very good clinician. She was trained in the McKenzie system. And when she first came to work in the lab in the experimental clinic, someone would come in with a lordotic back. In other words, they would stand, but their butt was stuck out. So they had a lot of curve in their low back. And she'd say, oh, we should fix that. And I said, why? How do you know if that's causing their pain or not. And then the next person will come in with a flat back. And she'd say the same thing. Oh, McKenzie system says we should correct that. And I said, well, I'm not so sure about that. So what she did was she screened 150 undergraduate students who hadn't got any back pain

yet. And she took the six most hyperlordotic, biggest curves, and the six flattest backs. Now, there's a school of thought. It was popularized by a Czechoslovakian neurologist, Vladimir Yonda. And he said, in order to change the curvature of a person's back, you stretch what is weak and you, sorry, you strengthen what is weak. you stretch what is tight. Those were his clinical words. So if a person had a lot of holo in their low back, they would strengthen their abdominals and stretch their extensor muscles. And someone who had a flat back, they would do back extensor muscle work and they would stretch the front. But before we started with all of that, we measured elastic equilibrium or what's called the neutral zone. So let me just explain the slide.

there. Here is my elbow. If I could become anesthetized and fall into a swimming pool, my joints you go to the position of least stress. So there is elastic equilibrium for my elbow. And if I extend it, I would get flexor stress. And if I flex it outside of that neutral, I would get extensure stress. You get it? Elastic equilibrium is the least restful position. So then we measured the six flatbacks and the six ones with a lot of curve. It was so interesting that they were very different of where they stood in elastic equilibrium. The ones with a lot of curve in their low back, they stood in elastic stress. But the flat backs stood with less stress.

And then when the flat backs sat down, down, they flexed, causing more stress. And when the ones with a lot of curve in the low back sat down, they relieved stress. They moved into their neutral zone. So if you see how interesting this is starting to get. In other words, do you really want to change their costs? Well, on six of the people, you'd be right on the other sex, you'd be wrong. So you had to measure elastic equilibrium because the goal of me looking at how you move and whatnot is to try and I'm stressed you. But I don't even know which way that's going to be until we measure where your stress neutral is. You follow. I do. Yeah. Okay. It's getting it depends. So then she trained

them under Yonda's system with the two approaches. She got the ones who had flatbacks. I never thought this would work. I didn't think physical therapists could change the standing posture. into a more correct one, so to speak. But she did. The old professor was wrong. She got the ones who were flat back, but not stressed in standing. She gave them a little bit more extensor curve. But guess what happened when they sat down?

Now they had less stress in sitting down, but more stress in standing. and the lordonic spines were the opposite. So here's my point for you. If I gave you a corrective exercise to fix a flaw, we are not reducing stress in one area without cost. The stress had to go somewhere else. Do you see where I'm coming on this? There's no free lunch.

So you want me to, you don't have pain, not yet. that's why when I say my tendency is just to let sleeping dogs lie until there's a problem. That's how I would answer that question. But now I'm going to give a different point of view. I've worked for different professional sports organizations over the years, and I remember all the 10 training camp and do some assessments on some of the back-pained players and on some of the non-back-pained players as well. And then I've brought this up a few times with the medical staff.

Let's watch each player. We know what their medical exam and our specific exams show. And now we go watch them play out on the basketball court or on the hockey rink or whatever it is. And we're watching the move now. And then I'll say to everybody, write down on a piece of paper who you predict is going to get injured. this next season. Now let's put it in an envelope. We're going to put it in the chief medical officer's desk sealed and we're going to open it up at the end of the season. And we'll see how good we really are. Isn't that an interesting one? And do you know that we could quite often predict which ones

we're going to get a back injury or they were landing funny on the court and it was going to be a right knee or whatnot. So that's how I would answer that on the other side as well. But those are extreme conditions of exposure. Do you follow? It's not Stu and Drew just getting through life. So I can go either way on that. But it's all, if you gave me a symptom, I'm locked on and now I have guidance. I figure out the mechanism of the symptom, try and remove it and rebuild your body to handle it. That's the easy thing. Pain is easy for me. But without pain, it becomes a different game and it's much more difficult. So I hope those two stories, I'm not trying to avoid the question, but that's why I'm answering it in the way that I are. No, it's super helpful. And again,

I always appreciate the precision. That's why we wanted to have you on. It is a topic that is deserving of precise language and all the nuances that are there. Stu, this has been fantastic. I want to just give you any opportunity here to leave our audience with any closing thoughts. We'll make sure to include your fantastic book, Back Mechanic, in the show notes. For those that are watching, you can also see a copy over here. It's a great question-and-answer format that walks you through all the basics of your methodology and my favorite part about it. You may not be able to see it here as I put it up, but there's a bunch of drawings inside of there

that give you perfect illustrations of how people often, are doing things incorrectly, basic movements, lifting things, chopping stuff, carrying heavy weight, holding suitcases, etc., that will give you some sense of maybe preventatively how to avoid a lot of these problems that people end up with later on. But Stu, back to you. Any final closing thoughts and anywhere you want to direct our audience to? I do think so from a spine perspective, but I would like to say back to you, Thanks for all you do. I've listened to many of your episodes over the years. I'm very interested in some of the metabolic issues, the cardiac issues that you tackle and the quality of your guests. They're fabulous. And in your interview and podcast today, your logic and follow-up and the way you posed some of the questions was perfect. So you made it easy on me.

Anyway, thank you for all you do and changing lives. I just get to do the easy job. I get to interview experts like yourself who have put in the years of work. It's a lot easier to come up with the questions than obviously do the work that you're doing. So thank you. And thank you for your continued effort. You know, I think that the fact that you have provided this resource of writing material, being on podcast, I really enjoyed your interview with Peter Atia,

and then also training other clinicians to continue the work and legacy that you've set up is fantastic. So thank you for that. And it's been a pleasure today to have you on the show. Well, myself included. So thanks so much, Drew. And I hope I never have to see you for your back. But if you do have a back symptom, let me know. We'll assess it.

And we'll see if we can sort out some cast to resilience. Yes. would, but if I do end up there, you'll be the first person I call. Stuart, thank you so much. Okay, thanks, Drew. Hi, everyone, Drew here. Two quick things. Number one, thank you so much for listening to this podcast.

If you haven't already, subscribe, just hit the subscribe button on your favorite podcast app. And by the way, if you love this episode, it would mean the world to me. And it's the number one thing that you can do to support this podcast is share with a friend, share with a friend who would benefit from listening. Number two, before I go, I just had to tell you about something. something that I've been working on that I'm super excited about. It's my weekly newsletter, and it's called Try This. Every Friday, yes, every Friday, 52 weeks a year, I send out an easy-to-digest protocol of simple steps that you or anyone you love can follow to optimize your own health. We

we cover everything from nutrition to mindset to metabolic health, sleep, community, longevity, and so much more. If you want to get on this email list, which is, by the way, free and get my weekly step-by-step protocols for whole body health and optimization, click the link in the show notes that's called Try This or just go to Drew Perot.com. That's D-H-R-U-P-U-R-O-H-I-T dot com and click on the tab that says try this.