Dynamic Dialogue with Danny Matranga - 337: Back Pain, Back Pain Management + More with Dr. Stu McGill

Episode Date: November 14, 2023

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Hey, everybody, welcome in to another episode of the Dynamic Dialogue podcast. As always, I'm your host, Danny Matrenga. And in this episode, I'm joined by Dr. Stu McGill, one of the world's most respected experts in the field of back pain and pain management. In this discussion, Dr. McGill and I will be talking all things back pain, where it comes from, how you can self-diagnose, tools for managing back pain, and what he's noticed are the most successful tools, traits, and tactics for getting out of pain. This is a revisit, if you will, of a discussion Stu and I had all the way back in 2020, but he's somebody whose expertise in this

area I think speaks for itself, and I know you'll enjoy the discussion while I get over this cold that I've had for a couple weeks. Thanks for staying with me, and enjoy the episode. This podcast wouldn't be possible if it wasn't thanks to support from our awesome partners, one of whom is Vivo Barefoot. Vivo makes the best barefoot training shoe on the market. For years, I stayed away from barefoot training shoes despite knowing the benefit of low cushion, wide toe box shoes for the health of our feet, the intrinsic musculature that helps support everything that we do. I stayed away from these

shoes because I thought they were ugly. But that was until, of course, Vivo started producing some absolutely gorgeous barefoot training shoes. These are low cushion, lightweight, breathable trainers that have a ton of bend, a ton of flex, low cushioning to provide for optimal stimulation of the proprioceptors at the bottom of your foot. Fun fact, 70% of the proprioceptive cells in your body, the cells that tell your body where it is in space to help you be coordinated, to help you create movement, balance, stability, all of these things. They're located on the bottom of your foot fighting to make contact with some kind of surface so they can get the tactile feedback they need to help you optimize and coordinate movement.

That's why when you're barefoot, you probably feel more stable and more connected to the ground. And I have never found a shoe that feels better to train in, not just feel more stable and more connected to the ground. And I have never found a shoe that feels better to train in, not just train my clients and stand around in for eight hours a day, but literally train in. Tons of fantastic mobility out of my toe box, the ability to spread my toes, all in one beautiful climate friendly package. I'm a huge fan of the Primus knit lights. I have them in obsidian. I have them in bright white, and I absolutely love this shoe. I have been raving about it for three or four weeks straight. I've never had a better training shoe in my life. You simply can't beat these. They feel great. They look great. My fiance even said, wow, those shoes,

and I quote, make it look like you know what you are doing, which that's all I need to hear. Not sure exactly what that means, but I'm guessing it means good things. All the trainers and coaches at my studio said they make my calves look great. And I think this is because when you're wearing a barefoot shoe, you're using more of the intrinsic muscle of your foot and ankle complex that is so imperative for movement. Trust me when I say you've never had a better pair of training shoes than you will when you try Vivo Barefoot. You can't beat these. And Vivo is offering listeners of this podcast a special 10% off order by using the code DANNY10 on vivobarefoot.com. You can just scroll down to the show notes and grab a pair, but these shoes are fantastic. They're beautiful.

They train incredibly well. They're durable, and I promise they'll be the best pair of shoes you've ever had in the gym. Again, that's vivobarefoot.com, and check out using the promo code DANNY10 to save 10% on the best pair of shoes you've ever owned. Welcome in everybody. Today we are talking back pain, but not with anybody, not just any old run of the mill expert. We are talking with the expert on all things back pain, Dr. Stu McGill. This is perhaps the world's most respected expert

on the back, the way it's put together, the way it's structured, what it does, and how to manage back pain. We're going to talk about a variety of different things that might impact back pain, how to look at it, how to adjust training parameters, what type of clinicians to look for, all kinds of stuff. So do sit down and enjoy this interview with myself and the amazing Dr. Stu McGill. All right, so Stu, how's it going, man? Very well. I'm calling you in Northern California, and I'm in Middle Ontario. Believe it or not, we still have a little bit of snow at the end of the drive here where it was built up with a plow. But it's almost gone. So we're looking forward to a nice summer.

Nice. Yeah, we're enjoying a 75 degree spring day, a light breeze out here. It's interesting. takes the bite out of the being stuck in your home, but it's a little bit of a slap in the face to know that you can't go out when it's 75 and sunny and you typically be out and about, but it's all for the best. For those of you who aren't familiar with Dr. McGill's work, I'll let him enlighten you on how it is he got to where he's at. But in short, he's kind of known world around as the man when it comes to all things back pain, spinal health, whatever you want to call it.

He is the guy when it comes to the back. And so, Dr. McGill, how is it that you kind of went about establishing yourself as such a force in the back and spine space? Well, a hard question to answer, and it could be a long answer or a short answer, but there was never really any great intent to end up where I am now. It was an in vitro laboratory where we took real spines and created the damage. So we were able to create an understanding of mechanical load scenarios and very specific types of tissue damage in the spine. Then we also had an in vivo laboratory where we made biological signal measures obtained from the real person, things like spine curvature, displacements, muscle activation patterns, external loads, et cetera, et cetera.

And we were able to figure out what the load distribution was on the various spine tissues inside of them. And that allowed us to determine distributions of stress because injury and pain occurs at the regions of the highest stress. So what strategy was the person using either intentionally or unintentionally that caused a stress concentration and the injury and pain. And then slowly we're able to put together some rules and guidelines generically, and then specifically for them, strategies that they can employ to take the pain away. way. The third part of the academic scientific probing and exploration of all of these ideas was the experimental clinic that we started about 25 years ago. And we would give thorough assessments to every individual, subcategorize their pain, give them what we felt was the most appropriate intervention. Then we would follow up to see, A, did they even comply with our intervention?

And how are they doing half a year and two years later? So we're one of the few operations in the world, actually, that has followed up with every single patient so we know our score. But it also showed us what interventions were most appropriate for what subcategories of back pain. But these days, I retired from the university three years ago, and I live in, we'll just call it Central Ontario now, about three hours north of the university. And I just see patients here before this virus situation anyway, and they would fly in from around the world, very elite athletes, and also people really struggling with their back. I'm not really here to see people who have first time back pain and they'll go to their physical therapist and, and hopefully they're, they're helped.

I'm dealing with the more challenging ones, the ones who failed. And I quite enjoy the challenge of really understanding the mechanism of their pain, their learning style, impediments that have caused past attempts to fail, what their expertise is, and can I tap in on that to assist them, et cetera, et cetera. It's a lot of fun and obviously greatly satisfying when you can change someone's life from being quite miserable to getting back to enjoying life once again. And I'll just finish off by saying, do we have 100% success? And the answer is absolutely not. But I will compare our success with anyone else. No, that's awesome. And that's actually kind of how I came to know about you as kind of this

mysterious figure who was the last stop for back pain because you had so many answers for so many people who tried everything. And then whether it was coming across your work in book form, or even going to see you or going to one of your courses, it seemed like, you know, once you got to Dr. McGill, you know, that was as far as you could go. He's got the ability to kind of see things in a way that nobody else does. So your reputation as an expert really precedes you in this space. And I would love to ask you just a few basic questions to kind of lay the foundation for our listeners, because back pain is something that's very common. It's very nuanced. A lot of people have probably dealt with it or know somebody who's dealt with

it. And it all kind of goes back to the spine and a lot of the organization and the function of the spine. So for people who are just listening and are not really aware, what is kind of the organization and the function of the spine. So for people who are just listening and are not really aware, what is kind of the general function of the human spine? What is it expected to do, withstand and resist? And why is it organized with its different curvatures and different vertebral types? Okay, wow, you've given me a few questions there. Just something popped into my head as you were saying that, Dan. It's interesting that when someone has knee pain, for example, or foot pain, they have it. And if there's something in their foot and it causes them to limp, fair enough. Everyone understands that analogy. Spine pain can be quite different. Spine pain can shut down what we call the neuro drive to the rest of the body.

So when we move, movement originates as a thought in the brain. And that thought gets translated into a thought in the brain. And that thought gets translated into a pattern of nerve pulses. They go down the nerves and create the desired movement by activating muscles in certain sequences. Back pain and spine pain can just shut that down. And that's one of the unique features of it and probably makes it more of a consequence in people's lives. So there's just a thought. But let me start this way because I think you used the words the general function of the spine.

So let's treat this, at least the beginning of the discussion, as a discussion of form and function. And what that means is you need design specs. Interestingly enough, there was a television show being put together in the UK, and they were going around to world experts and asking them, if you had a chance to redesign the body, how would you optimize it? So they got some knee experts and etc. And I happened to be the spine person that they asked. And I went through this question, which I think you're asking me now around form and function. Can we design it better?

And I thought, well, the spine has to bear compressive loads. That's what allows you to carry your children. It allows you to do a farmer's walk in the gym. You have to bend in all of the different directions. It has to support sheer loads. And then I said, okay, well, as you know, the discs are collagenous laminated structures. They do cause a lot of spine issues. Let's replace the discs in a person's spine with ball and socket joints. That would give us more mobility, more power production. But then think of this, stack a bunch of oranges, one on top of the other, and then stick a book on the top of the stack of

oranges, it would fly apart. So you would need so much stabilizing musculature on a stack of oranges to allow it to bear load. It would have tremendous mobility, but you couldn't stack load. So you start to realize that the basic form of the spine is pretty hard to improve upon. But along with all of that now, it means there are trade-offs with that design. So the discs are unique. They're not ball and socket joints, but a lot of people get into trouble when they start treating their spine as if it were a ball and socket joint.

A ball and socket joint, by definition, is designed to create power. So there's no coincidence that the torso has ball and socket joints at either end, the hips and the shoulders. Those are the power generators, which is a lot of force, a lot of torque through a great rotational range of motion. But the spine, when you measure it in elite performance, when you measure it in its ability to become less painful, generally speaking, you treat it to transfer power rather than to generate power. So let the hips generate the power and then you anti-twist or stop twist or stop extension or flexion, if you know what I mean, through the torso and transmit the power on through. So the disc gives a wonderful trade-off. It allows you to

have a slender abdominal region, for example, because if you had ball and sockets, you'd have a huge, very wide torso. And then the last bit of it all, yes, you have discs, but then you have facet joints in behind. And they allow you to store and recover elastic energy to allow you to kick, to punch, to run and catch your dinner if we're going back a few thousand years it allows competition but because it guides motion and helps support some of the sheer forces so all of these features of form and function define a function and but but people probably who get into trouble with their backs don't know the trade-offs and the rules that their spine lives by because it's not a knee joint and it's not a hip joint so is that a little bit of a start oh i i the other little bit that was was very curious

was you mentioned why do we have different curves in the back? Do you want a little bit of a fun analogy there? Yeah, actually, I would love that. I think you've done a fantastic job so far of kind of painting the picture of how it is that the spine works functionally. But from a visual standpoint, it's quite a strange looking structure and those curves particularly stand out. So I would love to hear this. Yes. Well, we are a biped, obviously. And if you believe in evolution, we came from whales, which interestingly enough, the water-based mammals, a whale, as you know, has a ball and socket joint in its vertebra to allow the big flukes generating huge power.

And as you go to land-based, the mammoths of, I got to get my number right. I'm going to say 20 million years ago, but it might be 12 million. They had ball and socket joints in their spine too. But as they became more upright, they had to have spinal discs. But getting back to the curves, which are so interesting. In your mind, envision every world-class sprinter that you know. Do you notice how they have a big hollow in their low back, a lot of lordosis? Now, in order to run fast and sprint, you must have a lot of lordosis because it pre-turns the pelvis and allows you to get more extensor power with the leg propulsion. So when a sprinter sprints, they can't reach out with their leg in front of them too much because if the foot falls ahead of the pelvis, you actually slow down. falls ahead of the pelvis, you actually slow down. So you've got to have footfall landing at the pelvis in the straight line and behind. So the more you can turn the pelvis with a lot

of lordosis, you need it for sprinting speed. However, you will never kick anybody in the head. Do you notice that the fighters in the UFC, if a lot of people know what I'm talking about, the MMA fighters do not have a lot of lordosis. In fact, many of them have very flat backs because it is such a mechanical advantage to play jujitsu, lay on your back, in guard, flex your hips, flex your spine. In other words, having lordosis would be a disadvantage and you don't find great jujitsu players with a lot of it. would be a disadvantage and you don't find great jujitsu players with a lot of it.

Likewise, in order to kick someone high to flatten the back and pre-turn the pelvis into the posterior pelvic tilt is a great advantage. But you will notice that those athletes are terrible sprinters. So it's so interesting and I can go through different curvatures and different features like that. But again, it comes back to this idea. There's always a tradeoff. You can't have it all. And the great clinicians, the great trainers recognize the features of that client in front of them, and they know how to optimize them. And then another feature that you might find interesting would be spine thickness. You don't find a top PGA golfer who's a heavy boned athlete.

They tend to have slender spines because a golfer is an elastic athlete. They're not a power athlete. They're not a strength athlete. They are a storage and recovery of elastic energy monster. Well, if you take a slender willow branch and bend it back and forth, it doesn't break. It's quite fine with that. But a willow branch doesn't support heavy load. It will crush if you squeeze it. Now, let's take a thicker branch. You can apply load end to end and it survives.

Now let's take a thicker branch. You can apply load end to end and it survives, but try and bend that heavier branch and it shatters right away. So this is why you don't find a middle linebacker on the golf tour. It would be so much stress for their back, nor will you find a top golfer playing middle linebacker. They're mutually exclusive. So not only does the sport find the spine, but the training of those optimizing the athleticisms within the tolerance so that you never create a stress that ends up with damage is the magic of it all. And that's the art and science of what you do and what we all try and do to

improve people's lives. But when we screw up, it's, it's misery. No. And, and that's, it's a great way of kind of creating a visual that there's a lot of inner person variability here and that perhaps there's a lot of inner person variability here. And that perhaps there's some self-selection with things like sport and just the way people may be structured or the way that sport may enhance or drive certain structural changes. And so because there's so much variability and requirement of the spine for different activities, there seems to be a lot of blanket advice as to how to deal with back pain and a lot of myths regarding back pain. As somebody who's dealt with kind of people up and down the spectrum, but particularly at the highest end, I'm sure you're familiar with a lot of these

myths. And just really quickly, could you perhaps hit on some of the more frustrating and quote unquote destructive myths in the health, fitness, pain management space about how to deal with back pain? What are the most common ones that you think are setting people back and having a long term healthy back? Frustrating and destructive are two words you use. How about this? So many people get the diagnosis, oh, they have nonspecific low back pain. That is the biggest myth going out there that is so destructive. There's no such thing as nonspecific

back pain. All that indicates is the person has never had a thorough, competent assessment so that they know with precision the precise mechanism of their pain. But here's the problem. It's destructive to them in that they don't have a clue on what they need to do to address their pain to stop the cause. They don't have a clue to know what tools and approaches to employ to restore their pain-free foundation and then build a progression to do what they want to do to get back to loving life. The frustrating part of it is those clinicians who give the diagnosis, nonspecific back pain are incompetent and no one holds their feet to the fire. So they've given the diagnosis and now they're off the hook.

They feel okay about it and the medical system continues to pay for this incompetence. So how about that? No, I love that. That's a pretty heavy opinion. It is. And it's actually something that I've heard quite regularly, that phrase, non-specific low back pain. So it actually lends itself well to the next question, which might be more specific back pain, and that is, what are some of the most common pathologies that cause back pain in the general population? We've talked about discs a little bit, and I'm sure they're

involved, but with the majority of people who are dealing with back pain, what common pathologies seem to pop up the most? Well, as you can imagine, it depends on the group. So even if we didn't do an assessment of the individual, just let's talk about groups of people. Yeah. Fine pathologies cluster around sports. Take a group of female gymnasts aged 10 to 15 years of age. gymnasts aged 10 to 15 years of age, their pathologies will be a much higher incidence of stress fractures in the pars, for example, spondylolisthesis, because the mechanism of that is repeated full range motion and rotation. Exactly what gymnasts do, particularly in the skeletally immature bone.

But, you know, golfers have a cluster. Baseball pitchers have a cluster. Olympic lifters have a different cluster than power lifters, even though they're both lifters. Interestingly enough, yeah, it is really interesting. You don't find many Olympic lifters who are true both lifters. Interestingly enough, yeah, it is really interesting. You don't find many Olympic lifters who are true Olympic lifters. I'm not talking about CrossFit doing Olympic lifters. I knew you were going to say that. But with Olympic lifters, they have very good backs as a rule. I don't see many for back pain

unless they have a bad hip or a bad knee that the stresses to protect that is propagating through the linkage into their spine. And now they're having a hip shift or something like that as they catch, say, in a snatch style of lift or something like that. But then, well, and then we could have the example of CrossFit, for example. No true Olympic lifter who's training for the Olympics would lift 10 times, get tired, and break form. Yeah. That's not their sport. They train singles and doubles. They never break form.

They try never to miss a lift because they never want to pollute the muscle memory of that Olympic lift with fatigue or bad form. But, you know, CrossFit, it's a sport. I get it. Their sport is can you hold the good form together even when you're tired and survive? So, you know, I don't necessarily recommend fighting in the cage either. However, a lot of our athletes do, and it's my responsibility to restore their backs and restore their careers. So, you know, it's not a judgment on the sport. I love sport myself. I get it. I get the war of it all, but nonetheless. So there's some opinions, if you will, on sport, but the real science of it is really done on occupational groups. I said to you, we followed the emergency task force, which is like the SWAT team of the

Toronto police force. We had 72 men and we followed them for five years. We had zero dropout. It won an award as the best study of that length of time with rigorous testing of the police officers who got back pain, who got other health issues, et cetera? Let me ask you a question. Where would you predict that the most dangerous place for an elite police officer is? Location-wise or in the back? Oh, man. The most dangerous place. Yeah. I don't know, some type of arrest situation where they were breaking in somewhere to arrest someone? I would have thought that as well. However, it turns out it's the gym, the training room. So, what we found with those elite police officers, and we've confirmed this with different occupational groups time and time again, the most dangerous place is the gym, particularly for those who train in a style where they might do, oh, they'll do 10 burpees, then 10 Olympic lifts, and et cetera. In other words, they are more fit when you measure them. However,

they're also much higher incidence of back injury. Now, the ones who are the most resilient, in other words, the most successful pain-free operators are the ones who have sufficient athleticism. Now, that's an interesting word. They have sufficient strength, but not too much. They have sufficient mobility, but not too much. And they move well. They move in a way that they don't create stress concentrations in their back. They have more load in their hips. When I measured elite power lifters, the higher you lift in your weight category to the world record, the more load is in your hips and the less load is in your spine proportionately. So there are skills that allow you to express your athleticism and do your job in a skillful way. So these are some of the stories. One other point in terms of back pain

pathologies and why they are so misunderstood, consider breaking your femur. So you've broken your femur within three months, you're back to work and probably you're quite fine after three months. Now have an end plate fracture or a little bit of a disc bulge. And what happens is you end up with a slightly flatter disc bulge, disc height, sorry. So you've lost a little bit of disc height. That sets up a cascade now that will last many years, about two years, because as you flatten the disc a bit, the disc bulges, the facet joints are now carrying more load. In other words, two years later, they start to get thickness to them, a little bit of an arthritic reaction. And then a few more years after that, the nerves are starting to get some friction on them as they slide by the thickened joint capsule of the facet joints, etc., etc., etc.

So this makes it a particular challenge for clinicians because they have to understand where in the cascade their particular client or athlete or patient, whoever they are, is. patient, whoever they are, is. And then, you know, at the beginning of the back pain cascade, sitting might cause pain and walking might relieve it. Towards the end of the cascade, it's the opposite. Sitting relieves their back pain. And now the treatment has to change. So there's a little bit of an essay, I suppose, on common back pain pathologies. They're not so common broadly. The cascade is common. However, each person is absolutely an individual. And when you get right down to it in our world, the clinical subcategories are subject to N equals one. Yeah. The dosage of an exercise or what is their strategy? What's their movement hack to get their baby out of the crib at two o'clock in the morning?

Yeah. That would be different for each person. No, and I really like that. I think it's particularly insightful to consider that there's clusters of the population that are perhaps experiencing similar back pain based on the movement they do, right? Like you made a point that depending on the sport people do, there's particular pathologies that may or may not be more common based on the movements they're doing and the stressors that they're spreading across their spine. Particularly for people who are lifting, whether it's recreationally, maybe it's semi-competitively, or even for coaches

and trainers who want to perhaps lay a foundation to manage the potential back pain problems or back issues that might arise. What are some of the strategies that you would implement? And I don't like the term, but to use prehab to kind of create a space where the spine can become more resilient? Are there movements that you like? Are there techniques that you like? Are there warm-up considerations that you like for people who understand that back pain might coincide with their activities if they do them improperly and want to give themselves a better chance to mitigate that? Well, yes. It's a wonderful... I see why you're so good and your podcast is doing well, Danny. You get right on the issue and you're very eloquent. So good for you. Well, I could take that

so many different ways, but I cannot give a single answer to say here is a great exercise routine and progression for lifting. But let me start this way. Lifting starts with a pattern and people are familiar with a hip hinge kind of a pattern. So establish a hip hinge. But let's take, I think of an example where hospitals and medical schools will bring me in and they say, well, you see three patients in front of our surgeons and our medics and our fellows and our nurses and physios, etc. And we want to see how you assess a patient. And it takes me back to a couple of years ago where they brought out this woman. She was in her mid-70s and she sat down on the stool on the stage, very emotional. And I said, well, tell me your story. And she said, well, you know, they think I'm not very good at getting off the toilet anymore,

and I'm going to fall. And I'm going to have to leave my home now, because they think I'll fall and be left there. She says, I don't care about that. She says, what really, no one will feed my cat. And she started to cry. She says, now I have to leave my home. My cat can't come with me to the patient care facility, et cetera. And I said, really, could you show me getting off the toilet? And she did, and she nearly fell. And then I said, okay, did you ever play baseball?

And she said, yeah, I used to love playing with the boys when I was a younger woman. I said, great, play shortstop for me. So I drew upon something that she was already familiar with. I didn't have to coach anything. I just said, go play shortstop. And she moved her hips back and she slid her hands down her thighs and she grabbed her knees. What fabulous, you know, just getting to know her that much. And then I said, great. Now here's what I want you to do. Change the shape

of the curve of your back, hump up like a camel. And she did that. And I said, does that hurt? She says, well, no. And I said, do the opposite, lift your tail. And she didn't quite that. And I said, does that hurt? She says, well, no. And I said, do the opposite. Lift your tail. And she didn't quite get that. I said, stick your bum out a little bit. And she got it. And she goes, oh, no, no, that causes a bit of pain. I said, okay, go somewhere between the camel and that. And she did that. And I said, now lean forward, push your toes into the ground, lean forward through your ankles. You're a leaning tower and push down, carry more weight through your arms. And I said, don't lift with your back and stand up. What I want you to do youngster how to pull a broomstick off the ground and then start to add weight. But that's the foundation of lifting competence. Yeah.

And then I showed her that and I said, now sit on the stool. She did the most wonderful squat and sit with competence. And I said, okay, now we're going to get up, spread your knees, get your feet underneath you, sniff a little air, lean forward through the hips and repeat the movement. Now pull your hips through as you transfer the weight. She did it perfectly. She was up and down. And then she started to smile. And I said, what's up with you? She says, I don't have to leave my home, do I? And I said, no, you don't. Now, was that a psychological intervention that I did? Because it's so totally changed her psychology, her self-confidence, her perception of herself, or was it a coaching session, or was it a biomechanical session,

coaching session, or was it a biomechanical session, or was it a neurological session? It was all of those things. So, there's just an example. You said lifting as a tool. I'm not going to give her lifting as a tool, but I'm going to borrow the mechanisms, the techniques, the coaching techniques from Olympic Lifting 101 and Powerlifting 101, because that was a deadlift, but I will never deadlift her, not in a million years. So now let's extend that logic a little bit. Let's take a 28-year-old stay-at-home mom. She's got two little kids. She goes to the gym and trains with a trainer, and the trainer is Facebook trained. And then the trainer says, I'm going to get you to lift your dead. I'm going to get you to deadlift your body weight in three months. That's our goal.

And now she ends up at BackFit Pro as a disabled patient because they never created the adaptation. There was no way she could lift. She could create the bony adaptations in her spine within three months. Do you notice how the grand old women and men of powerlifting are doing it in their 30s and even into their 40s? Yeah. It took that long to develop a very mature strength. So, you know, that stay-at-home mom, I would never be having her deadlift. What I would have her do, though, is learn the shortstop squat that we discussed.

And I'd have her pick a sandbag off a bench. Yeah. And that's her baby out of the crib. That transfers to her life. And then we discuss, hold the sandbag in tight. Now, do a drop step, turn and walk. You see how trainers have the opportunities to change people's lives by transference,

but the missing part for so many trainers is the transference from what they do on the training room floor to that person's real life. And again, well, I'm going to say this. Some people, some of your listeners will not want to hear this, but this is my clinical truth. More than half of the people who come here have been caused by trainers. Now, it's not an indictment of trainers, not at all. It's just that those are the ones who live on Facebook. They don't listen to you. They don't listen to good science. They don't do the work to get educated in all of these issues. And they'll listen to someone who says, oh, you've got

nonspecific back pain, get back strength through deadlifts. If that's their level, strength through deadlifts. If that's their level, they may get lucky, but they will lose more than they help. So this notion of transference is huge. And I'm not talking through my hat here. I can prove. We studied the Pensacola, Florida Fire Department. We worked with them for two years. So it's a big group. We did all kinds of trials with them over the years. Do you know the James Andrews Institute, the Surgical Institute? Yeah, big sports. Yeah, correct. Yeah, absolutely. If you're a pro baseball player and you need shoulder surgery, chances are you will be going to the Andrews Institute. He's a big wheel. But he's got great forethought in a lot of these things. And he's very aware of occupational disorders. So anyway, we worked with the

Andrews Institute and the Pensacola Fire Department. And one of our studies was a training study. One group was obviously a control group. They just did their usual thing. Another group trained with the trainer pushing them, do more reps, you know, counting them and all that kind of thing. Not so concerned about perfect form, nor sometimes selection. They were sort of standard gym exercises. In fact, we were mimicking the common gym practice in many locations. But the third group was a group called Movement Matters.

Now, are you familiar with Exos? It used to be called Athletes Performance. Yes, very familiar. But now it's Exos. And a good friend of mine for many years has been Mark Verstegen, who runs that operation. We took Exos coaches, and they were already well-trained, but we pointed out what we want. And we want them to coach showing every firefighter, if they had a valgus buckling knee,

if they were doing a pull on a fire hose or on a cable in the gym, we would show them that they can correct that by externally rotating through the hip. You know, the knee will follow what the hip tells it to do. Basically that level of coaching, we would coach strategic instructions on if we needed more proximal stiffness in the core, say a hip was dropping on the swing leg side, we'd say, push your fingers into your lateral obliques. Now, harden your abdomen out against the fingers. Now walk. And that would correct their hip drop, for example, which was not only stressing, say, a piriformis on the stance leg side, but it was also stressing their spine. Nonetheless, they were coached at that level.

Then I should have said prior to doing that training trial, we measured them on the fire ground. We measured them chopping holes in roofs of burning buildings, battering down doors, pushing forward and advancing a loaded fire hose. And that's one that's spraying water. There's a tremendous reaction off of that. You've got to really lean into it, if you know what I mean. It's a heavy push. And then we measured their fire ground competency after we finished the training trial. We never trained fire ground activities. It was a study of transference.

What you do in the gym, does it change a person's life when they're out there battling a fire? Anyway, long story short, the ones who just trained for fitness, the trainer was yelling at them to do more reps and this kind of thing. They got fit. There's no question. However, when they returned to the fire ground, they had more innate horsepower in their body and their movements were worse. They had more knee valgus, more out of plane, sagittal plane spine deviations under load, which we know are proven injury markers. That valgus marker of the knee has been shown by Hewitt at the Mayo Institute. And he's done the best trial ever on NCAA female basketball players who have the highest incidence of torn ACLs.

They have six times the rates of the men. Well, there's a reason for it, but he was able to document the mechanism and come up with an intervention. And by the way, the intervention of more torso stiffness and more strategic hip mobility turned out to be exactly what we do for backs. There's a fusion of these ideas through the body. But I'm probably talking too much. But, you know, my point is, I have opinions for a reason. They didn't come out of thin air. They came out of studies like the study with the Pensacola Fire Department that cost half a million dollars to measure the fire ground loads before and after conduct the training trials i mean these were big research operations so the results matter but you don't hear about it on facebook or i'm not picking on facebook but i know it's yeah it's

it's the guys who want to argue without context in social media when they're not savvy and aware of there's a lot of science that has gone on to guide us in what we do. We should be using it. Hey, guys, just wanted to take a quick second to say thanks so much for listening to the podcast. And if you're finding value, it would mean the world to me if you would share it on your social media. Simply screenshot whatever platform you're listening to and share the episode to your Instagram story or share it to Facebook. But be sure to tag me so I can say thanks and we can chat it up about what you liked and how I can continue to improve. Thanks so much for supporting the podcast and enjoy the rest of the episode. Yeah, well, certainly. And you would

expect as such, given that back pain is quite common. I want to go back though a little bit to kind of the story that you told about the woman who was worried about potentially having to lose some of her independence and that coaching session, whether it was biomechanical, psychological, physical, that you took her through that kind of gave her that confidence. And this is something that I see a lot with some of the clients that I work with, which is that a little bit of the right type of communication and the right type of education can really empower somebody to get through back pain, whether we know exactly what's causing it or not.

And the more research I've done into pain science, particularly recently, I've become aware of this biopsychosocial model and how important it is, the dialogue we have with either clinicians, trainers, or even ourselves about our pain. And I know that there are a lot of people listening to this who have clients with back pain, or perhaps they themselves have back pain, and they don't have a diagnosis yet. Perhaps they're not sure what's causing it. But I believe there's probably great power in how they communicate with themselves about that back pain, or even how a coach would communicate with them about that back pain. Do you have any tips for whether it's clinicians, trainers, or just people dealing with back pain, how to think, organize, and even have a dialogue with themselves about that pain?

Are there tools people can use to manage it or at least have some confidence around it so they can experience what this woman did? I have several opinions, so I'll try and organize them like this. First of all, be present and be a good human. It astounds me sometimes when I'll go into a therapy clinic and the therapist without assessment will give a person, now you've got back pain, I'll go sit on a gym ball and do one-arm cable pulls or something like that. And then they go and sit down at their desk and write notes

or go and start training someone else. This shouldn't happen. So there's the be present and be a good human. You know, you live by the golden rule. The next thing is if you cannot read a person, you're in the wrong profession. So, you know, Vince Lombardi famously responded when he was asked, you know, what's your secret to coaching football teams? And he said, it's not that I know football very well. It's that

I know men. And I use that quote often for clinicians who have to change people's lives. If you can't read the person, and if you cannot see the pain, if you cannot see that they have a short attention span, so that you have to coach in single sentences, and you have to layer down the movement skills. Or if you just tell a person, oh, I heard that movement, posture doesn't matter, which is quite common now in some therapy circles. Yeah, that's become a very sexy thing to say. Well, then I will so disagree with that. And I would put that person under a bar, just put a bar on their back. Now do a pelvic tilt back and forth 10 times. And you will find right away the pain and where why posture matters. You know, it's, it's just astounding to me and all the work that we do. Uh, you know, I was with, uh, uh,

someone yesterday. Uh, are you familiar with Chris Duffin's transformer bar, for example? Yeah, very much so. Yeah, well, we have one at BackFit Pro. And just so your people understand, it's a bar with a yoke. And there's a cam mechanism where you place the load forward or backward because of this dangling cam on the bar, because what it does is it manipulates the thrust line through the linkage, which exactly determines how much load goes through the knee, through the hip, through the back, through et cetera. If you want to spare a knee, you tune it to spare the knee.

It's all posture driven. It's a hundred percent posture driven. Every single back pain is influenced by posture unless they have cancer or an aneurysm or an infection or some other non-mechanical reason for their pain. I think I've made my point. But getting back to the biopsychosocial model, when we started the back pain clinic 25 years ago, I set aside two hours to see a back patient. And my colleagues would say, two hours? No one's ever done that before. What are you going to do? And do you know, Danny, in a year, I moved up to three hours.

Because we would start and say to the person, welcome, tell us your story. And they would tell us they would give us gold as to and we're picking it up. What are their movement habits? What are their impediments to not complying to past suggestions? They are revealing their emotions, their learning style. All of these things go into understanding their pain, their habits, the pressures in their life. So it mystifies me now that people have to be told,

oh, there's a biopsychosocial model here. I used to be chair of the Department of Kinesiology at the university, which has four subdivisions, biomechanics, physiology, neuroscience, and a psychosocial division. That was our approach to looking at human movement and optimizing health, avoiding injury and disease. So it somewhat is humorous on one hand and mystifying to me on the other that now people have to be trained on this. But do you know now there are

some schools in physical therapy that do not teach mechanics? It's basically all psychosocial interventions. Well, if they can prove through assessment that that person's pain is purely from a psychosocial disorder, then they're on the right track. Yeah. But what our work shows and has always shown is that back pain begins with a mechanical trigger. Yeah. However, let's go back one layer.

Genetics loaded the gun. Now, if you're an NBA center, chances are you've got long legs, short body. Your whole leverage ratio changes. Do you really want to do deadlifts? Yeah. You know, it doesn't make sense. But if you have another kind of athlete with a totally different confirmation, then you'll arrive at a very different tool. But nonetheless, genetics matters. I've already told the story about spine thickness and baseline curvature and all of these kinds of

things. So genetics loads the gun. It's the exposure to activity that pulls the trigger. Now, exposure to activity can either be anabolic or catabolic. So for sure, you don't reach optimal health being a couch potato. You've got to hit it right. There's a tipping point, and that's determined by biology. You've got to hit it right. There's a tipping point and that's determined by biology. So that exposure, if you cross the tipping milieu, modulates how your brain perceives the pain. And we know if you're an extrovert, if you're an introvert, if it's an introvert and I yell, if you're an introvert and I yell at you and berate you, chances are that goes into crush loads in your body. You will contract your muscles. And if we measure the effect, it can be

a 25% increase of crush load down your back. It was there a dichotomy or a separation between your psychology and the biomechanical load? No, it was all in one. You're Danny, that's who you are. So do you see why now people have to be told about a biopsychosocial model. I mean, what the heck were they thinking before? No, it's quite true. There's a little bit of a, but I'll just finish that off if I may. Sorry to interrupt. But now here's the next era of problems. Those who are interpreting the biopsychosocial model, and they are putting far too much emphasis on the downstream psychology and not addressing the mechanics up front, that is the problem. And they are saying that the person has psychosocial issues

without an assessment. No, it's very true. Yeah. So, do an assessment, be thorough, be aware of all of these things, and that turns No, it's very true. or even somebody who's creating your own workout program, maybe you're listening to this and you're thinking to yourself, well, I am a little bit taller and I've bought into the dogma of perhaps CrossFit or powerlifting or Olympic lifting that I must do these certain lifts. But perhaps mechanically, you know, there's some disadvantage the way people are built in these lifts, disperse forces, perhaps in a way that's suboptimal for their longevity. And one of the things I've seen as a coach is while the deadlift is a pretty effective lift, it's not the only way to hinge. And you might introduce different analogs of the deadlift or even a shortstop deadlift, perhaps. There's different variations that you will use

to best suit the individual. And I think for anybody who's listening that's a fitness enthusiast or a trainer, you have to be aware that we have these fundamental movement patterns that we might want to expose people to, but they're not limited to one type of lift. They're not limited to one lift. So So if you want to teach your client how to hinge, you might make consideration first, what's the best option for their body at this point, the way they're built and their pain, which kind of just brings me to my last question. And it's one that might be quite contentious because there's quite a bit of animosity between these different camps. But for people who are, you know, they might not have access to you, but they've listened

to this and they're like, man, you know, I need to go get an assessment on this back pain. I want to know what the structural root cause may be. Do I go to a personal trainer and get strong because I've heard that all I need to do is deadlift? Do I go to a chiropractor because I've heard that I'm malaligned and I simply need to become realigned? Or do I go to a physical therapist and get some more acute treatment and maybe soft tissue work. Do you have a hierarchy of clinicians or practitioners that you think people should go to if they're looking to get to the root of what might be causing their pain? Yes, it's a great question, one that we've struggled with for years. That's why we began a

training program of our own. So if you go to our website, you'll see that there's two levels of clinicians trained in the McGill method. And some are chiropractors, some are physical therapists, some are medical doctors, some are trainers, etc. So we don't really care about the medical designation or the trainer's designation. We care, do they have competency in conducting an assessment of the person to understand the mechanism of their pain? Whatever that mechanism happens to be, do they have the tools to remove the cause of pain? the tools to remove the cause of pain? And do they have the skills to create a foundation within that person's body to meet the desired activity goals pain-free? That's it in a nutshell. So there's no profession that does that. So we have McGill Method certified people, and they take our three courses, which is a foundation in how the spine works. They have to do the master clinical assessment course.

If we do that live, that's two days, by the way. And that's more than they will get in their entire physical therapy career in many circles. And then the third element is called enhancing performance. And we use examples from top athletes on how they organize superhuman performance without breaking their bodies. And can we learn from that to apply to the average person? And the example there is, you know, why would Honda compete on the F1 racetrack? Well, the reason is they learn about elite automotive technology. So the gear change technology in your Honda Civic is exactly the same. It was born on the F1 racetrack.

So we do exactly the same thing learning about human optimization. on the F1 racetrack. So we do exactly the same thing, learning about human optimization. And then we apply those principles to people who are really struggling just to, it might be to get out of bed or to get out of a chair, for example. So those certified people, I have not worked with them personally. However, they've had to pass a written exam and a practical skills exam. They go on the internet with one of our adjudicators and we have to see them assess and come up with a coaching session with progression in it. The highest level is what we call the master clinician. Those are people who I have worked with and I know that they are competent in getting people when you think of the medical system, clinicians are trained to perform procedures. And that's how they're reimbursed.

They perform a procedure. And each group that you just mentioned has a set of procedures. Whether or not they fit that exact patient or not isn't their issue. It's if you come to this particular clinician, you know what you're going to get. By dumb luck, it might be the secret special approach that fits. But, you know, if you had someone with a very unstable joint, would you go and send them for manipulation? Probably not. I hope you wouldn't. But, you know, or you will have a surgeon who has a back pain. Patient says, well, you're not quite ready for surgery. Go to Pilates class.

Well, when you look at the Pilates spectrum, some exercises might be fabulous, but the next exercises might be poison. It's not a matter of going to Pilates class. It's a matter of knowing that if you had more proximal stability here and a bit more mobility there, you would take the stress away that's causing your back pain. Or maybe you are not allowing enough time for adaptation. You do deadlifts three days a week. Wait a second. Do you know a world-class power lifter? Cause we've worked with many of them. They might do heavy deadlifts one day a week, and then they allow five days to allow the mechanostimulation to stimulate bone, create more strength, et cetera. So, you know, that boy, there's wheels within wheels here. Um, so that, that's my answer. But there are times, I mean, I have quite a Rolodex. Are you old enough to know what a Rolodex is? Yes, but only through movies and TV. I think I've seen one in my life. Okay. So I still have a Rolodex. And what that is, it's a thing of

business cards. And I just go through people's business cards. Now, I know people's Rolodex these days is their phone, but I'm too old for that. So let's say I have a patient who comes in and we confirm that they have a Tarloff cyst, which is a nasty little cyst on a nerve root. So when they drive a car that puts nerve tension on the sciatic nerve and no exercise, nothing else is going to get rid of their back pain. Shit happens. Sorry for the expression, but that's their category. So now I do not have the skills to deal with a Tarlow cyst. However, I have a surgeon who I know has an outstanding success rate because I follow it. And he happens to be a surgeon in Dallas, Texas, Frank Fagenbaum. So if you fit that category, I refer you to Frank Fagenbaum.

So if you are a world-class sprinter or even a college sprinter who comes in, and I know that if we could get a little bit more elasticity out of that foot, more storage and recovery of elastic energy, I know we will take some load off the right hip and chances are that's going to unload the back. Bingo. I know the manual therapist that has created many gold medal Olympians. You probably know these same people too. When you go and work at the Olympics, when you work in the UFC, when you work at world-class events, it's the same people every time who are the gurus in each of these techniques. And it's just like professors, policemen, trainers, there are the elite and

there are the ones who are not so good. So we go to the elite when I don't have or our people don't have the expertise. So does that kind of give a little bit of an answer? Yeah, yeah, quite a bit. I think it continues to hammer home the point that there's no substitution in this space for truly knowing what you're doing and what you're working with and to look at each person as an individual. And I think for anybody who's made it this far, this would probably be a really good opportunity for them to kind of become a little bit more of an expert in their own health. And I know that you have several books and several resources, and one book in particular that really shines with people dealing with back pain. Could you tell the listeners who

are perhaps saying, okay, this is all really insightful. I understand more about my back. I feel empowered. And I want to learn some of the things I can do. Can you tell them a little bit about the work and the resources that you've put out there for just general public? Yes. With the background, when I started to write books, I wrote them for my clinical colleagues. I never thought in a million years I'd be writing for the lay public. But some savvy lay public people would read my medical textbooks and they'll say, wow, this was really good, but it's a tough read. Could you put it into our language? So I wrote Back Mechanic.

You can get it on Amazon or BackFit Pro. And Danny, it was the most challenging book I've ever written. So it's easy for me to write referenced material in my language, et cetera. But it's not very consumable. So to write that in a consumable way was the challenge. The next challenge was the book publisher said, you've got to write a book, fix your back pain in five easy steps. And I said, that's a lie. Any book that says that is untruthful, and I'm not doing it. So I wrote Back Mechanic, which was, it took me five years to create the balance between enough truth and enough guidance and enough about here, I'm going to guide you through a self-assessment. And based on those results, you are going to name activities that don't hurt you.

You're going to name activities that do trigger your back and they form patterns. I'm going to coach you through the pattern recognition to hone in on a subcategory. Now, if you fit this subcategory, here's what you must stop doing first and foremost to wind down the cause. And here's what you should do to build the base foundation. So it was a challenge to get that magical balance between not too much and still have validity. Then I needed to measure the effectiveness. So I can say that of the people who now here's the background information. You mentioned there are people who they've tried everything and surgery is the last uh option if you have been

told you've tried everything and surgery is your last option and you read back mechanic and you follow the details 95 of them will avoid surgery and after one year they will be glad they did so now i have an efficacy statistic that goes along with that. So that's back mechanic. That's fantastic. The coaches and the athletes, I wrote ultimate back fitness and performance. So you're out of back pain, but you have a history of a back mechanism. You don't want to re-trigger that and go back. So follow these rules now with your particular condition and build your athleticism. If you're a your particular condition and build your athleticism. If you're a strength athlete wanting to restore your athleticism, I wrote a book with Brian Carroll,

who was a world-class powerlifter. He'd had world records, pardon me, in two different categories, weight categories. And we took him through a rehab program and he came back to win once again. So it's his story with a lot of extra generic thoughts on restoring strength and my big book on how to really competently assess back pain and some of the science behind it. That's low back disorders. But anyway, there's a few of the resource materials. Finally, for the people who are trainers, we are, I'm putting my lecture

parts of my clinical courses online and they're going to be available. The first one, the assessment is going to be available within a few weeks. Excellent. Yeah. Anyway, you can find all that material at backfitpro.com. No, that's fantastic, Dr. McGill. And again, I just wanted to thank you for coming on today and providing a really, really solid foundation for people to kind of look at their back as something that's more than just black and white. And I think for people who are dealing with back pain, trainers who have clients who are dealing with back pain, a conversation like this will give them a little bit of hope. It will inspire them to explore and perhaps educate themselves a little bit more so they can help more people or help themselves. So, your time your time was tremendously appreciative or I'm tremendously appreciative of your time and your time was tremendously appreciated. And, and I thought

that this was just an absolutely fantastic, uh, masterclass, if you will, on back, uh, back pain, back structure. So they can find your work at backfitpro.com and they can find you on social media where? Danny, Sarah at Backfitpro runs the social media. Got it. I don't need, you know, I give her content to put on, but we're apparently Backfitpro is on Facebook. Okay. And apparently Backfitpro is on Instagram. I'm sorry, I don't know the handles and all this sort of.

That's actually, I would say that's a good thing in the long run. Yeah, I'm so sorry. I wish I was more savvy in that. The world is a better place if Dr. McGill is focusing less on social media and more on educating, I would say. saying less on social media and more on educating, I would say. Yeah. What I do say is you can do Facebook and social media, or you can become a master of the craft. You can do both. I think that's a great note to end on, Dr. McGill. So again, everybody, this has been Dr. Stuart McGill on all things back. And do check out his work, particularly his books and his courses.

Thanks again so much for coming on, doctor. Yeah. Thanks, Daniel. And I will say this. I see why your podcast is getting traction. You're very dialed in on honing in on the relevant issue and your eloquence is second to none. So good on you. Tremendously appreciate that compliment, man. You've made my week. Okay. Thanks again, Ben. So there you have it. That was the interview with Dr. Stu McGill. Thanks again to Dr. McGill for coming on and sharing his insights on all things back pain. A truly fantastic resource. Always a great guy to sit down and talk with.

Very appreciative of his time. And do check out his books and courses. I promise you, it is money well spent, particularly if you're dealing with pain. Thanks so much for tuning in. Do feel free, if you enjoy dealing with pain. Thanks so much for tuning in. Do feel free, if you enjoyed the episode, please share it. Tag both myself and Dr. McGill so we can get this out to more people and help people have a little bit more control over their pain and a little

bit more confidence. Thanks so much for listening and have a good one. you