How Stuart McGill Explains Back Pain to a New Client

This is session number 67 of the Performance Place Sports Care Podcast. Barrel House, you'd know? Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, everyone. Thanks for joining me again. I'm Dr. Sebastian Gonzales with the Performance Place Sports Care Podcast. So, Barrel House is one of my favorite places. And if you know me pretty well, you'll know that Barrel House, I get excited about it. And Barrel House is a brewery. It's in Paso Robles, California, which is a place where we spent a lot of time growing up, at least over on the coast side, which is Cambria.

So, we venture into Paso Robles, and this is, again, it's a brewery. We went there for the first time a couple years ago. So, it was probably 2000. Well, I guess it was 2016. But we showed up, and there's the nicest people there. You know, like, they tell you all about the community of Paso Robles, as well as the brewery in the whole region, and how it kind of got developed. And it was just nice. Every time we went back, there's just so many nice people to talk to. The beer was great. The ambiance is awesome. And so, I guess it's one of my favorite places. So, if you ever get a chance to go there, just give a big, loud Barrel House yell, and yeah, it's a good time.

So, I don't think you'll be disappointed. So, in this podcast today, I'm actually going into, I mean, I'm having a great expert on back pain or back biomechanics. Come on. His name is Dr. Stuart McGill. He's a professor of spine biomechanics at the University of Waterloo. So, he's been on a fair amount of podcasts, which I have shared with some of my patients. And I actually started to share the podcast that he was on with my patients with back pain. And the reason why I did this is because a lot of times, if you work in this type of realm, if you're a PT or a chiro or you're an MD, you try to explain back pain to people or explain their injury.

And sometimes it takes, actually, a lot of times it takes some time to sink in, to really understand. And what I suggested to at least the first patient, I put them on, I had them listen to a podcast right there in the office. And I came back about 10 minutes later, and she basically said after about two minutes, she tuned out. She just couldn't pay attention. And it wasn't that the topics were extremely complex with back pain, but it was just a little bit more than she can tolerate. And I thought I would ask Dr. McGill to come on, and we'll answer all of the basic fundamental questions that a lot of new patients ask about back pain.

So, part of the reason for this podcast here, this session, is kind of for a selfish reason, because I really want people in my clinic to understand back pain. And I thought, man, if I could have Dr. McGill come on and explain it, he explains it so well. He's had so much experience in his labs and writing books, and he explains back pain in a very mechanical way. I think they would get it. I think they would have success in life. So, that was the goal with this today. And I strongly encourage the other doctors, MDs, chiropractors, PTs, or people that don't understand back pain, share this podcast with your friends or your patients who have it.

Because I can't tell you how many times I've seen people, they come in with back pain, and they're extremely emotional about it. I mean, if we break this thing down, and when you hear Dr. McGill speak about it, we can mechanically break this whole thing down. It's not an unknown type of condition to work with. We can figure this thing out. But a lot of people end up having lifetime medication. They have surgery. They have lifetime disability from it. It's very frustrating for them. But we can figure this out. In the rare cases that we can't figure it out, then I think we need to explore malignancy, tumor, infection, or the large types of things.

So, if you are experiencing back pain, or you have friends or family or patients experiencing back pain, I strongly suggest you have them listen to this podcast. We're going into the most commonly asked questions. I might go a little bit deeper into some secondary level questioning, but all of the stuff that has to do with mechanics of the spine and the technical terminology, we're going to try to leave that out. And it's not to dumb the idea down or dumb the concepts down, but it's to make it understandable for people so they have some type of actionable process after. So, we're trying to combat patient misunderstanding and only have them do medications, painkillers, and injections when it's actually needed.

Because a lot of times that is a really quick fix for people. And before we go into the interview, I just want to remind everybody, please go on to iTunes and review. That helps a lot. I get a lot of feedback from that. But also, too, I want you guys to check out the other podcast. We have other experts on for different types of conditions. Shoulders, knees, hips, ankles, even weight loss, and a lot of things sports injury related. So, my goal is to further educate patient populations. And if you're a healthcare provider, please share these with your patients. So, it'll save you a lot of breath, and it'll help them comply with their care much, much better.

And they'll get better, faster. So, here we go with the interview. Okay, everybody, here is our interview with Dr. Stuart McGill. Dr. McGill, say hi. Well, hello to all your listenership, and to you, Sebastian Gonzales. Well, thanks for coming on. I've really, really wanted to have you on for a long time. And not until, I don't know, do you know Dr. Seth Meyers? He's in Idaho or Kansas? Well, I know of him, absolutely, yes. Yeah, he's actually on right before you on the podcast. So, he spoke about a lot of your stuff, and I thought, we should just have the master on right here. So, I thought we'd go over today some of the questions that first-time patients have on back pain.

Because from a healthcare side or like a clinical side, we see a lot of patients who don't really understand back pain, and they're very emotional at the time. And I think sometimes explaining something logically and mechanically to someone who's a little bit emotional, sometimes we have to get really in-depth into education, which I thought we'd go through these questions that we, as healthcare providers, get all the time. Sound good? Yes. Okay. So, first off, is all low back pain created equal? You're starting with the big philosophical questions first. Well, I'm going to give you probably a big answer on this with maybe three levels, some logic, some examples.

Let me reverse that a tiny bit and say, well, have you ever heard of nonspecific head pain or leg pain? Is leg pain created equal? I mean, we don't even put up with such a notion. It could be torn knee ligaments, a vascular complaint, a cut, or whatever. So, this notion of back pain, it is so non-homogeneous, and what I mean by that is one person might have back pain because they've got a disc bulge. The next person might have it for an entirely different reason. So, starting out with that logic and set point, all back pain has a cause, and if we can obtain a specific and a precise diagnosis of the pain mechanism, then we can address it appropriately.

So, is it created equal? Right off the top, three contrasting examples of back pain come to mind. Think of a person who's in their mid-20s, 30s, 40s. They work sitting at a computer eight hours a day. Sitting at the computer for 20 minutes gives them back pain. And yet, they could stand up and go for a two- or three-mile walk, and that would be therapeutic. Now, let's take the next person who is newly retired, and they have more of a stenosis or arthritic mechanism to their back pain. And interestingly enough, the precise opposite occurs. Walking starts to cause back pain, and sitting down is relieving.

And then, I can give a third example of, let's take a young athletic team. You can take a football team or a baseball team. And when you study the back pain patterns, you'll see that they form cluster groups. For example, one team might have four stress fractures on their roster, in their back. And those stress fractures were not caused by baseball. It was caused by the strength and conditioning coach, who was getting them to do full range of motion, loaded rotations, and eventually caused a spondy or spondylytic fracture, and maybe full-blown spondylolisthesis. Each one of those would have a different time course, a different symptom pattern, and really a very different strategy to address them.

And as you know in my books, I give many more examples. But, you know, there's an example. One's a programming flaw. One is the person who sits and works at a computer for eight hours and then goes to gym for the one hour at night and does basically a bodybuilding program, and they wonder why they still have pain. Had they reassessed the programming to really try and create an antidote for the common stresses of sitting all day, that would be a very different approach than the older adult. So if I could just leave that notion and finish off the answer on a more philosophical level, because I've already talked about the importance of obtaining a precise diagnosis of the pain mechanism.

You know that there is no provision in the current medical system to get a thorough assessment of your back. If the patient is lucky, they wait for a while and get a 15 or 20-minute assessment of their back pain. Now, your practice is probably different than that. I set aside three hours when I see a patient, and we do provocative testing to really isolate precisely the specific motions, postures, and loads that trigger their pain. All the time, I'm assessing their learning style so I know how to coach and get what I need from the patient. I let them talk freely, and they tell me about the various impediments in their life that have prevented previous attempts to reduce their back pain sensitivity from working, et cetera, et cetera.

So that is certainly a huge impediment in the medical system. But what that produces is many clinicians who really haven't been trained in the nuances and mechanisms of this broad spectrum of back pain, and they will do some sort of nonspecific treatment to this nonspecific back pain, and they fail. And then they tell the patient, well, there can't be anything wrong with my therapy, therefore, the pain must be in your head. And the patients I get who've failed different approaches, many of them have been told that the pain is in their head. And this is just a pure default of incompetent clinicians.

I've had people come who are on the brink of suicide. They're very solid citizens. Some doc has told them the pain is in their head when they know it's in their back, and they can change the pain by doing different activities or avoiding some activities, and it drives them to the brink of some of them considering suicide. So there would be a very iatrogenic cause of pain with secondary issues as well. So there is a huge answer to a very huge question. I hope I didn't get too far off topic, but I really wanted to begin with addressing this idea of just generic back pain. There is no such thing. It's all specific, and it needs to be subclassified and treated with precision and specificity.

Okay. Yeah, you didn't throw me off topic there. I wrote a couple of things down. We'll revisit a little bit there. So what I'm hearing is, so first off, the majority of back pain has a logical reason, it's mechanical, and it's not in their head. Is that what I'm hearing first? Well, it does go into their head when they've been told it's in their head, and it drives them crazy. So that's a little bit of an it depends answer. But generally speaking, when their pain mechanisms are recognized and they address them mechanically, the psychological subissues tend to resolve. But if all you do is treat the psychological through cognitive behavioral approaches, etc., chances are that pain is going to come back to revisit them.

Okay. Okay. So you said there's three kind of major categories I guess we can differentiate back pain into. There was the young kind of disc-based person. There was the older arthritic or stenosis. And then there was a special population, athletic, and they're in the middle. So each of them, I'm guessing, you said they have different symptom patterns. Within each collective group, let's just start with like a disc young kid. Are all these people going to be the same, or is there even different subsets in there of how they feel, how they respond, and so on? Well, I teach a master level course in assessment, and the theme of it is we get right down to a subject category, N equals one.

And what that means is there's no two back pain mechanisms that are exactly the same. So if we keep slicing it down, what is the magic dose to wind down the pain sensitivity? What is the precise exercise, the order, the dose, etc., to build that foundation for pain-free movement? It's going to be slightly different. So you could have two people with exactly the same category, but they're in different positions in the program progression. One might be more advanced. So their program, you know, you just don't give a person a set of exercises to say, well, go away, there you are. You will start by establishing movement patterns that avoid their pain mechanism and wind it down, and then you might add some hip-mobilizing patterns, and then you might add some spine-stabilizing patterns.

Then, you know, if they want to eventually play tennis, you're going to have to add some footwork. Anyway, you get the idea. So, yeah, when we're dealing with the person and the thorough assessment, we'll slice it right down. So they are a category of back pain of one themselves. So, as you know, I wrote down a little bit of a list of things to go through today. I'm going to jump around slightly because I think we're going to go right down this path. With people, since they have a very unique mechanism of injury and a unique injury, do they, how active or how much are they participating in their own resolution of their back pain?

Is it, I mean, because I know a lot of people go in, they say, hey, I want this treatment, I want that one. Hey, can you stretch me out? How much do they have to, should they understand about their back pain to make it resolve and not come back? Well, I've already mentioned that most, well, family docs, if we were to take them as a clinical category, they get virtually nil training on what to do with patients who come in with so-called back pain. And when you speak with them, they will freely admit that they don't know what to do when the patients come in. So they end up giving what they know, which is a analgesic pill, a pain pill.

So, because of that, I would suggest that the people become savvy and advocates for themselves. Now, again, I'm not trying to plug my stuff here, but that was why I wrote the book, Back Mechanic. I had written textbooks for clinicians, so they were very heavy textbooks. I never envisioned 15 or 20 years ago writing a book for the lay public. But the lay public would read my heavy clinical textbooks and say, this is insightful for the first time, we're learning about the real mechanisms of pain. Would you write one for the lay public? So that was why I wrote Back Mechanic, to guide the reader through a self-assessment, obviously a simplified self-assessment, and then to discuss some of the controversies with them.

And then it became empowering. They realized that they were accountable and in control for winding down their pain sensitivity and building this foundation. So the answer to the question, in a long-about way, is yes, they must become active participants and really advocate for themselves. Because no one knows their pain better than themselves. They just need a little bit of guidance in interpreting it. Yeah. I actually, as I mentioned to you, I read a strong majority of the book. And actually, the first page, and I'm going to flip through real quick, there was a myth-busting section. I thought it was amazing.

And even the first part, I got a highlighter out and I started doing some highlighting on it. And I think it was very empowering, I think, to hear that we're debunking these myths surrounding back pain. And I totally agree with you when you were saying that you made the book for clinicians, but the general public, they have a whole different reading level. And that's not to sound insulting. It's just they didn't have the education in this stuff. So, how are they supposed to expect to be educated about their injury unless something like your book came out? By the way, everyone should pick the book up.

I will put a link in the show notes. Can I say something about that, Sebastian? Sure. Look, we know each other well enough now for the last 15 minutes that I can call you, Sebastian. You can call me, Stuart. How's that? Sounds good. I'm going to get one last Dr. McGill in, though, okay? Everyone, Dr. McGill. Stuart. Yeah. Oh, now I got sidetracked with what I was going to say. Myth-busting. Education, public education. Oh, yes, yes, yes. It's so interesting that when I speak with patients, it's amazing how often they will say, you know, thank you. You're the first doc who didn't treat me like a five-year-old.

You explained it in a way that we understood. You know, a car mechanic, a plumber, an electrician, a stay-at-home mom who has to pick out her baby from the crib at 2 o'clock in the morning. They know what a reaching load is. They know the price they pay and the pain pattern afterwards. They aren't so unteachable. They're, in fact, easier to teach than some of the high-level docs. They certainly have a longer attention span. I'll say that. You mean we've lost already a strong majority of the docs five minutes into this podcast, didn't we? Well, look, all I'm doing is combating this attitude of medics that people aren't smart enough to understand good explanations.

I think it's just that the explanations have been poor. They've been poorly coached in movement. I lay the fault at the feet of the clinicians. I'm sorry, but that's my opinion. Yeah, I do agree with that. I've mentioned it a couple times in this podcast before. So I put out some videos on exercises or rehab that I want people to at least have a basic knowledge in. And I have a good friend who's a clinician. He says that we can't expect people to know any movement through video. We have to cue them. I said, I know, but maybe we just haven't found a good way to do it. You know, I think people are really teachable.

It just takes a little bit of time. That's my personal opinion on it, though. Well, yeah, my opinion is the same, only stronger. I think great clinicians are great teachers. And, again, if a person isn't getting it, then I look at the inadequacy of the teacher, not really the learner. Have they even considered the learning style? You know, just your learning style. Think of the, for the patients listening to this, think of the times that they've been to the doc and they look over at the top of the doc's head. The doc can't even look up at them and relate to them and understand whether they're getting the point or not or what the progression should be.

It's, anyway. Well, you brought up a tangent I should probably take. And we mentioned about short exams, but we haven't really mentioned the people that only look at MRIs because there's docs that only solely look at MRIs and see the structure as the pain generator with these people. Can you elaborate a little bit about MRI findings and pain mechanism with back pain? Yes, absolutely. First of all, this will be heresy to say, but I don't think radiologists who never see the patient should be giving an opinion on a back image. And I say that for a few reasons. First of all, the image shows a picture of the anatomy which shows both the wound and the scar.

So what I mean by that is, say the clinician saw an in-plate fracture, which is the beginning quite often of a flattening disc and a broad-based disc bulge. Now, is that one week old? Is it a wound and painful? Or is it 15 years old, a scar that is no longer a pain generator? So without having the patient to provide context as to whether or not they're seeing the wound or the scar, they shouldn't be reporting on whether this is clinically significant or not. Every single spine you look at, you will find issues with it. But they're only interpretable within the context of whatever the patient has shown you as being the clinical causes of their pain.

So that's my first point. There are many clinicians and scientists who argue over the point, well, MRI findings aren't related to pain. And they often bring up the issue, well, disc bulges. Half of people who never have back pain show disc bulges on MR and quite the opposite. Well, yes, I get that. But if the person has a disc bulge and the radiologist is on their game and they really bring up the resolution and play with the image so they see the nature of that disc bulge. Some have an open fissure, delaminated collagen, a direct pathway for the pressurized nucleus in the middle of the disc to seep its way through the delaminations to create what we call a dynamic disc bulge.

Now, clinically, that should change shape. If a person sits for a while or does gardening or poor form deadlifts, they will pressurize the nucleus and that bulge will physically grow. So will their symptoms. They will say gardening, sitting and deadlifting very deep causes my back pain and my leg pain. However, if I go for a walk or if I preserve a neutral spine while I'm sitting or lifting, I don't get the pain or the radiating symptoms. So now, given that clinical report and history, the doc can link whether or not that disc bulge links to the symptoms. But this discussion that MRIs are useless because they may or may not show a bulge and it may or may not be symptomatic, I don't think those people have been schooled well enough to know that you have to have the person in front of you to give that context.

Now, if you have that, that scan is very important because it shows you the mechanism and therefore you have clues to start trying to see if you can wind your pain down. So with things like disc bulges, like I know that I have patients come in that actually had a guy just yesterday. He was very in, I don't want to say blaming the disc bulge, but he just couldn't let go of the idea. And I was like, how big is it? Because he had one years and years ago and he said just three millimeter. And I said, well, I have a three millimeter. We're very different. We feel very different, you know. So I guess my question is, is do we do you feel like we have to get rid of a disc bulge to decrease pain or does it ever go away?

Because it seems like a lot of people hang on the idea that part of them is broken. Well, I certainly know where you're coming from on that. And there is no answer to the question that you've just posed because it may with one person and not the next. There are some people who show very discogenic pain patterns and they have very tiny disc bulges. Others have enormous bulges with visible compression of lateral nerve roots in the central cord. And they have no symptoms at all. But the ones who do have symptoms are the ones that I'm concerned about. But, you know, I never look at an MRI scan or a picture until the very end of the consult or at least till the very end of the pain provocation testing.

I want to know what is symptomatic. Let's say we get them to sit on a chair and they slouch in the chair and pull up on the seat pan so they're compressing their back with a fully flexed spine. And if the person says, you know, my pain is really ramping up now. All right, let's lay prone and I'm just going to apply a little bit of traction to your back for about one minute. Now get off the table and stand up. Are you better or are you worse? And if they say, you know, my pain is now gone, what you're showing is that the disc bulge is dynamic. So when you take a picture of it, and I've done this a few times with my radiology colleagues, we will put someone, usually a radiologist, with a known active disc bulge into the scanner.

But before we put them in, we flex them and then we hold them there for 10 minutes. Then we take a picture and the bulge is visibly large. It's not a three millimeter bulge anymore. It's a six millimeter. And then we get them to come out and lay prone for five minutes, go back into the scanner. Now the disc bulge is only two millimeters. So we've got an understanding now. It's a dynamic bulge. We can clearly see the open fissure on the MRI if you know what you're looking for. Now you've got a very precise understanding of the mechanism. So if that person can avoid the full flexion that will hydraulically increase the pressure through the fissure and cause the disc bulge to grow, they've already found a strategy to manage it.

And, you know, we've got players in professional sports, all of the professional sports, Olympic athletes, PGA golfers, et cetera, who all have the bulges as I've just described. Every single one of the ones that I've mentioned are able to manage it to subclinical levels and play professional sport. Now, obviously, there are failures in there as well. But there's, I guess, an answer to the question. Well, so, I mean, I actually, I think it'd be kind of fun just to play with disc on an MRI. I was kind of jealous. So, with that being said, since you flexed them forward, and I know that we're only focusing on disc stuff right now, I feel like flexion is sometimes in the patient's eyes, or I guess to break that down further, flexion would be rounding, rounding forward, or poor sitting posture.

Should it be avoided, or are patients, I've seen patients that think flexion is completely evil, and they can't do it whatsoever. Is there a time and place for it, or it should be avoided forever if you have a disc injury? Well, yeah, you're being very absolute now in the comments, and I know where they're coming from. Yeah, I'm acting like I'm a patient right now. Yeah, yeah, I know. You're very good at your interviewing. This is good. Well, you know, again, my answer is it depends. What you do is you show the patient the mechanism of their pain. So, have them sit on a chair and pull up, but have them sit very tall and ask them, did that cause pain or not?

And most of the time, if they have a discogenic, disc bulge category of pain, they will say, you know, that doesn't cause any pain at all. It's very tolerable. And then you say, okay, now sit slouched. And some of them will say, oh, yeah, well, there's my pain. And I said, well, now you have a choice. So, if you didn't pull up, it doesn't cause pain. Okay, you can move your spine and tie your shoes and all these kinds of things. But as soon as you load that flexion, you see that's your pain generator. Now, the curious thing about back pain is you don't get used to it, generally speaking. If you create pain, you lower the threshold for triggering it again.

In other words, you sensitize it or tenderize it. But if you can avoid pain, the pain slowly winds down, usually. And if you avoid it for a while, the trigger threshold increases. So, now you can start to have fun. You can go to the dance on Friday night and move your spine around and have all kinds of fun. It's not being loaded, but you're moving your spine pain-free. But you had to earn that pain-free capacity by avoiding the pain trigger for a while. Now, again, the answer was it depends. If you're picking up a heavy load and you flex and cause the pressure through the open fissure, if you have that category of pain mechanism, then guess what?

The next day, you have a good chance of being locked up again and having another acute episode. I mean, these things don't come out of thin air. There is a definite mechanical cause that once it's discovered and precisely understood, the avoidance strategy, again, becomes very precise. I mean, I can give you examples of, I've measured some of the celebrity yoga masters who contort their spines into all kinds of positions. Now, if you take a thin branch and bend it around like a willow branch, it really doesn't create any stress. Just like a thin-spined person who really works on mobility. But what you'll find is most of those people, the great majority, have very little strength.

They even have trouble squatting their body weight, some of them. So, if you then contrast that with a person who's a construction worker or they want to do some powerlifting and deadlifting, you have to adapt the spine precisely the opposite way. Much less mobility, stiffen up the collagen in the discs to allow the spine to bear a lot of compressive load. Generally, that favors heavier boned people. If you take a thicker branch and bend it around, it breaks much sooner because the stress in a round tube is a direct function of its diameter, bigger diameter. It creates much higher stress when you bend it.

So, these are all examples of, once again, the precise understanding of their patent mechanism leads you to the answer every single time. But it's not the same answer in everybody. And this idea that people are fearful of moving, I get those patients as well. And almost all the time, they've been created by clinicians. Clinicians who didn't know how to coach movement, didn't know how to teach them how to tie their shoe or sneeze or get on and off the toilet, etc. In ways that avoided their particular pain trigger. If you have a certain type of arthritis and a stenotic spine, bending forward, as you know, is a relieving position.

Or say they have vascular congestion as a part of their back pain and sciatica mechanism. Sitting in flexion is what relieves them. So, anyway, do you see how, again, people try and box me in and commit me to say, you know, it's heresy. Never flex your spine. Well, first of all, you know, do you want to be a yoga master or do you want to set a powerlifting record? But you can't have it both ways. You know, we measured Middle Eastern belly dancers, which was kind of a fun study. I forget how many women we had, but they had amazing motor control and fantastic ability to move their rib cage separate from their hips.

And it was a lot of really fun study to conduct. But, you know, not one of those women could do a confidence set up. And my point in that was they had this marvelous mobility, but no strength. And it's very, of course, you're going to find the rare freak of nature touched by the hand of God who can do everything with resilience. But that's not the vast majority of people. You've got to choose. And once you make that deal, be consistent in the training and you will increase your whatever goal it is, whether you want strength and load bearing or mobility, and do it in a, create it in a resilient way.

Yeah, I think I, I listened to a podcast you did. I think it was on STEM, um, S-T-E-M is the podcast. And, uh, I thought I, so I don't mean to misquote you if this is not what you said, but I thought it was something around different spines for different purposes. Does that sound, is that kind of like summing up what you're, what you're talking about with? Absolutely. Have you ever, uh, worked with a world champion power lifter and watch them walk from behind? They have a very stiff spine and they have to, that's the only spine that will bear, uh, picking up half a ton of load off the ground. Um, now, uh, I know that there's strength and conditioning coaches who are training NFL football players like they were power lifters.

Do you know one power lifter that can tie his own shoe or, uh, put, you know, raise their arms over their head? It's very difficult to do. So why would you do that with someone who needs to throw a football, which is a very elastic athlete? So a tennis player or, or an athlete who has to move explosively needs a certain amount of, of elasticity in their body. So, you know, these are all examples of tuning the body and choosing appropriate, uh, exercises, which is, is, is, is again, it's, it's very, very, uh, precise. So, um, it's, it's, it's a continuum. Yeah. You know, there's not a yoga master and there's not a power lifter.

There's somewhere in between that, that people can seek, but with the right guidance, uh, they should be able to find that sweet spot, so to speak, of maximum function and, and minimal pain for their particular body type and age and injury history and all the rest of it. Okay. Sounds, sounds good. I think that was a perfect answer. I was trying to box you in. Um, so let's, let's go through a couple. I get used to that. It's funny. I, I've actually been, I've been accused by a couple of my, um, friends and people know me really well. They're like, why do you always ask questions that leads people down the same path?

I'm like, I'm really not trying to, I'm, I, I don't want to lead the conversation. I do. I try to do open ended, but, uh, uh, so let's go through some, uh, common approaches for treating back pain. Uh, cause I know that a lot of listeners probably have tried this stuff or they've heard it worked for one of their friends or so on. Um, so I thought the first that we should hit is rest or avoid. Avoidance of activity is what do you, do you have any input on that? Well, I'm assuming you're going to give me a list of these in turn and pretty much the answer for every single one that I'm anticipating.

You're going to answer is it depends. So that's why if you follow the algorithm that I put in back mechanic, do the assessment, eliminate the cause and, and build the foundation for pain-free movement. Um, so rest and avoidance of activity. Well, you've had patients who are absolutely locked up. They are in excruciating pain. Um, I would say for someone like that, there's nothing else they can do, but to rest and, and take it easy that day. They, they physically cannot tolerate anything else. So for them, a very short period of rest, uh, it may last, uh, a couple of days, um, and now avoidance of activity.

If, uh, let's say reaching their arms over their head to change a light bulb or something like that triggers a, a back pain attack. I would say, don't do that for a while. So, so there's, uh, examples, but as a general answer, I would say, uh, no, you don't rest and avoid activity. You avoid the activity that triggers the pain mechanism. Okay. I like that. So the next one is going to be, there's, it seems to be a strong movement of people wanting to stretch in foam roller back or at least lumbar spine, uh, low back for everybody. Not that's listening. How do you feel about that? Uh, I have strong opinions about that because I, I'm getting patients caused by it.

So I am not the scientist who can pull up our studies that say foam rolling is good or bad for the quadriceps, the deltoids, the latissimus dorsi. So I, I don't have an opinion on that, but I absolutely have an opinion when it comes to foam rolling up and down the lumbar spine. Typically a person is laying on their back, rolling a foam roller up and down. That might be a lacrosse ball or something even more pointed. When you put all your body weight on the spinous process. So that's the little bone that you feel as you run your thumb up the midline of your back. When you put your full body weight, which creates a sheer load on the spine, that is how to create back pain.

So now let's go back one level. Why are you doing it in the first place? If it feels good to, uh, put pressure on the muscles, uh, I do not think there's a substitute for an intelligent hand. Go to a therapist who's skilled in manual therapy and get the, uh, precision therapy to the location that needs it. Um, but, but don't push on the spinous processes with full body weight that, uh, will, will cause issues. So summary, I don't have an opinion on other areas of the body. I would not foam roll a low back. Okay. Okay, good. Um, next one then I'm guessing, I think I've heard you speak about this before.

Uh, if the hamstrings feel tight, should you stretch those? If you have low back pain? No, the answer is it depends. Um, for the, uh, people who are again in that magical discogenic, uh, age group. So let's say mid twenties to, to, uh, early fifties and they perceive they have tight hamstrings when they get back pain. When we measure the source of that more than half the time, it's not tight hamstrings. It's tight nerves, tight sciatic nerve because of the, uh, disc bulge. So get it assessed and know whether it is because you have a tight nerve or, uh, a tight muscle. Now, a quick test for your people would be to sit slouched.

And if that causes the perception of hamstring pain or tightness, now flex your neck and look down. And if that tightens the hamstring, you never changed your hip or your knee. What you did was change the nerve tension. If that tightens up the hamstring, you've got nerve tension, not muscle tension. When you stretch a nerve, you will sensitize it. So it triggers off at an even lower threshold next time. So, uh, absolutely do not stretch that category of hamstring tightness perception. Now we can go to the other end of the spectrum where people truly do have tight hamstrings and they are stressing their spine because of it.

So then it would make good sense to, uh, mobilize, uh, those muscles. I think, I think I was reading your back mechanics. It was, um, something to the degree of the, you're talking about asymmetries with the hamstring. Yes. Okay. Well, let's talk about that. Um, isn't it, it's interesting that in studies of the military, there's, there's been one in the U S. There's been one in Norway where they measured the hamstring flexibility of all the incoming recruits and who developed back pain, uh, over, I think the next two years of mandatory service. There really was not a link between, uh, coming in with tight hamstrings and developing back pain.

However, there was a mild link between having asymmetry right and left sides and hamstring tightness and developing back pain over the next two years. Um, but you know, I'm, I'm going to say something else because this, uh, I'm a Canadian, you're an American. Uh, I'm assuming this is going to be podcast in the U S and the training mentality, the overwhelming training mentality in the U S is to lengthen the hamstrings as if this is good for athletic performance. Let me ask a few provocative questions. Do you think some of the best dunkers in the NBA have loose hamstrings or tight hamstrings? Yeah, I'm pretty sure they're probably tight.

Absolutely. And I'm the guy who's met, who's measured them. Um, yes, they bounce off at pre tightened spring. They don't do a deep squat. They, they, they, they, um, create a string, a spring by pre tensing the muscle. And so they just pop off and into the ground after taking two steps to dunk a basketball, we measured, uh, the, uh, the fella who was the halftime show at the NBA all-star game. And this last time around the Raptors hosted it, it was in Toronto and this fella came out and he's, he's quite modest in height. He's about six foot one, but he'd put on the most amazing dunking show and the NBA players all know this fella.

Well, when you measure his hamstrings, they are tight, tight, tight. He is a tuned spring. When you measure Olympic high jumpers, they have tuned springs. In other words, they're elastic athletes. So when you get into throwers, kickers, jumpers, leapers, they are highly tuned elastic athletes. And my advice is be very judicious in, uh, how you might want to stretch that hamstring. So there's yet another, uh, element for consideration in this whole hamstring stretching question. Okay. Um, next one would be then how do you feel about, and I do get a lot of people that come in with this. They say that when they crack their back, their low back, it feels good.

So they're doing it on their own, but sometimes they ask me as well. Um, do you have any input on cracking? Well, I do. Yeah. And, and, and sorry, it depends. When I see a person who, uh, we're having, we're starting out the, uh, assessment now with an interview and the interview, it might last 20 minutes or even 30 minutes long. And I'm just listening to, to, to, to tell their story, uh, why they have pain, how they perceive it. And they might do two or three self manipulations during those 20 minutes. Now I have a hypothesis. And my hypothesis is they have a proprioceptive system that gives very high priority to the stretch reflex.

So then I'll ask them, could you tell me about your current training program, dollars to donuts. They're going to start out talking about mobility. Well, yes, I stretch my hamstrings and then I do the, the runner stretch and I do this stretch and I do the scorpion stretch, stretch, stretch, stretch. And I could have predicted that because that's the body type and the neurology that likes that behavior. Well, interestingly enough, the more normal response to a stretch reflex is to decrease the joint angle because it's a warning system telling your body that that is a compromised joint position.

One that is now becoming unstable. You probably don't want to spend too much more time there. Isn't that interesting? So, yeah. And then I'll say, well, you know, I pull my knees to my chest in the morning. Why? Their neurology gives them the jolly. They get 20 minutes of analgesia for pulling their knees to their chest. But what they didn't realize was they were being fooled. Their proprioceptive system gives them the 20 minutes of relief. And then the back pain grumpiness comes back just as hard in another 20 minutes. So what do they do? They self-manipulate and they do another self-stretch.

And what I say is let's – now we've recognized that phenotype of neurology. Every time you feel the need to self-manipulate or pull your knees to your chest, I want you to try something else now. And we might define their mechanism of pain as – let's say it's a disc bulge. They'll say, now I simply want you to lay on your tummy for three minutes every time you feel that urge. And it's a hard thing for them to do. But after two or three days, they'll say, you know what? For the first time, I'm winding down my pain sensitivity and I don't have the need to self-manipulate anymore. So there's just a story that some people will relate to.

But generally, the self-crackers don't get better. I've noticed a lot of things that people come in kind of doing to decrease their pain. A lot of it is – I guess not all of it is short-lived. I guess it does depend. Ah, I used that one that time. But I would imagine that are they – they're drawn to that because it just makes them feel good for X amount of time. Is there a time and place for things like that or is it always just kind of like the neurology is tricking you? You know, Sebastian, I don't really know the answer to that. Yeah. I don't know. I'm, again, one of the few in the world who's measured the mechanics and neurological change from some of the chiropractic and osteopathic manipulations.

Okay. And what we've measured is much more of a neurological change or reset than a mechanical reset. So, again, it comes back to this idea of neurology and are they manipulating neurology for the better or worse in terms of pain sensitivity. But, you know, once again, I think the assessment that understands and probes why they behave and move the way they do will reveal the pain mechanism. And if it's part of the mechanism, you know, if they keep self-manipulating and they can have continued to stay in pain, it's not working well, is it? Yeah. Actually, I was listening. I was really intrigued by, this is another reason I wanted you to come on, where you did a, there's a podcast you're on where you're talking about like the fireside evaluation that you, you have the fireplace set up in the room and you just, you listen to them and interacting with them.

And before you even start the evaluation, right? I mean, it's, it's just the, the observation I think is, is amazing to figure out how to manage these people and how to get them out of pain. Yeah. They come in through the front door and if I get a chance, I watch them walk up the driveway and then they come in the front door. And, uh, it's funny, you know, if they're from the Southern U S they never ask, they just walk right in. They don't take their shoes off. But if they're Canadian or from the Northern U S they, they will automatically take their shoes off or they will say, shall I take my shoes off?

And that is always a huge part of the examination. They reveal to me right away why they have back pain. It's so interesting that the ones who have flexion intolerance go into full flexion to, to, uh, take their shoes off. Usually not always, but, but the vast majority of the time. And then they sit down on a couch that we had custom made. It's very, very hard foam and, uh, they mostly sit in their pain. So the extension intolerant back pain person sits in jacked extension. And the person who, uh, has a disc bulge, uh, generally speaking sits in selection. And then, um, I have a little pneumatic cushion, uh, on that chair.

And then I say, look, let's, let's adjust this. And then I'll adjust it opposite to what they're sitting. And they'll usually say, Oh, how did you know that feels so much better? You know, but then, uh, they come in and just complete the, the visual picture. There's a fireplace, a gas fireplace. And we sit in front of that. And, uh, I take a certain body position. It's at 40, 45 degrees to them. So I'm not in their face, but nor do they ever see the top of my head, which some of them are used to seeing from their usual, uh, clinical, uh, interactions. Uh, I mean, the seating is laid out, the, the lighting, the fireplace, it's all been well thought out.

And then my first question to the, to me is, uh, uh, tell me why you're here. Tell me your story. And I listened to what they put priorities on. Is it their job? Is it their inadequacy with their spouse? Is it their, their failing as a, as a, as a, as a, as a parent to play with their kids? So I'm learning, what do we need to do? Or they might say, uh, something like, uh, what, what, what have you done in the past? Well, uh, you know, this last doc told me to exercise and go outside and walk and whatnot, but in my neighborhood, I can't go out and walk at night. So for the first time, I'm the one who understands that they have a social impediment.

They live in a neighborhood where it's dangerous for them to walk out at night. So guess what? The compliance will be if I give them exercise in that same neighborhood to go out for a walk in the evening. It's not possible. They're going to fail. So to, to, to, to see why it's, if I'm going to be the guy who makes the difference, I have to understand all of this and put it together to create, uh, the best possible plan. These are people, I don't see the average back pain patient. I've seen the one who's failed 10 different approaches and they're, they're at the end of their, their, their, their way up now.

Yeah. Well, I think it's, I think it's amazing the, the, the time that you spend. And like, we definitely don't spend as much time here. I try to at least spend an hour the first time. And I always tell them that we might not get to any hands-on, we might get to anything. We might get to only just assessment, but it really depends on how far the rabbit hole is, you know? But I think it's important to go the right direction in the beginning rather than just, you know, speed off into the wrong direction. Um, something, something I think you should definitely speak about on here is, uh, building a resilient back.

And I know there, you have the McGill big three exercises. Um, and I know that correlates with the core and how it works and so on. Can you go a little bit into, um, proper core training and, and the big three? Yeah. If I can just preface that, Sebastian is, uh, I know I'm known for the big three, but we do so much more than that. And there are some people that think, oh, those are just the McGill exercises. And that all, that's all he does. That will not get people into the Olympics and into the UFC and all that sort of stuff. So, of course, this is just the beginning. But, um, what is required to build a pain-free foundation is a strategic tuning of the body.

So, we've talked about elasticity a little bit and mobility in the hips and shoulders. But core stability is non-negotiable for pain-free function for three reasons. And I'll, I'll give the three reasons now. And I should also say that there are very few, uh, university laboratories in the world that measures fine stability. That means everyone else is just hand-waving about it. They'll say, oh, that's a stable pattern. Well, how do they know, how do they know what the muscles are that, uh, actually create a stable spine? Well, as I said, we were one of the, uh, institutions that, that quantified stability and, and measured it.

So, with that, um, uh, preface, uh, the three reasons why, why core stability is non-negotiable are these. The first one, the spine by nature is a flexible rod. Well, it's nice to have a flexible rod if you want to dance. Or if you want to throw a ball or tie your shoe, very handy. But, uh, in all of those times when you're moving your spine around a lot, if you put high load on it, that increases the risk of, uh, mechanical damage. So when you're picking up something heavy, and it might be, again, stay at home mom picking up her baby at two o'clock in the morning, or it might be, uh, an office worker who wants to come home and do a little power lifting.

They have to stiffen that flexible rod to allow the flexible rod to bear load. They've got to turn it into a beam. So you do that by, uh, strategically bracing the core muscles to stiffen the rod, and that unleashes the hips to be ball and socket joints. And you hip hinge and all the rest of it, uh, to create this very resilient, uh, linkage. The second reason has to do with proximal stiffness for distal athleticism. So let me start off with, uh, an example of a, of a pec muscle. So your bench press or chest muscle on the proximal side of the shoulder connects to your rib cage on the distal side, it connects to your arm bone or your humerus.

When you activate that muscle, it flexes your arm around on the distal side, but on the proximal side, it bends your rib cage towards your, um, uh, shoulder joint. So if all you used was the bench press muscle to push somebody or push an object, you would collapse your, your, your torso would rotate. Your rib cage would bend towards your, your, uh, shoulder joint on the proximal side, and it would mildly pull your arm around on the distal side. But if you could lock down your core, so 100% of that muscle contraction was, uh, sent to the distal side, your arm would come around with great force.

So do you see why you had to stiffen proximally to get distal mobility, just like a backhoe has to put down stabilizers to anchor into the ground, to allow the bucket to actually dig earth. Uh, if you don't put down the stabilizers, the whole tractor just, just moves around. So now let's talk about walking. Um, in order to walk, you have to stand on one leg and swing the other through. If you don't have core stability, your pelvis drops down on the swing leg side. Um, if you go to the neurology ward of the local children's hospital, you might find a child with a paralyzed quadratus lumborum. That's a core muscle, a very important core muscle that runs up and down either side of the spine.

When they take a step, so say their left QL is paralyzed. When they stand on the right leg and swing the left leg, the whole pelvis collapses and falls down on the left hand side. You need those core muscles to hold your pelvis up to allow the legs to drive you forward. Otherwise you, you, you, you, as I said, your, your torso just bends and the spine collapses. So this notion of proximal stability is absolutely critical. There's no linkage in engineering that could function otherwise. Now the trick is to tune that stability and stiffness. So if all you're doing is bending down to pick a pen that you dropped on the floor, you need mild stiffness.

But if you're going to pick half a ton off the ground, you need a lot of stiffness. So that's the tuning aspect that people don't often get. Some people coach it poorly and over brace their, their patients, which I think you alluded to earlier, that the person is way too stiff and they're just crushing themselves. The third element of core stability are joint micro movements. So let's use a knee injury example. Consider a knee where the ligaments have been partially torn or stretched. The doc performs a drawer test. And in other words, they shear the knee and they'll see micro movements, uh, that indicate the integrity of the knee.

And if it's pain generating, it sends off a flash of pain to the patient. Well, we do exactly the same thing with spines. If a person has disrupted a disc or the ligaments, that particular joint becomes a bit lax. But when you probe that with your thumb, you will find which joint has micro movements that are causing pain. Then ask the person here, let's try this abdominal bracing strategy. Push your fingers into their abdominal wall laterally and say, push my fingers out and then probe the painful joint. And if they say, Oh, you know, that doesn't cause me any pain. You just proved that it was some micro movement and laxity that triggered their pain.

But you've just found a bracing strategy to take their pain away. But the patient might also say, Oh no, that bracing causes more pain. All right. They have compressive intolerance. Then you might say, well, let's try a pec lat, uh, compression strategy and see if that works. So in other words, we, we play with the bracing strategy to control out the pain causing joint micro movements. Anyway, there are three quantitative, uh, and measurable explanations of why, uh, core stability and, and core, uh, athleticism and tuning is, is non-negotiable. Okay. So when, when people choose their core programs, I know that probably a lot of people are on the other end thinking, okay, I'm going to, I'm going to go pick some stuff off of YouTube right now, is there, is there criteria that they should be looking for when they choose a, an exercise for their core or do you have some suggestions on that note?

Yeah, man, you're good at your job. Yeah. Well, that's how we came up with the big three. So let's take someone at the low end of the clinical spectrum. They have, uh, diagnosed now a little bit of instability as, uh, a part of their pain mechanism. So how do you get them going? We came up with the big three. We didn't invent those exercises, but we quantified a broad spectrum of stabilization exercises where we tried to minimize the load on the spine. So you have to spare the spine. Otherwise the exercise will just create more pain, but you have to gear up. You have to guarantee that you're actually stiffening and stabilizing the pain mechanism.

So those were the three exercises that kept bubbling up to the top of sparing the spine and guaranteeing stability. So that's where they came from. But of course, uh, you know, back mechanic really gets its whole point is to get people out of pain, but it doesn't train them. So then we move them to my second book, ultimate back fitness, and we shift the paradigm. They're out of pain, but they have a history of pain. We won't go back and trigger the original, uh, offending, um, uh, instigators, but now they have to judiciously create a progressive program. Uh, they may incorporate the big three, uh, but then we would add more stabilization work for sure.

But again, your listeners might find this interesting. There is one category of back pain patient that right after doing the big three exercises, they're pain-free and they're pain-free for a couple of hours. And what we measured with that subcategory is they have a residual stiffness. Their neurology after doing those exercises keeps a tone to their core for an hour or two afterwards. We find that some sprinters sprint faster. They get, they get to cut a little bit harder because the proximal stiffness is greater so that the muscle activation is creating more athleticism distal to the hip joints and the shoulder joints, propelling the arms and legs.

So again, there's, there's wheels within wheels of this. It, it, it, well, as you know, it's been my, my, my, my never ending source of, uh, uh, fascination and entertainment and everything else for the past 32 years. Yeah. I, I, uh, with those people, then you said there's a subcategory then, because it probably everyone's on the other end is thinking, I wonder if I'm that one. I wonder, I wonder if my back pain could be lucky enough to where it feels good after these exercises, what, what type of symptom patterns would those people have? Or like, um, have you recognized any, any, uh, thing that they have in common?

Oh, what a beautiful question. You know, I, we've got to syndicate you. You are good at this. Um, well, yes, the answer is, uh, what I would ask people to do is to establish a baseline. So stand up and know your pain. So know its location, its pattern, and its intensity. Now do the big three. Don't, don't do major reps and sets. Maybe do three 10 second holds, uh, another three 10 seconds and then another three 10 seconds. Uh, and then stand back up again. If the patient now recalls their previous, uh, baseline, they will know whether they're better or worse. If they just got better. Beautiful.

We just found a, uh, replacement activity that gives them some temporary resilience. What we would say to that category of patient is you're going to do your big three twice a day, do them mid morning. And in mid afternoon, now we're creating two windows of opportunity. It's like giving them a drug or an opioid only. There's no side effect. So slowly we're winding down their pain sensitivity and creating a bigger window every single time. Okay. So then I guess my question further on that note is then if they stand up and they're on pain medication or some type of thing that numbs the pain is there, they can't assess it.

It's better not to be on pain meds, of course, anytime you're registering pain. So, uh, one of the instructions to any patient coming to see me is try and not take your pain meds on the day of the consult. Okay. So I'm getting a very true read of their pain sensitivity. Okay. So you, you mentioned holding for 10 seconds and I saw you put stuff out there before on, uh, endurance versus strength. Um, the terms, at least in regards to core, um, why do you suggest 10 second holds? Cause I know a lot of people, there's a glorification of like holding planks for 10 minutes now, you know? Right. Well, that's not to get people out of pain.

That's either to test or to show off to your friends or it's for performance training, whatever it happens to be. But that is not a strategy to get out of back pain for several reasons. Um, the first reason why 10 second holds, well, you will find that some people get back pain because of muscular ache. When you do the big three or virtually any isometric exercise, the muscle, uh, contracts and goes into a turgor that clamps down the capillary bed. So the internal blood supply of the muscle is shut off once you go into a, a, an isometric contraction like that. So that will create back muscle cramps in some patients.

But what we found, we measured with a near infrared spectroscopy, which is, uh, uh, an instrumentation that measures blood oxygenation and muscle hemoglobin and myoglobin in, in the muscle. And, uh, it starts to drop off rapidly in oxygenation after about eight seconds. So that's why we release the muscle every eight to 10 seconds to reperfuse with, with oxygen and minimize the chance of back muscle cramps in an already back pained person. The, uh, next reason why we need to build endurance before strength is the majority of current back pain. People have back pain because of the way they move.

Once they get tired, think of the last time you hurt your back or tweaked a painful body part, it was when you broke form. So we measured this and proved it in auto workers and, uh, hydro linemen, guys who, who climb, uh, hydro poles. Um, we, we measured guys chroming Chrysler car bumpers, which weighed about 75 pounds. Do you think it was the strong ones or the, the, the moderately strong ones that, uh, got more instances of repeated back pain throughout the year? Yeah. It was probably the strong ones, wasn't it? It was the strong ones because they would lift the car bumpers, no problem for a few reps, but then they got tired faster.

And when they got tired, they broke form and that's when they hurt their back. But the other guys who weren't as strong, but had more endurance could lift with perfect form to protect their back and joints for many more repetitions throughout the day. So there's a little bit of a nuance to that being strong or endurable. It's the ratio. If you have a lot of strength and you're a worker and you do different jobs, then you need a foundation of endurance to keep good form. If you're an Olympic weightlifter and you come out and do one world record Olympic lift, that's one exertion. You don't get tired and there's not a second rep to break form on.

So it doesn't matter. But now think of some of these exercise programs that you might be familiar with, where first of all, the athlete does 10 burpees and then they go and do 10 Olympic lifts. And when you look at the 10th Olympic lift, it is horrible form. Now you know why you're seeing them as a patient. They broke form because of the programming. So I don't know Olympic lifters that do 10 repetitions. They might do a single lift or a double or a triple at the most, at least the ones I've worked with. I've worked with some pretty good ones, but they never, ever train to fatigue because that's when you get hurt when you're handling high load.

So that's why the endurance foundation is so important for people who are exerting high strength repeatedly. So there's some nuances in there as to why endurance is important. Another one just came to mind, Sebastian. So you know that there are certain patterns of movement that a back pained patient needs to follow to avoid their particular pain triggers. Well, sometimes if a little bracing makes them more resilient and takes their pain away while they're gardening, okay, they learn to do that. That's not a strength challenge. That's an endurance challenge once again. So the way out of back pain is not through strengthening the back in design of the program.

It's by designing an endurance back program. And now, of course, they get stronger as a side effect, but that's not what is programmed. Okay. Stuart, I got a good one then to follow up on this. So I'm going to quote that a lot of people say to me, I have a weak low back. Can something like that address issues where people have weak low backs? Well, look, it depends. That doesn't surprise you. When a person comes and says that I have a weak low back as an excuse, then I will try and detect that and I'll try and figure it away. How can I empower this person? I'm not going to tell them, look, you're weak and you're weak minded and all the rest of it.

No, I'm going to detect that they have a, probably a lack of confidence because the experts have told them to do things in the past that have only hurt them. So all they've known is failure. I have to figure out a way to empower them. And it's usually proving to them that they can take their pain away. So I will create their pain. I'll show, I'll say to them, show me what causes your pain. And then immediately, if I can define the pain mechanism, I'll try and mitigate it somehow and show them, ah, you just took your pain away. Now that may involve a little bit of strength. And as you know, I'll quote my good friend, Pavel Satsulin, strength is a skill.

And when you show a person how to use their body, all of a sudden they unleash what's strength they had, but they didn't know how to unleash it. So I have a week back, figure out a way that they can start moving and training in a way that doesn't trigger their pain and give them some confidence that they can continue the progression and, and get what we would then call sufficient strength. And I've, I've, I've, I've measured some of the top athletes in different sports with the exception of powerlifting. The best players are not the strongest players. Obviously in powerlifting, the strongest guy usually wins, but in American football, hockey, baseball, UFC, it's not the strongest who wins.

The strongest guy tends to push his punches with muscle. They're slow. It's the elastic fighter who can snap, uh, and, and land with precision. That is the, the, the deadly UFC fighter. Um, so it's so interesting, um, you know, uh, just try and achieve sufficient strengths skillfully and in a resilient way. So, you know, is figure out why they're saying I have a week back and, uh, go with it accordingly. I feel like that is one of the perfect answer to start closing the podcast down, but I, I, I can't let you go unless I, until I hear what you personally do for your back or spinal health. Okay.

Well, the answer to that, I, I wasn't anticipating that one at all. That's a very, very few people, uh, ask me that. Um, I don't know if you've ever been to one of my courses, but a, I have to train to be able to put one of those courses on. And if I go and work, I mean, I'm, I'm putting on a performance enhancement, uh, uh, course at Chris Duffin's Kabuki Strength up in Portland at the end of the month. You know, I've got to be in shape to do that. Uh, you know, I can't be a skinny old man walking in and not, you know, ask someone, oh, could you mind handing me that kettlebell? You know, it doesn't work.

But I also have quite an injury history myself. Um, and, and I'm, I'm also, I'll reveal I'm in my sixties. So what I do for my own back has radically, uh, evolved over the years. Uh, there's no question when I was, uh, you know, I, I played football and hockey, uh, as, as, uh, uh, a young man and I played old timers hockey till the end of my thirties. So I was definitely training for performance then. Um, and I, I, I even did a little bodybuilding in my, uh, late teens, uh, and then tried for maximum strengths and personal bests and all the rest of it. Then, uh, in my forties and, and really into my career as a professor and a clinician, I had to back off on that and I got a bit soft, but I, I did my core work, the big three, a little bit of hip mobility, shoulder mobility, et cetera.

Now I train not to lose anymore. I don't want to gain anymore. I just don't want to lose anymore. So I do balance training. I do footwork, uh, which living in Canada, you have to recover from falls on slippery surfaces. I spend a lot of time in the woods, uh, crawling over slippery rocks, rocks and logs and that kind of thing. Um, so I have to keep a reasonable amount of mobility. I work on grip strength, uh, and my, my grippers haven't declined, uh, very much and they come in, uh, darn handy. Um, I can also tell you I've had hip replacement. Uh, so I do a, uh, gluteal, uh, reprogramming exercise routine every day, uh, a little bit of, uh, hamstring and so as lengthening, uh, that's about all that I can, uh, think of at the moment.

But it's certainly been a phase, uh, through my life. Yeah. It sounds like a bit, but I still can't get past it. Somewhere out there, there's, there's pictures of your bodybuilding competition. I never went into a competition. No, not at all. I, I was just, uh, I, uh, was interested in, uh, American football through high school and university. So I had to keep the beef on and, and that was really the, uh, the way to do it. Uh, then, but, uh, I'll tell you in those days, it didn't help me attract women. I'll, I'll admit that. So that didn't help. I thought you just like wore a tank top on the, in the summer of Canada and had the pythons hanging out.

No, no. Well, I'll tell you that didn't work for this, uh, this fellow at all. So, um, well, I, I, I, I ended up with a pretty good wife though. And so I don't, I don't know what, what on earth she, she found attractive, but, uh, anyway, yeah, well, I, I, I, um, uh, you'll probably be happy to hear. I don't think that works much in America either. So, so, so how, how can everybody reach you? And I know I'm going to put the show notes in the show notes for your back mechanic book, um, that everyone should definitely get. Um, how can they reach you if they want to find out more about you and the stuff that you put out?

Well, uh, we do have a website, backfitpro.com and it's just, as it sounds, B-A-C-K-F-I-T-P-R-O backfitpro.com. And, uh, it, uh, has links to our, our books and videos. There's a lot of information on there though. There's, there's quite a number of free videos, uh, links to some YouTube, uh, work, um, uh, a few articles, um, yeah, that, I, I guess that sort of thing. There's also a list of providers as well. And we don't take that designation lightly. Uh, I, I refer, uh, to our network of providers. Uh, I've worked with them all. Uh, they've all taken my courses and I've personally worked with them and made sure that they are very competent, uh, in, uh, performing, uh, uh, an assessment that will reveal the precise cause of the person's pain and they know what to do to, uh, coach the person and empower them to, uh, really, uh, desensitize their, their, their back issues.

And in some cases for the athletes build that, uh, uh, uh, resilience and performance once again. Awesome. Is, is there anything you think we missed on here that, uh, that everyone needs to know? I don't think so. Uh, I will, if this is my last bit, I'm going to say something, uh, Sebastian, you are good at your job. I, I, I, I think Joe, Joe Rogan better, uh, look out. Uh, you did a phenomenal job on that. Well, thanks. I, uh, I'm definitely, I'll be honest with you. Some of the people that I interview, I I'm a little intimidated. I don't know if I can, uh, I'm like, can I, can I do this interview well?

So it takes me a little time to loosen up. It's, uh, it's, it's not something that I'm developing overnight. My first podcasts were, I think, terrible. So thank you for the praise. Yeah, well, we all wish we could have, uh, those, uh, back. I was out driving this morning and I drove by a church and you know how churches have, uh, different marquees out front. And the saying this morning struck me and it said, everyone gets a second chance. It's called tomorrow. Isn't that beautiful? Yeah, it is. I don't know who makes those things, but they really have, they have good sayings on those things. Yeah.

Well, cool. Well, thank you for coming on. Um, I will put all your contact and all of the links in the show notes and, uh, yeah, sounds good. Thank you, doctor. Yeah. Fantastic. Thanks for, uh, for all of that and, uh, hope your listeners, uh, obtain some value. Awesome. All right, everyone. That was Dr. Stuart McGill. Um, always great on podcasts. I love to hear his. So he does have a lot of information out there in other podcasts, but again, the reason why I thought I would, uh, include these, this questioning series for you guys is mainly because we do have, we still do have a lot of patients who, um, misunderstand back pain.

And even when I referenced some of the other podcasts, which were amazing, by the way, they, they still didn't understand it. Cause I think it was a little bit too technical. So I thought I would go down a questioning series that, uh, we get asked a lot of as healthcare providers. So I will put this on the website. So it's P two sports care.com slash podcasts, podcasts is where you can find the show notes and you can find all of the stuff for Dr. McGill and what he spoke about on the podcast on there. If you haven't gone to iTunes already, please go to iTunes and subscribe us. And by the way, I, I've barely found out how I was looking at trying to figure out how where I can find the reviews for myself or actually reviewing other podcasts.

Cause I've been on other podcasts and I wanted to check theirs out and also leave one too. And I couldn't find for the life of me, how to review a podcast. So, um, you took a little bit of digging. So if you don't know how to review this podcast, just go into Google and put in how to review a podcast and it'll take you down the questioning series. So that's how you do it. I greatly appreciate any feedback, good or bad you have on that. Okay. Honest feedback. I will speak with you guys soon. If you have more questions or experts that you want on, reach out to me on p2sportscare.com. Talk to you soon.