– [Narrator] Welcome to the Performance Place Sports Care podcast, where you can learn about sports injuries theory, rehab, diagnosis, and how to understand the Doctor lingo you didn’t understand at your appointment, and now your host Doctor Sebastian Gonzales.

– [Dr Sebastian Gonzales] Hi everyone, thanks for joining me again, I’m Doctor Sebastian Gonzales with the Performance Place Sports Care podcast, Barrel House is one of my favorite places, and if you know me pretty well, you know that Barrel House I get excited about it, 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 went to Paso Robles again this is a brewery, we went there for the first time a couple of years ago, so I guess it was 2016, but we showed up and there’s the nicest people there, they tell you all about the community of Paso Robles, as well about the brewery and the whole region, and how it kind of got developed, and it was just nice every time we went back there there was just so many nice people to talk to, the beer is great, the ambiance is awesome, and it’s one of my favorite places, so if you ever get a chance to go there, just give a big Barrel House yell, and it’s a good time, so I don’t think you will be disappointed.

So in this podcast today I’m actually having a great expert on back pain or back biomechanics, his name is Doctor Stuart McGill, he is a professor of spine biomechanics at the University of Waterloo, 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 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 time it takes sometimes to sink in, to really understand, and what I suggested to at least the first patient, I had listened 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 could tolerate, and I thought I would ask Doctor McGill to come on, and we’ll answer all the basic fundamental questions that new patients ask about back pain, so part of the reason for this podcast here, this session, it’s kind of a selfish reason, because I really want people in my clinic to understand back pain, and I thought if I could have Doctor 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 today, and I would strongly encourage the other doctors and these chiropractors, or people who don’t understand back pain, share this podcast with your friends or your patients who have it, because I can tell you how many times I’ve seen people, come in with back pain, and they’re extremely emotional about it, if we break this thing down, and when you hear Doctor 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 where we can figure it out, I think we need to explore malignancy, tumor, infection, or the large types of things, so if you’re experiencing back pain, are you have friends or patients experience back pain, I strongly suggest you have a 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 the stuff that has to do with the mechanics of the spine and the technical terminology, we’re going to try and leave that out, and it’s not to dumb the idea down or dumb the concepts down, but it’s to make it understandable to people, so they have an actionable process after, so we are trying to combat patient misunderstanding, and only have them do medications, pain killers, and injections when it’s actually needed, because a lot of times that is a really quick fix for people.

And before we go onto the interview, I want to remind people to go into iTunes and review, it helps a lot, I get a lot of feedback from that, but also to I want you guys to check out the other podcast, we have other experts on for other 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 are a healthcare provider, please share these with your patients, it will save you a lot of breath, and it will help them comply with their care much much better and get better faster, so here we go with the interview. Okay everybody here is our interview with Doctor Stuart McGill, Doctor McGill say hi.

– [Dr Stuart McGill] Well hello to all your listenership, and to you Doctor Gonzales.

– [Dr Sebastian Gonzales] Well thanks for coming on, I’ve really, really wanted to have you on for a long time, and not until, do you know Doctor Seth Meyers, he’s in Idaho, or Kansas?

– [Dr Stuart McGill] I know of him, absolutely.

– [Dr Sebastian Gonzales] He is 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 would go over today some of the questions that first-time patients have on back pain, because from a healthcare site, or a clinical side, we see a lot of patients who don’t really understand back pain, and they are very emotional at the time, and I think sometimes explaining something logically and mechanically to someone who is a little bit emotional, sometimes we have to get really in-depth into education, I thought we go through these questions which we as healthcare providers get all the time, sound good?

– [Dr Sebastian Gonzales] Yes. So, first off is all low back pain created equal?

– [Dr Stuart McGill]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 non-specific 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, 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 setpoint, all back pain has a cause, and if we can obtain a specific and 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 is in their mid-20s, 30s, 40s, say they work sitting at a computer eight hours a day, sitting at the computer for 20 minutes gives them back pain, and yet they can stand up and go for a three or four 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, 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 will see that they form cluster groups, for example one team might have four stress fractures on their roster, in their back, and those stressed 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 spondylitic fracture, and maybe full-blown spondylolisthesis, so 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 there is an example, one is a programming flaw, one is the person who sits and works at a computer for eight hours, and then goes to gym for one hour at night, and basically does a bodybuilding program, and 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 of 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, they will do some sort of non-specific treatment, to non-specific back pain, and they tell the patient there can’t be anything wrong with my therapy, therefore the pain must be in your head. And the patients I get, who failed different approaches, many have been told that the pain is in their head, and this is just a pure default of incompetent clinicians, I’ve had people, who were on the brink of suicide, they are very solid citizens, some doctor has told them that 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 iatragenic cause to 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 sub classified and treated with precision and specificity.

– [Dr Sebastian Gonzales] Okay, you definitely didn’t throw me off topic there, there are a couple of things we’ll revisit a little bit there, so what I’m hearing is that 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?

– [Dr Stuart McGill]Well it does go into their head, when they have been told it’s in their head, and it drives them crazy, so that’s a little bit off at it depends answer, but generally speaking when their pain mechanisms are recognized, and they address them mechanically, the psychological sub issues can be resolved, but if all you do is treat the psychological through cognitive behavioral approaches et cetera, chances are that pain is going to come back to revisit them.

– [Dr Sebastian Gonzales] Okay, you said there is three kind of major categories, I guess we can differentiate back pain into, there was the young disc-based person, there was the older arthritic or stenosis, and then there was the special population athletic there in the middle, so each of them I’m guessing, they have different symptom patterns, within each collective group, let’s just start with A disk young kid, are all these people going to be the same, or order different subsets in their how they feel and how they respond and so on?

– [Dr Stuart McGill]Well I teach a master level course in assessment, and the theme is we get right down to a subject category N equals one, and what that means is there are 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 et cetera, to build that foundation for a pain-free movement, it’s going to be slightly different, so you could have two people with exactly the same category, but they are in different positions in the program progression, one might be more advanced, so their program, you don’t just give a person a set of exercises and say 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, and then if they eventually want to play tennis, you’re going to have to add some footwork, but anyway you get the idea, when we’re dealing with the person in the thorough assessment, will slice it right down, so they are a category of back pain of one, themselves.

– [Dr Sebastian Gonzales] So as you know I wrote down a list of things to go through today, I’m going to jump around slightly, because I’m gonna go right down this path, with people since they have a very unique mechanism of injury, in a unique injury, how active or how much are they participating in their own resolution of their back pain, I know a lot of people go and they say I want this treatment, I want that one, can you stretch me out, how much do they have to understand about their back pain to make it resolve and not come back?

– [Dr Stuart McGill]Well I’ve already mentioned that most family doctors, if we were to take them as a clinical category, they could 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 with patients, so they end up giving what they know which is an 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 in Canada, 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 are learning about the real mechanisms of pain, would you write one for the lay public? So that is 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 participants and advocate for themselves, because no one knows their pain better than themselves, they just need a little bit of guidance and interpreting.

– [Dr Sebastian Gonzales] Actually I did mention to you I read a strong majority of the book, and actually the first page, I’m going to flip through real quick, it was a myth busting session, I thought it was amazing, and even the first part, I got a highlighter out and I started doing some highlighting on it, I think it was very, it was very empowering I think to hear that we are debunking these myths surrounding back pain, and I totally agree with you when you’re saying that you made the book for clinicians, but the general public they have a whole different leading 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 be expected to be educated about their injury, unless something like your book came out, by the way everybody should pick the book up, I will put a link in the show notes.

– [Dr Stuart McGill]Can I say something about that Sebastian?

– [Dr Sebastian Gonzales] Sure.

– [Dr Stuart McGill]We know each other well enough for the last 15 minutes that I can call you Sebastian and you can call me Stuart, how’s that?

– [Dr Sebastian Gonzales] Sounds good, I’m going to get one last Doctor McGill and, okay, everyone Doctor McGill.

– [Dr Stuart McGill]Now I got sidetracked with what I was going to say.

– [Dr Sebastian Gonzales] Myth busting, public education.

– [Dr Stuart McGill]Oh yes, it’s so interesting that when I speak with patients, it’s amazing how often they will say 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, 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 are in fact easier to teach than some of the high-level docs, they certainly have a longer attention span, I’ll say that

– [Dr Sebastian Gonzales] You mean we have lost already a strong majority of the docs five minutes into this podcast, didn’t we?

– [Dr Stuart McGill]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 purely coached in movement, I lay the fault at the feet of the clinicians, I’m sorry but that’s my opinion.

– [Dr Sebastian Gonzales] Yes, I do agree with that, I mentioned that a couple of times on this podcast before, so I put out some videos on exercise rehab, and I want people to have at least a basic knowledge in it, and I have a good friend who is a clinician who says that we can’t expect people to know any movements through video, we have to cue them, I said I know, but maybe we just haven’t found a good way to do it, I think people are really teachable, it just takes a little bit of time, that’s my personal opinion on.

– [Dr Stuart McGill]My opinion is the same, only stronger, I think great clinicians are great teachers, and again if a person isn’t getting it, I look at the inadequacy of the teacher, have they even considered the learning style, adjust your learning style, think of the patients listening to this, think of the times they’ve been to the doc and they look over 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.

– [Dr Sebastian Gonzales] So 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 is docs that only look at MRIs and see the structure as the pain generated for these people, can you elaborate a little bit about MRI findings and pain mechanism with back pain?

– [Dr Stuart McGill]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 clinicians saw an end plate fracture, which is the beginning quite often of a flattening disc, and a broad-based disc bulge, Was 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 are 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, disc bulges, half of people who never have back pain showed disc bulges on MRI and quite the opposite, 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 think gardening, sitting in bed lifting very deep causes my leg pain and my back pain, however if I go for a walk, or I preserve in neutral spine while sitting or lifting, I don’t get the pain or the radiating symptoms, so now given that clinical report, and history, the doctor can link whether or not a 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 try and wind their pain down.

– [Dr Sebastian Gonzales] So with things like disc bulges, I have patients come in, actually I had a guy yesterday, he was very, I wouldn’t say blaming the disc bulge, but he just couldn’t let go of the idea, and I said how big is it, because he had one two or three years ago, he said three millimeter, and I said I have a three millimeter, we’re very different, we feel very different, so I guess my question is, do you feel 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 to the idea that a part of them is broken.

– [Dr Stuart McGill]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 discalgenic pain patterns, and they have very tiny disc bulges, others have enormous bulges 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 I never look at an MRI scan or a picture until the very end of the console, or at least until 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 are compressing their back with a fully flexed spine, and of 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, and if 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 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 bulges 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 we have 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 I’ve mentioned are able to manage it, to some clinical levels and play professional sport, now obviously there are failures in there as well, but there is a guess an answer to the question.

– [Dr Sebastian Gonzales] I think you would be kind of fun to play with the disc on an MRI, I was kind of jealous, so with that being said, since you flex them forward, and I know were only really focusing on disc stuff right now, I feel like flexion, sometimes in the patient’s eyes, I guess to break that down further, flexion would be rounding, rounding forward, or sitting posture, should it be avoided, I’ve seen patients who think that flexion is completely evil and they can’t do it whatsoever, is there a time and place for it, or should it be avoided forever if you have a disc injury?

– [Dr Stuart McGill]Well yes, you’re being very absolute now in the comments, and I know where they’re coming from.

– [Dr Sebastian Gonzales] I’m acting like I’m a patient right now.

– [Dr Stuart McGill]Yes, you’re very good at your interviewing lessons. 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 yes, when 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 your pain generator, now the curious thing about back pain is it 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 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 are moving your spine pain free, but you had to earn that pain-free capacity by avoiding the pain trigger for a while, 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 spine 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 bodyweight some of them, so if you then contrast that with someone who is the construction worker, or they want to do some powerlifting or dead lift, 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 thicker bone 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 creates much higher stress when you bend it, so these are all examples of once again the precise, understanding of their pain mechanism lead 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, in ways that avoided their particular pain trigger, if you have a certain type of arthritis, cystinotic spine, bending forward as you know is a relieving position, or say they have vascular congestion, as part of their back pain and sciatica mechanism, sitting in flexion is what relieves them. So anyway, do you see how again, people try to box me in and commit me to say it’s heresy, never flex your spine, will first of all, 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 really fun study to conduct, but you know not one of those women could do a competent situp, and my point was they had this marvelous mobility, but no strength, of course you’re going to find the very 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 have 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 an resilient way.

– [Dr Sebastian Gonzales] Yes I listen to a podcast you did, I think it was in Stem, S-T-E-M podcast, and I don’t mean to misquote you if this is not what you said, I thought it was something around different spines for different purposes, is that kind of summing up what you’re talking about?

– [Dr Stuart McGill]Absolutely, have you ever worked with the 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 will bear picking up half a ton of load off the ground. Now, I know that there are strength and conditioning coaches who were training NFL football players like they were powerlifters, do you know one power lifter that can tie his own shoe, or 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 an athlete who has to move explosively, needs a certain amount of elasticity in their body, so these are all examples of tuning the body, and choosing appropriate exercises, which is again, it’s very precise, it’s a continuum, there’s not a yoga master and there’s not a power master, there’s somewhere in between that people can see, but with the right guidance they should be able to find that sweet spot so to speak of maximal function and minimum pain for their body type, and age and injury history and all the rest of.

– [Dr Sebastian Gonzales] Okay sounds good, I think that was the perfect answer, I was trying to box you in last.

– [Dr Stuart McGill]I get used to that.

– [Dr Sebastian Gonzales] I’ve actually been accused by a couple of my friends and people who know me really well, they’re like why do you always ask people questions that leads people down the same path, I’m like I’m really not trying to, I don’t want to lead the conversation, I try to be open ended. So let’s go through some common approaches for treating back pain, because I know a lot of listeners have probably tried this stuff, or they’ve heard it worked for one of their friends or so on, so I thought the first we should hit is rest or avoidance of activity, do you have any input on that?

– [Dr Stuart McGill]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 then build the foundation for pain-free movement, so rest and avoidance of activity, well you’ve had patients who are absolutely locked up, they are in excruciating pain, I would say for someone like that, there’s nothing else they can do, but to rest and take it easy that day, they physically cannot tolerate anything else, so for them a very short period of rest, it may last a couple of days, and avoidance of activity, if let’s say reaching their arms over their head to change a lightbulb or something like that triggers a back pain attack, I would say don’t do that for a while, so there are examples, but as a general answer I would say no, you don’t rest and avoid activity, you avoid the activity that triggers the pain mechanism.

– [Dr Sebastian Gonzales] Okay, I like that, I like that. So the next one is going to be, there seems to be a strong movement of people wanting to stretch in lumbar spine, low back for everybody who is listening, how do you feel about that?

– [Dr Stuart McGill]I have strong opinions about that, because I am getting patients caused by it. So I am not the scientist who can pull up our studies who say foam rolling is good or bad for the quadriceps, the deltoids, latissimus dorsi, 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 lying on their back rolling a foam roller roller up and down, it may 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 the thumb up the midline of your back, when you put your full body weight, which puts a shear 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 put pressure on the muscles, I do not think there is a substitute for an intelligent hand, go to a therapist skilled in manual therapy, and get the precision therapy to the location that needs it, but don’t push on the spinous processes with full body weight, that will cause issues, so summary, I don’t have an opinion on other areas of the body, I would not foam roll their low back.

– [Dr Sebastian Gonzales] Okay good, the next one then, I think I’ve heard you speak about this before, if the hamstrings feel tight, should you stretch those if you have low back pain?

– [Dr Stuart McGill]What the answer is again it depends, people who again are in the magical discogenic age group, so let’s say mid 20s, to early 50s, 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, its tight nerves, tight sciatic nerves, because of the disc bulge, so get it assessed, and know whether it is because you have a tight nerve, or 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 in an even lower threshold next time, so absolutely do not stretch that category of hamstring tightness perception, now we can go to the other end of the spectrum where people do have tight hamstrings, and they are stressing their spine because of it, so then it would make good sense to mobilize those muscles.

– [Dr Sebastian Gonzales] I think I was reading your Back Mechanics, it was something to the degree of you were talking about asymmetry with the hamstring?

– [Dr Stuart McGill]Yes, okay let’s talk about that, it’s interesting that in studies of the military, there’s been one in the US, there’s been one in Norway, where they measured the hamstring flexibility of all of the recruits, and who developed back pain over I think the next two years of mandatory service, there really was not a link became coming in with tight hamstrings and developing back pain, however, there was a mild link between having asymmetry right and left sides in hamstring tightness and developing back pain over the next two years, but you know I’m going to say something else, because I’m a Canadian, you’re an American, I’m assuming this is going to be podcast in the US, and the training mentality, the overwhelming training mentality in the US 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?

– [Dr Sebastian Gonzales] I’m pretty sure are probably tight.

– [Dr Stuart McGill]Absolutely, and I’m the guy who’s measured them, they bounce off a pre-tightened spring, they don’t do a deep squat, they create a spring by pre-tensing the muscle, so they just pop off into the ground after taking two steps to dunk a basketball. We measured the, fella who was the halftime show at the NBA All-Star game, this last time around, the Raptors hosted it it was in Toronto, and this fellow came out, and he is quite modest in height, he’s about six foot one, but he 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 are 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 how you might want to stretch that hamstring, so there is yet another element for consideration in this whole hamstring stretching question.

– [Dr Sebastian Gonzales] Okay, next one would be, and I do get a lot of people who come in with this, they say that when they cracked their back, their low back, it feels good, so they’re doing it on their own, but sometimes the ask me as well, do you have any input on cracking?

– [Dr Stuart McGill]Well I do, yes, and sorry, it depends, when I see a person, we are starting out the assessment now with an interview, and the interview it might last 20 minutes, or even 30 minutes long, and I’m just listening to them tell their story 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 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 doughnuts they’re going to start out talking about mobility, well yes I stretch my hamstrings, and then I do the runner stretch, and do this stretch, and do the scorpion stretch, stretch, stretch, stretch, and I could have predicted that, because that’s the body type and then neurology which likes that behavior, but interestingly enough the most normal response to the stretch reflex is to decrease the joint angle, because it’s a warning system telling your body 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? And then I’ll say well I pull my knees to my chest in the morning, why, their neurology gives them their 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 proprioception of system gives them the 20 minutes relief, and then the back pain grumpiness comes back 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 numerology, 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 defy their mechanism of pain, let’s say it’s a disc bulge, I’ll say now I simply want you to lay on your tummy for three minutes, every time you feel that urge, and is a hard thing for them to do, but after two or three days, they’ll say, do you know what, for the first time I’m winding down my pain sensitivity, and they don’t have the need to self manipulate any more, so there’s just a story that some people will relate to, but generally the self crackers don’t get better.

– [Dr Sebastian Gonzales] Yes, 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 how use that one, but I would imagine they are 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 the neurology is tricking you?

– [Dr Stuart McGill]You know Sebastian, I don’t really know the answer to that, I don’t know, I am again one of the few in the world who is measured The mechanics and neurological change from some of the chiropractic and osteopathic manipulations, and what we have measured is much more of the 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 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, if they keep self manipulating and they can continue to stay in pain, it’s not working well is it?

– [Dr Sebastian Gonzales] Actually I was listening, I was really intrigued, here’s another reason I wanted you to come on, there was a podcast you were on where you were talking about the fireside evaluation, you have the fireplace set up in the room, and you listen to them and you’re interacting with them, before you even start the evaluation right, it’s just the observation, is amazing to figure out how to manage these people and how to get them out of pain.

– [Dr Stuart McGill]Yes, they come in through the front door, and if I get a chance, I watch them walk out the driveway, and then they come in the front door, and it’s funny you know, if they’re from the southern US, they never ask, they just walk right in, they don’t take their shoes off. But if they’re Canadian, or from the northern US, 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 revealed 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 take their shoes off, usually, not always, but the vast majority of the time, and then they sit down on a couch that we custom-made, it’s very very hard foam, and they mostly sit in their pain, so the extension intolerant back pain person sits in jacked extension, and the person who has a disc bulge generally speaking sits in flexion, and then I have a little pneumatic cushion on that chair, and then I say look, let’s adjust this, and I’ll adjust it opposite to what sitting, and they will usually say, oh, how did you know, that feel so much better, but then they come in and just complete the visual picture, there’s a fireplace, a gas fireplace, and we sit in front of that, and I take a certain body position, it’s at 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 your usual clinical interactions, I mean the seating is laid out, the lighting, the fireplace, it’s all been well thought out, and then my first question is tell me why you’re here, tell me your story, and I listen to what they put priorities on, is it their job, is that their inadequacy with their spouse, is that their are failing as a parent, to play with their kids, so I’m learning what do we need to do, or they might say something like what have you done in the past, well this last doc told me to exercise 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 that understands that they have a social impediment, they live in a neighborhood where is 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, there are going to fail. So do you see why, 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 the best possible plan, these are people, I don’t see the average back pain patient, I see the one whose failed 10 different approaches, and that they are at the end of their wits now.

– [Dr Sebastian Gonzales] I think it’s amazing the time that you spend, and 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 not 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, rather than just speed off in the wrong direction, something I think you should definitely speak about on here is building a resilient back, and I know you have the McGill big three exercises, and I know that correlates with the core and how it works and so on, can you go a little bit into proper core training and the big three?

– [Dr Stuart McGill]Yes, if I could just pre-face that Sebastian, I know I’m known for the big three, but we do so much more than that, and there are some people that think those are just the McGill exercises and that’s all he does, that will not get people into the Olympics, and into the UFC and all that sort of stuff, of course this is just the beginning, but 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 head and shoulders, but core stability is nonnegotiable for pain-free function for three main reasons, and I give the three reasons now, and I should also say that there are very few university laboratories in the world that measure spine stability, that means everyone else is just hand waving about it, they’ll say oh that’s a stable pattern, but how do they know, how do they know what the muscles are that actually create a stable spine, well as I said we were one of the institutions that quantified stability and measured it, so with that preface, the three reasons why core stability is nonnegotiable, 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 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 mechanical damage, so when you’re picking up something heavy, and it might be a stay at home mom picking up her baby 2 o’clock in the morning, or it might be a office worker who wants to come home and do a little powerlifting, 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 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 to create this very resilient linkage, the second reason has to do with proximal stiffness for distal athleticism, so let me start off with an example 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 humorous, 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 shoulder joint, so if all you used was the bench press muscle to push somebody or push an object you would collapse, your torso would rotate, your rib cage would bend towards your 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 percent of that muscle contraction was sent to the distal side, your arm would come around with great force, so do you see why you had to stiffen approximately to get distal mobility, just like a tractor has to put down stabilizers to anchor into the ground to allow the bucket to actually dig the earth, if you don’t put down stabilizers the whole tractor just moves around. So now let’s talk about walking, 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. If you go to the neurology ward of the local children’s hospital, you might find a child with a paralyzed quadratus laborum, 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 double 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 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 patients, which I think you alluded to earlier, that the person is way too stiff and there just crushing themselves. The third element to 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, in other words they shear the knee, and see micro-movements 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 which 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 the micro-movement and laxity that triggered their pain, but you have 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 let’s try a pec/lat compression strategy and see of that works, so in other words we play with the bracing strategy to control the pain causing joint micro-movements, anyway there are three quantitative and measurable explanations of why core stability and core athleticism and tuning is nonnegotiable.

– [Dr Sebastian Gonzales] Okay so when people choose their core programs, I know probably a lot of people are on the other end thinking I’m going to go pick some stuff off of YouTube right now, is there are criteria that they should be looking for when they choose an exercise for the core or do you have some suggestions on that?

– [Dr Stuart McGill]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 diagnosed now a little bit of instability, as 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 try 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 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 Back Mechanic really gets, it’s 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 are out of pain, but they have a history of pain, we won’t go back and trigger the original offending instigators, but now they have to judiciously create a progressive program, they may incorporate the big three, but then we would add more stabilization work for sure, but again your listeners might find this interesting, there’s 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 new 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 to cut a little bit harder because proximal stiffness is greater so that muscle activation is creating more athleticism distal to the hip joints and shoulder joints propelling the arms and the legs, so again there is wheels within wheels, as you know my never ending source of fascination and entertainment and everything else for the past 32 years.

– [Dr Sebastian Gonzales] Yeah, with those people, you said there is a subcategory then, because everybody on the other end is probably thinking I wonder if I’m not one, I wonder if my back pain could be lucky enough to where it feels good after these exercises, what type of symptom patterns do those people have, or have you recognized anything that they have in common?

– [Dr Stuart McGill]Oh what a beautiful question, you know, we have got to syndicate you, you are good at this. Well yes the answer is, what I would ask people to do is 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 do major reps and sets, maybe do three 10 second holds, another three 10 seconds, and then another three 10 seconds, and then stand back up again, if the patient now recalls their previous baseline, they will know if they are better or worse, if they just got better, beautiful, we just found a 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 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 time.

– [Dr Sebastian Gonzales] Okay, I guess my question further on that note is, if the stand up and there on pain medication or some type of thing that numbs the pain, they can’t assess it right?

– [Dr Stuart McGill]It’s better not to be on pain med is of course, any time you’re registering pain, so one of the instructions to any patient coming to see me, is try and not take your pain meds on the day of the consultation. So I’m getting a very true read of therapy and sensitivity.

– [Dr Sebastian Gonzales] Okay, so you mentioned holding for 10 seconds, and I saw you put some stuff out there before on endurance versus strength, the terms at least in regards to core, why do you suggest 10 second holds, because I know people do glorification of holding planks for 10 minutes now.

– [Dr Stuart McGill]Will that’s not to get people out of pain, that’s 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, the first reason, why 10 second holds, well you’ll find that some people get back pain because of muscular ache, when you do the big three, virtually any isometric exercise, the muscle contracts and goes into a turner that clamps down the capillary bed, so the internal blood supply of the muscle is shut off, once you go into an isometric contraction like that, so that will create back muscle cramps in some patients, but what we found, we measured with near infrared spectroscopy, which is instrumentation that measures blood oxygenation and muscle, hemoglobin and myoglobin in the muscle, and it starts to drop off rapidly in oxygenation after about eight seconds, so that’s why we release the muscle every 8 to 10 seconds to reperfuse with oxygen and minimize the chance of back muscle cramps in an already back pained person, the 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’s when you broke form, so we measured this and proved it in autoworkers and Hydro alignment, guys who climb hydro poles, we measured guys chroming Chrysler car bumpers, which weigh about 75 pounds, do you think it was the strong ones or the moderately strong ones that got more instances of repeated back pain throughout the year?

– [Dr Sebastian Gonzales] It was probably the strong ones wasn’t it?

– [Dr Stuart McGill]It was the strong ones because, they would lift the car bumpers no problem for a few reps, but then they get tired faster, and when they get tired they broke form, and that’s when they hurt their back, but the other guys who were a 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 nuance to that being strong or durable, it’s the ratio, if you have a lot of strength and your work 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 do 10 Olympic lifts, and when you look at the 10th Olympic lift, it’s 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 work with, I worked with some pretty good ones, but they never ever train to fatigue, but that’s when you get hurt when you’re handling high loads, so that’s why the insurance 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, so you know that there are certain patterns of movement that back pained patients need to follow to avoid their particular pain triggers, well sometimes if a little bracing makes them more resilient and takes the pain away when their 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 in strengthening the back, in design of the program, it’s by designing an endurance back program, and of course they get stronger as a side-effect, but that’s not what is programmed.

– [Dr Sebastian Gonzales] Okay Stuart, I’ve got a good one to follow up on this. I’m going to quote what a lot of people say to me, I have a weak low back, can something like that address issues were people have weak low backs?

– [Dr Stuart McGill]Well look, it depends, if that doesn’t surprise you. When a person comes and says I have a weak low back as an excuse, then I will try to detect that, and I will try to figure out a way how can I empower this person, I’m not going to tell them, your weak and you’re weak minded and all the rest of it, no, I’m going to detect that they probably have a lack of confidence, because the experts have told them to do things in the past that have only hurt them, so all they have known is failure, I have to figure out a way to empower them, and it’s usually proving to them that I can take the pain away, so I will create their pain, I’ll say to them, show me what causes your pain, and then immediately if I can define the pain mechanism, I will try to mitigate it somehow and show them you just tuck your pain away, now that may involve a little bit of strength, and I’ll quote my good friend powerful Pavel Sasoli, strength is a skill, and when you show a person how to use their body, all of a sudden they unleash what strength they had, but they didn’t know how to unleash it. So I have a weak back, figure out the way they can start moving and training in a way that doesn’t trigger their pain and gives them some confidence that they can continue the progression, and get what we would then call sufficient strength, and 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 America football, hockey, baseball, UFC, it’s not the strongest two wins, the strongest guy tends to push his punches with muscle, their slow, it’s the elastic fighter who can snap and land with precision who is the deadly UFC fighter, so it’s so interesting, just try and achieve sufficient strength skillfully, and in a resilient way, so figure out why they’re saying I have a weak back, and go with it accordingly.

– [Dr Sebastian Gonzales] I feel like that is a perfect answer to start closing the podcast down, but I can’t let you go until I hear what you personally do for your back, or spinal health?

– [Dr Stuart McGill]Well the answer to that, and I wasn’t anticipating that one at all, very few people ask me that, 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 putting on a performance enhancement 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, I can’t be a skinny old man working in and asking do you mind handing me that kettle bell, it doesn’t work, but I also have quite an injury history myself, and then also I’ll reveal I’m in my 60s, so what I do for my own back has radically evolved over the years, there’s no question, I played football and hockey as a young man, and I played old-timers hockey into my 30s, so I was definitely training for performance then, and I paid for it, I even did a little bodybuilding in my late teens, and then tried for maximum strength in personal bests and all the rest of it, then in my 40s and really into my career as a professor and a clinician, I had to back off on that, I got a bit soft, but I did my core work, the big three, a little bit of hip mobility, shoulder mobility, et cetera, now I train not to lose any more, I don’t want to gain any more, so I do balance training, I do foot work, which living in Canada you have to recover from falls on slippery surfaces, I spent a lot of time in the woods crawling over slippery rocks and logs and that kind of thing, so I have to keep a reasonable amount of mobility, I work on grip strength, and my grippers haven’t declined very much and they come in darn handy, I can also tell you I’ve had hip replacement, so I do a gluteal reprogramming exercise routine every day, a little bit of hamstring and salas lengthening, that’s about all that I can think of at the moment, but it’s certainly been a phase through my life.

– [Dr Sebastian Gonzales] I can’t get past that somewhere out there there’s pictures of your bodybuilding competition.

– [Dr Stuart McGill]I never went into a competition no, I was just interested in American football through high school and university, so I had to keep the beef on, and that was really the way to do it then. I’ll tell you, in those days it didn’t help me to attract women, I’ll admit that

– [Dr Sebastian Gonzales] That didn’t help, I thought you just wore a tank top in the summer in Canada and had the pythons hanging out?

– [Dr Stuart McGill]I’ll tell you that didn’t work for this fellow at all, but I ended up with a pretty good wife though, I don’t know what on earth she found attractive, but anyway.

– [Dr Sebastian Gonzales] You’ll probably be happy to hear I don’t think that works much in America either. So how can everybody reach you, I’m going to put the show notes in the show notes for your Back Mechanic book that everyone should definitely get, how can they reach you if they want to find out more about you and the stuff that you put out?

– [Dr Stuart McGill]Well 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 it has links to our books and videos, there’s a lot of information on there though, there’s quite a number of free videos, links to some YouTube work, a few articles, yeah I guess that sort of thing, there’s also a list of providers as well, and we don’t take that designation lightly, I refer to our network of providers, I’ve worked with them all, they’ve all taken my courses, and I’ve personally worked with all of them and make sure they are very competent in performing an assessment that will reveal the precise cause of the person’s pain, and they know what to do to coach the person and empower them to desensitize their back issues, and in some cases for the athletes, build that resilience and performance once again.

– [Dr Sebastian Gonzales] Also, is there anything you think we missed on here that anyone needs to know?

– [Dr Stuart McGill]I don’t think so, if this is my last bit, I’m going to say something Sebastian, you are good at your job, I think Joe Rogan better look out, you did a phenomenal job on that.

– [Dr Sebastian Gonzales] Well thanks, I’ll be honest with you, some of the people I interview, I’m a little intimidated, I don’t know if I can do this interview well, so it takes me a little while to listen up, it’s not something that I’m developing overnight, my first podcasts were terrible, so thank you for the praise.

– [Dr Stuart McGill]Well we all wish we could have those back, I was out driving this morning and I drove by the church, and you know how churches have 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?

– [Dr Sebastian Gonzales] Yes it is, I don’t know who makes those things, but they have good sayings ON those things. Well cool, thank you for coming on, I will put all your contacts and all the links in the show notes, and sounds good, thank you Doctor.

– [Dr Stuart McGill]Yeah fantastic, thanks for all of that, and hope your listeners obtained some value.

– [Dr Sebastian Gonzales] Awesome, all right everyone that was Doctor Stuart McGill, always great on podcasts, I always like to hear his, he does have a lot of information out there and other podcasts, again the reason why I thought I would include this question for you guys, it’s mainly because we still have a lot of patience misunderstand back pain, and even when I referenced some of the other podcasts, which were amazing by the way, they still didn’t understand it, because I think it was a little too technical, so I thought I would go down a questioning series that we get asked a lot of as healthcare providers, I will put this on the website, so it’s P2sportscare.com/podcast is where you can find the show notes, and you can find all of the stuff for Doctor McGill and what he spoke about on the podcast, if you haven’t gone to iTunes are ready, please go to iTunes and subscribe to this, and by the way, I’ve barely found out, I was looking and trying to find out where I can find reviews for myself, or actually reviewing other podcasts, because 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 it took a little bit of digging, so if you don’t know how to review the podcast, just go to Google and put in how to review a podcast, and it will take you down the question series, so that’s how you do it, I greatly appreciate any feedback good or bad you have on that, 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.