Peter Attia MD287 ‒ Lower back pain: causes, treatment, and prevention of lower back injuries and pain
CHAPTERS
- 0:00 – 13:39
Peter's history of recurring, debilitating back pain
Peter recounts back pain episodes at 21, 24 and 27, the last leading to a free disc fragment at L5-S1 and two surgeries. Stuart McGill recognizes the pattern of an open fissured disc bulge and explains how it fits Peter's story.
- •Three episodes roughly every three years, each lasting about two weeks
- •The third episode progressed to burning nerve pain in the left foot
- •Surgery found a roughly five-centimeter free fragment from the L5-S1 disc
- •Peter's MRI looks terrible at 50 yet he has little pain
- •Stuart identifies a left-sided open fissured disc bulge from the story
- 13:39 – 24:48
Anatomy of the spine, discs, facets and the instability cascade
Stuart walks through spinal anatomy: a flexible rod that can stiffen, discs as layered collagen fabric holding a pressurized gel, and facet joints that guide motion. He describes how disc damage shifts load to the facets and how painful episodes fade as joints stiffen.
- •Discs provide flexibility and stiffness without needing huge musculature
- •Delaminated collagen lets the nucleus seep out or form a fragment
- •Facet joints thicken and take more load after disc injury
- •Facet pain is an ache that takes months to wind down, versus weeks for disc pain
- •A damaged level shows shearing motion, the marker of instability
- 24:48 – 31:30
Acute versus chronic pain and whether discs have nerves
Stuart explains that he does not categorize pain by duration and that most supposed chronic pain is repeated insults. He then describes how a healthy disc has no nerves or vessels, but a damaged disc grows them.
- •Most so-called chronic pain is repeated acute attacks through the day
- •True chronic pain involves a changed, traumatized brain
- •Healthy discs lack nerves and vessels because internal pressure kills sprouts
- •Damaged discs grow vessels and nerves, then eventually gristle and lose pain
- •Staying stacked and tall keeps the nucleus from squirting out
- 31:30 – 48:34
Why L4-L5 and L5-S1 take the brunt, and how loading adapts the spine
Stuart explains that the thick lower vertebrae tolerate compression but not bending, and that disc shape and facet orientation add risk. They discuss load versus deformation, and how powerlifters and yoga practitioners adapt differently, producing posterior versus anterior bulges.
- •Thicker lower vertebrae are stress risers under bending
- •Larger spines have limacon-shaped discs that tolerate twisting poorly
- •Open facets in gymnasts and dancers link to spondylolisthesis
- •Peter uses concrete and rebar to illustrate tension and compression
- •Powerlifters bulge posteriorly; very flexible spines bulge anteriorly, so training types shouldn't be mixed
- 48:34 – 56:31
What caused Peter's first injury: delamination and the immune response
Stuart reconstructs how years of loading delaminated Peter's disc from the inside out until the nucleus met the immune system for the first time. They discuss anti-inflammatories versus letting inflammation clear extruded material, and Peter's use of a muscle relaxant.
- •Hockey players' yearly MRIs showed how a training change altered the spine
- •Delamination accumulates inside while the outside looks pristine
- •Nuclear gel meeting blood triggers an intense inflammatory lockup
- •Recent literature suggests inflammation helps resorb the bulge, so anti-inflammatories could go either way
- •Peter finds a baclofen-type relaxant helpful for breaking muscle tension
- 56:31 – 59:37
Posture cues for Peter's current aches
Stuart guesses that Peter's current low-grade aches come from micro shear movement and lost disc height. He proposes postural cues and a prone breathing technique as a challenge to avoid the muscle relaxant.
- •Low-grade aches differ from the heavy acute attacks of youth
- •Stand tall with ears over shoulders and shoulders over hips to relax the erectors
- •Soften the knees rather than ramming them into hard extension
- •Lie prone and melt into the table with each exhale
- •Peter agrees to visit Stuart on his next Toronto trip
- 59:37 – 1:15:16
The McGill Big Three and how stability creates performance
Stuart says the Big Three are not for everyone and that assessment leads the solution. He explains proximal stiffness, using a backhoe analogy, and describes the curl-up, side plank and bird dog, along with their pain relief and performance effects.
- •The Big Three are not appropriate for everyone, such as very stiff body types
- •Proximal stiffness stops energy leaks, as with a backhoe's stabilizer bars
- •Modified curl-up, side plank and bird dog spare the spine
- •Ten-second repeated holds build endurance without fatigue
- •Training raised core stiffness and punching force in athletes
- 1:15:16 – 1:25:34
Energy leakage, longevity, and the woman who feared leaving her home
Peter links energy leakage to injury risk and longevity rather than just performance. Stuart tells a story of coaching an older woman through a hip-hinge squat on a stage, and argues clinicians should learn from elite athletes.
- •Natural stability allows force transmission without leakage
- •Stability matters for preventing injury when climbing stairs or carrying loads
- •Stuart taught a woman in her seventies to rise from a toilet in three repetitions
- •Technique learned from elite lifters helped her avoid leaving her home
- •Elite athletes give insight that can be brought down to others
- 1:25:34 – 1:37:09
Deadlifts, squats, and training for sufficient fitness
Peter says he is conflicted about deadlifting as an audit of stability versus its risk. Stuart explains microfractures from personal bests and proposes goals such as playing on the floor with grandchildren, using alternatives like backward hill walking and grip strength.
- •Student fitness data showed a decline in the late '90s and a recovery
- •Peter values deadlifts as an audit but uses single-leg alternatives
- •Personal bests cause end plate microfractures that need about a week to heal
- •Stuart reframes goals around playing with grandchildren at eighty
- •Sufficient strength, mobility and endurance beat maximal lifts; grip strength matters
- 1:37:09 – 1:49:18
Psychological trauma, empowerment, and understanding the mechanism
Peter asks about the psychological toll of back pain. Stuart tells stories of a suicidal patient and a former police officer who were helped by identifying the mechanism of their pain, and cites the clinic's follow-up data.
- •A patient told his pain was in his head was suicidal until Stuart found his trigger
- •Coaching muscle control stopped the movement that trapped the sciatic nerve
- •A police officer felt a pamphlet on living with back pain destroyed his career
- •Showing a mechanism and strategy empowers patients
- •Two-year follow-up found 95% of those told they needed surgery avoided it
- 1:49:18 – 1:56:10
Why assessment is rare and training clinicians through BackFitPro
Peter asks which providers best pursue mechanistic understanding. Stuart says no billing code exists for assessing back injury mechanism and describes his BackFitPro Summit course and exam for clinicians.
- •Mechanistic thinking depends on both the individual and their training
- •There is no billing code for assessing back injury mechanism
- •Stuart's clinic allotted two hours, later three, per patient
- •The Summit course is 50 hours online plus three days hands-on, with an exam
- •Passion matters more than the clinician's professional background
- 1:56:10 – 2:11:22
When surgery is appropriate and virtual surgery
Stuart explains virtual surgery, which mimics surgery's forced rest while retuning mobility, stability and movement skill. He lists red flags, then describes cases where surgeons do best: heavy stenosis, myelopathy, trauma, and some spondylolisthesis, while arguing nerve pain is not an automatic surgical indication.
- •Virtual surgery mimics post-surgical rest and retrains movement
- •Red flags and patterns that don't fit are referred back to a physician
- •Surgeons are at their best with heavy stenosis, myelopathy and trauma
- •Degree of slippage isn't the deciding factor in spondylolisthesis; assessment is
- •Sciatica in NHL, tennis and UFC athletes was managed without surgery by modifying movement
- 2:11:22 – 2:20:33
Tarlov cysts and what MRI cannot show
Stuart describes finding a Tarlov cyst through directional nerve-tension testing before consulting imaging. He then explains how MRI is a static picture that misses dynamic instability, using whiplash patients studied with video fluoroscopy.
- •Tarlov cysts are often drained but tend to come back; a Dallas surgeon is referred to
- •Stuart reads MRIs only after assessment informs what to look for
- •Whiplash patients were called pain magnifiers because MRIs showed nothing
- •Video fluoroscopy showed a clunk where rotation stops and shear begins
- •Deep neck flexor activation arrested the clunk in most people
- 2:20:33 – 2:26:54
Muscle bulk, stiffness, and why inactive people can hurt
Peter relays a surgeon's observation that his bulky back muscles protect him while an inactive patient with pristine discs is in pain. Stuart responds that hypermobility, muscle bulk and stiffness matter, and that arthritis can stabilize a joint.
- •Former Mr. Olympia competitors ache after losing muscle bulk
- •Regaining muscle adds controlling stiffness and relieves aches
- •Stuart suspects the pain-ridden patient is a mobility-focused, unstable person
- •More pillows in bed correlates with more joint instability
- •Arthritis can stabilize a joint and relieve pain
- 2:26:54 – 2:45:19
Advice for young people, resources, and getting a consult
Stuart discusses how hard it is to motivate young people, and Peter explains how his year-long injury changed his behavior. Stuart points to his book Back Mechanic and the BackFitPro clinician directory, and shares how retiring from a sitting job improved his health.
- •Motivating a 30-year-old to walk and sit upright is hard
- •Peter calls his third episode the best worst experience of his life
- •Back Mechanic teaches a self-assessment because no nonspecific back pain exists
- •Stuart sees patients only after they have read the book
- •BackFitPro lists certified and master clinicians
