Peter Attia MD287 ‒ Lower back pain: causes, treatment, and prevention of lower back injuries and pain
EVERY SPOKEN WORD
130 min read · 26,387 words- 0:00 – 0:30
Intro
- SMStuart McGill
Ultimately, what we're trying to do is to empower people in showing them they have the ability within themselves. They just need to understand the mechanism. And most of the time, they are able to mitigate the cause and then build a robust foundation.
- PAPeter Attia
[upbeat music] Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Attia. [upbeat music]
- 0:30 – 14:11
Peter’s experience with debilitating back pain
- PAPeter Attia
Hey, Stuart. Thank you so much for joining me today. Um, wish we were doing this in person 'cause there's so much I'd love to get into, but I have a feeling we're gonna be able to do a pretty good job remotely, and I get the sense that you're very well-versed at communicating your ideas in two dimensions rather than three. So anyway, uh, great to make your acquaintance today.
- SMStuart McGill
Yeah, same here, Peter. I've been looking forward to this day for quite a long time. Um, at some point, I'm going to thank you for writing your book. You are one of the few people on this planet who, uh, A, I allowed, and B, I did change my behavior. So, uh, thank you very much for that. And, uh, let's, uh, let's see where we go today.
- PAPeter Attia
I don't... You're, you're gonna leave me hanging with that. I'm, I can't... I'm, I'm curious to know what it, what it was. Uh, were you a smoker who somehow stopped? No, I'm kidding. I, I... What was it?
- SMStuart McGill
[laughs] Well, uh, I, uh, couple of years ago, uh, my family doc right now is one of my former students. This is, this may bring a smile to your face. I don't remember this, but apparently, when he was an undergrad and he asked me to write the letter of recommendation for medical school, I told him, "Of course I'm gonna write this, because one day I'm gonna need a, a good doc when I'm an old man." Well, wouldn't you know? Anyway, so, uh, we did my bloods, and I was just on the edge of, uh, what the cardiology association is saying, needing, uh, Crestor or Lipitor or something like that. And this doc knows me well enough. Uh, he said, uh, "Let's run the experiment." And, uh, so we're, we're, we're doing it for three months. I'm, uh, living Peter Attia's life. And then I love to work hard physically and finish it off with a beer, which of course, six days out of seven, I'm denying myself of that. But, uh, long story short, I have my bloods done again in two weeks, and we'll see if this three-month experiment has, uh, uh, paid off. He says, "No, it's in your genetics. You're not gonna move the marker." But, uh, my sister says, "Oh, no, you, you will." She did. So, uh, anyway, uh, thanks and no thanks, but, uh, I think I'm sleeping a little bit better. I think I'm a little more mentally sharp, but we'll see over the next hour if [laughs] that's true. But anyway.
- PAPeter Attia
[laughs] Well, we, we can revisit this. I'll, uh, I'll, I'll reserve the right to come back and say m- maybe, um, maybe you don't have to be, uh, quite as restrictive and, uh...
- SMStuart McGill
[laughs]
- PAPeter Attia
But I, I, I, I, I, I, I don't necessarily believe in denying all the, all the pleasures of life. Uh, and I-
- SMStuart McGill
Well, there were some paragraphs-
- PAPeter Attia
And I, and I certainly don't, uh... and I don't deny them myself, so, um-
- SMStuart McGill
There were some paragraphs in your book that just burned into my memory. The, the, the day you allowed yourself some french fries and I thought, "Oh, okay, I'm, I'm gonna stay with the plan, come hell or high water." But anyway, there you go. [laughs]
- PAPeter Attia
Well, I'm, I'm gonna start with a story, um, Stuart, because, uh, it's a story that some of the listeners might know but, but, uh, you, you probably don't know in this level of detail, and it sets the stage for why this is a topic that is of great interest to me personally. Um, and of course, by extension, I, I suspect that there are very few people who are going to listen to us today who can't relate to the subject at hand. So, uh, the very abridged version of the story is, um, I, I grew up, uh, doing all sorts of really aggressive things and really took to powerlifting when I was probably 14, um, and found myself reasonably strong for a little scrawny kid. And between about the ages of 14 and 19, I really, really pushed. Uh, couldn't bench press to save my life, but seemed pretty strong in a squat and deadlift. Um, and kind of ignored any claims my parents made that maybe I was doing a little too much. Um-
- SMStuart McGill
[laughs]
- PAPeter Attia
And, and, um, uh, truthfully and sadly, had no formal instruction. There was no... You know, I was just watching the other grown men in the gym who were insanely powerful, um, and, and sort of just trying to replicate what they were doing. But, but truthfully, had no sense of what I was doing. Anyway, fast-forward, um, I am 21 years old. I'm rowing at the time, so rowing crew. And for the first time in my life, I experienced lower back pain. And, um, this really rocked my world because I always thought that people who got lower back pain were people who did nothing. I... it... I, I never really thought someone who was as active as, as I was could get it. And for about two weeks, Stuart, it completely d- it completely disabled me. Um, you know, I could sort of get around, but barely. Um, and being a college student, I didn't really have any resources. I didn't know what to do. I, I was able to get to... This was actually, I think it occurred during the summer, so I didn't have classes, but, you know, I had to stop rowing, I remember that, and otherwise, I was able to work Um, it went away, and I thought everything was fine, and I never thought about it again until the summer three years later when I was 24 years old. And I remember exactly where I was. I was in San Diego riding my bike up the steepest hill in San D- San Diego, which is a certain patch of a mountain called Mount Soledad. And, uh, there's a, a s- a section of this thing where you make a sharp right turn, and at that moment it's about a 25-degree pitch, [lip smack] and s- I experienced this very sudden pain in my lower back, and like a typical idiot, just kept on pushing and climbing to the top and finished my ride, but then went on to experience the exact same thing, Stuart. For two weeks I was debilitated, couldn't do a thing other than sort of lay around and walk. But then it got better, and I kinda just forgot all about it. And then fast-forward to the big one. It's now-
- SMStuart McGill
I'm doing pattern recognition here, Peter.
- PAPeter Attia
Yeah. Yeah.
- SMStuart McGill
[laughs]
- PAPeter Attia
So the big, the big one occurred in my third year of medical school. I'm now 27 years old, and the remarkable consistency of this is not lost on me. It is every three years by the summer, the summer of '94, '97, and 2000. And I'm riding my bike from class to the gym and, um, I get to the gym, hop off my bike to lock it up, and all of a sudden I feel that same familiar de- just horrible pain in my back. [clears throat] But this time it's a little worse than the, the previous two bouts, and it was so bad that I did something I'd never done before, Stuart. I decided not to go into the gym. And so I just slowly got back on the bike and limped my way back to my apartment and wasn't able to do anything other than just sort of lay in bed. I assumed I'd be fine the next morning, [lip smack] and I woke up the next morning and actually couldn't get out of bed. Uh, luckily my roommate and I each had separate phone lines, so I was able to call him [clears throat] from my room. [clears throat] And, uh, so began the-- a really painful journey over the next couple of weeks where the only place I could find relief was bent at 90 degrees forward, where I would basically stand and bend over the nurses' station. By this point, I was doing my clinical rotations, and as every good gunning medical student knows, there was no way I was going to miss a day of this. So [clears throat] I would drag myself into the hospital each day and somehow manage to get through this. The nurses took pity on me, and so did the residents, and they were injecting me full of Toradol, [lip smack] and this went on for a month. And, um, and it got so bad that eventually the pain progressed from just being debilitating in my lower back to a nerve pain that felt like my foot was being skinned. And it was interesting in that the pain in my lower back started to subside as it was replaced by the feeling of my left foot being skinned from the bottom. Um, uh, I'm not gonna go into the more details of the story 'cause it gets worse and worse before getting better. But needless to say, um, I, I have a graduate degree in back pain. Um, there's a happy ending to this story, Stuart, which is after this partic- this bout, wh- uh, c- which occurred when I was 27, which took a year to resolve, um, I made it kind of a mission to figure out what was going on. And I'm not suggesting that I have, but I know so much more now than I did then. And fortunately, um, any time I've had back pain since then, it has been a very, very short-lived experience. Um, I'll plant one last seed before we jump into this, just for both you and the listener, so that we can come back to it. [lip smack] If you are to look at an MRI of my spine today, um, you would ask yourself, maybe not you because you're so well-versed, but a reasonable person would look at an MRI of my spine today at the age of 50 and say, "How does he walk?" Like, "H- uh, this person must be in so much pain he doesn't know his name." And yet I can tell you for the most part, I'm not at all. Occasionally, I get a little tight in my, you know, my lower back musculature, but you know, I don't have radicular pain. I d- I'm not r- I'm not limited in anything I do. Um, [clears throat] again, suggesting that the correlation between the image of my back on an MRI and my symptoms, uh, is pretty light. Okay, so with all that as a backdrop, um, the fact that you're smiling so much as I tell you this story, i- it tells me not that you're taking pleasure in my pain, but rather the familiarity of my story.
- SMStuart McGill
Exactly. I've been doing pattern recognition. There's only one thing that would account for the repeated acute episodes. In the interim between each one you were quite fine, then it shifted to a radicular pain, and now you're at the stage of your life where it's more a, a- an occasional grumpiness when you cross what we call the tipping point. So if you-- did the pain go to your foot, Peter?
- PAPeter Attia
Yes. It-
- SMStuart McGill
Did it go to your toes? Big toes or little toes?
- PAPeter Attia
No, it was actually really interesting. It was, it was a, it was a burning pain that was like the bottom of the foot was being skinned. I should have-- I, I-- There's one detail I should have, um, uh, shared with you that might explain this. When I finally did have surgery, um, it, it, it turned out I had a free fragment that was about five centimeters long from the L5, S1 n- um, disc. So that free fragment had b- broken off.
- SMStuart McGill
Well, I was gonna guess this for you actually.
- PAPeter Attia
Yeah.
- SMStuart McGill
Now, I was gonna ask you which foot, and did it, uh... So the fifth root goes to your big toe. But anyway, you carry on. Sorry.
- PAPeter Attia
Yeah. And so, so basically, the really, really unbearable pain I was having presumably was because that free fragment was parked on the S1 nerve root. Um, and even though it ended up taking two surgeries to get that out, uh, and those surgeries ended up causing more damage that needed more repair, that turned into a journey of, uh, a thousand cuts, um- You know, I was on the, I was on the, I was on the road to recovery. But, but the radicular pain seemed to be directly a result of the, um, [lip smacks] S1 nerve root.
- SMStuart McGill
Right. Well, if, if you want me to react to that story a little bit, I h- I'm smiling because you told me exactly what the pain mechanism was. I knew it was a disc with an open fissured disc bulge. It would be on the side of your foot pain. W- was it right or left? So what, what, what foot was it?
- PAPeter Attia
It was left.
- SMStuart McGill
Okay. So you had a, uh, posterior left-sided biased open fissured disc bulge that would open and close as a function of the flexion postures, bending down to, uh, lock your bicycle. Uh, you know, you, you just gave it to me every single time, and then you were able to, uh, vacuum that in. It lasted for a couple of weeks. Now you're in the unstable phase. So if you want, I can, uh, show and, and tell... If you want me to show you. Do you want me to show you a couple of mechanisms?
- PAPeter Attia
It-- Yeah. In fact, what I was gonna suggest, even before we get into that, 'cause I wanna-- this is exactly where I wanna go, Stuart, is, um, let's walk people through the anatomy of the back. Now, I understand that there are some people who are gonna be listening to us, so whenever possible, do your best imagining somebody can't see us. But I think there's also gonna be enough people watching on video, um, and we'll certainly refer people to the video, at least for this section, in addition to some diagrams. But let's really explain to people what this remarkable structure [swallows] of the human back is, right? The stability, the flexibility, the mobility, the amount of nerves, muscles, and ligaments that are involved.
- 14:11 – 24:48
Anatomy of the back: spine, discs, facet joints, and common pain points
- PAPeter Attia
It's, um-- You could almost argue it's a miracle we don't get more injured, even though the frequency with which we do is intense. Take us, take us through the anatomy.
- SMStuart McGill
Right. I would almost argue the opposite, Peter. There was a television show that they were producing and asking various experts around the world, "If you got to re-engineer your particular area," me being the spine guy and, and, uh, on this thing, you know, they had a cardiac person, a endocrine system person-
- PAPeter Attia
Mm-hmm
- SMStuart McGill
... immune person, et cetera, "how would you re-engineer it and make it better?" And every expert said they couldn't. It was perfect. So everything in terms of systems in your body comes with a trade-off, and there are rules that manage the trade-off. So with that, I can start the, uh, anatomy. Uh, the spine is a series of vertebrae, as you know, forming a flexible rod. This allows us to dance and move and procreate, tie our shoes, and do all of these wonderful things. But at some point, you now, say, are picking your child out of the crib. You reach across the crib, gather your child, pull them in. If you had a flexible rod, consider a, a series of stacked oranges, it would fall apart. Uh, so you need a flexible rod that you can then stiffen to bear a load. You cannot push rope, but you can push stone or, in this case, an I-beam to, to bear a load. So all of these things are necessary to have a functional spine. Uh, what else can I say? Let's look at the structure of the discs, which are the, uh, fabric. It, it, it-- Uh, the disc actually forms the subcategory of a biological fabric. It's not a ball and socket joint. Could you imagine if we had vertebrae with ball and socket joints? Like, you would need an enormous musculature around that flexible rod to control all the ball and sockets. You would need an enormous motor cortex to coordinate all of these. You would be so wide you couldn't walk, you couldn't run, uh, et cetera. But we have this very slender torso because we have discs. Now, the stress-strain curve of a disc starts out with a little bit of a neutral zone in the neutral range, and as you approach the end range, the disc provides stiffness, a mechanical stop to motion. Fabulous. I didn't need all this complex musculature to do so. So the disc creates tremendous evolutionary efficiency in, in your spine. Um, let's see now. Either end of the torso strategically is a ball and socket joint. The ball and socket joints of the hips and shoulders are designed to create power. Power is force times velocity. So if you were to watch a sprinter sprint, the extensor muscles explode like a hammer hitting a stone, a stiffened structure. If they hit rope, they, you-- the hips would bounce and, ugh, you couldn't run anywhere. You can't even walk without sufficient stiffness, um, in the core. So, uh, I can get into, uh, uh, an interesting discussion of how stability works proximally to unleash and enable this distal, uh, athleticism. So in terms of anatomy, we have a flexible disc that is a fabric. That great advantage is the efficiency of your dimensions that I'm talking about. We're light, narrow in the waist, we can run, et cetera. The price that you pay, though, is being a structure of many collagen fibers. If-- Let's take my shirt, which is a fabric. If I wanted to delaminate the fibers, I would have to create stress-strain reversals back and forth, and slowly, we would debond the fibers. This is what happens to people's discs. They debond the fibers with too much load and motion simultaneously, and this is what you must have done as a younger fellow. But the concentric rings of collagen that are held together with collagen type X, the binding substance, uh, they hold a pressurized gel, which is this incompressible hydraulic fluid that creates the ball. That gets pressurized, but it's always seeking the weakness in the wall. If you delaminate the collagen fibers, then the nucleus seeps through, and in some situations, the fibers are pulled together and they, uh, create a fragment, as you descri- uh, described earlier. Or if it's an open fissure and contained underneath the posterior longitudinal ligament, there's a good chance it's going to get vacuumed back in, and off you go for another two or three years. Um, uh, I, I don't know how much... Well, I, I can talk about the nerves, I suppose. Uh, if you have a disc bulge, there is the spinal cord centrally behind the vertebra, and at each lumbar or spinal joint is a pair of nerve roots.
- PAPeter Attia
Sorry, maybe, maybe one thing we can talk about before that, Stuart, is the other point of fixation, which are the facet joints. So if, if-
- SMStuart McGill
Yeah
- PAPeter Attia
... anteriorly this structure is bounded and the vertebral bodies are stuck together through their sharing of the disc, on the back, we have these other joints that come from each of them called these facet joints. So yeah, why don't you-
- SMStuart McGill
Right
- PAPeter Attia
... talk a little bit about that?
- SMStuart McGill
I don't know if you can see those, but the facet joints are guiding of motion. So, uh, you can see as I'm flexing and extending and twisting this model spine, these are articular joints in the back that are guiding motion. Uh, what you will find if I... Uh, I, I know what I'm gonna find if I look at your MRI. At the level of the disc bulge, the facet joints will now be getting a little thicker, a bit more gnarly-looking. Am I, am I right? Because the facets almost always, two or three years after a major disc, uh, injury, they take much more load. As you... Th- think of, uh, air in your car tire. If you let a little air out of your car tire, it bulges on the road. It gets a bit sloppy to drive your car. You have to tune the pressure. Um, a- this is exactly what happens with your body. So when you lose the controlling stiffness of the disc, you get more work performed on the facet joints, and they wear a little bit faster than the adjacent joints, and they grow thicker. And facet pain is very different from disc pain. Uh, it's more of a, an ache. Uh, it comes on a bit more slowly. Uh, if you have a wound-up facet joint, it can take two or three months to wind it down work, versus a disc that, as you described, you can wind down in a couple of weeks. Um, but if I can show this as a model now, this disc is normal. This bottom disc, L5, is normal. L4 has been damaged. I'm just going to apply a torque to this spine. Do you see how m- the majority of the motion now is occurring at the joint that's lost stiffness? Think of it like a knee that has a damaged ACL ligament. It no longer has the guidance, and the rotation motion of the knee, which is normal, is now substitute with shearing motion. So shearing motion, uh, indicates it's the metric for instability. So now you can see the shearing instability, and now look at the work being performed by the facet joints at the level of the disc being damaged and losing stiffness. Now, those will get grumpy, and they will wear a little bit faster if you continue with the behavior that you did prior to. So injury and this cascade changes the rules a little bit. So initially, uh, the, the goal was to create power in the shoulders and the hips, and transfer it through a controlled spine. But now the game has changed a little bit. You're 50 years old. You will have a little bit of, uh, joint instability. It's more important now to create a muscular girdle around the, uh, joint that has lost a bit of stiffness. And for the next little while, uh, do your core exercises, develop a bit more muscular control, arrest the shearing motions, and, uh, by the time... But you and I are very similar, by the way. So I'm in my l- late 60s now. My pain is gone. So the joint has become so stiff, it's, uh, it's... I can still do everything I want to do, but the joint itself has, uh, stiffened up. And, and, uh, Professor Kirkaldy-Willis, the, the famous, uh, uh, Canadian spine surgeon, wrote a book called Managing Low Back Pain, and he described very well the process that, uh, most of us go through, the instability and the very acute episodes that come every two or three years that are very debilitating, to a muscular ache, and you wake up in the morning on one side with this ache in your back. But if you push one heel away or put a pillow under your waist or something like that, you can get rid of the ache. And then if you live a little bit longer and behave by the new rules, you're back to, uh, I, I don't have any back pain [laughs] now. And I can encourage that, uh, you will seek that, uh, relief as well.
- 24:48 – 31:30
Lower back injuries and pain: acute vs. chronic, impact of disc damage, microfractures, and more
- PAPeter Attia
Stuart, give us a sense of the, the prevalence of acute lower back pain episodes. So i- is it acute-- is an acute lower back pain episode defined as one that lasts up to some period of time, two weeks or something like that?
- SMStuart McGill
No, I, I don't define it that way at all.
- PAPeter Attia
Okay.
- SMStuart McGill
And you'll be surprised, I'm not the guy who can give you those statistics. I don't worry about those sorts of things. All I worry about is the people who come here and ask for help with their back pain. So I, I'm not out there doing population studies to track incidents. And even having said that, when I used to study that as a younger scientist, what is back pain? What's an acute episode? Is it sufficient to be debilitating so you don't have to work? I was a professor, I could have an acute attack and go to work. If I was a construction worker, I couldn't.
- PAPeter Attia
Yeah.
- SMStuart McGill
So even the definition of whether it was disabling or not gets lost. So I didn't really get into those statistics. Um, but having said that, uh, I don't categorize pain as being acute, lasting a certain period of time, and chronic, lasting a longer period of time. Because when we measure people here with back pain, very rarely do we find chronic back pain. It's almost always due to them repeatedly insulting their back with many acute attacks and offenses all day long. So they think they have chronic pain because it lingers. When we show them a strategy or whatever the, the treatment happens to be to stop the insults that occur throughout the day, all of a sudden their pain goes, and then they realized, "You know, I never did have chronic back pain." So chronic back pain to us is pain that is intransigent, unrelenting.
- PAPeter Attia
Mm-hmm.
- SMStuart McGill
Um, their brains have changed. They've been traumatized. That is chronic pain, and not always having a strong mechanical trigger. So, uh, that's how we-
- PAPeter Attia
Yeah
- SMStuart McGill
... separate chronic, uh, and acute. But the pattern that you described of the, uh, two-week disabling, terribly disabling pain you had, there's only one thing that that could be, and that was an open fissure disc bulge.
- PAPeter Attia
Yeah. Let's talk about the mechanism of the discomfort. So w- um, for example, is that disc actually innervated? Is the pain that's being perceived due to sensory fibers of the disc? Or is it the response of the body sensing that damage going into some sort of protective mechanism that is, you know, seizing all the muscles within the proximity of it?
- SMStuart McGill
It could be either or it could be both. Um, so here's how I would answer that. A healthy disc-- So get one here. And by the way, all these models that I'm using, highly biofidelic models are made by Dynamic Disc Designs. So when a disc is healthy, uh, you know, people say, "Well, d- what's the number one thing you can do to keep a healthy spine?" And I will say, "Keep your end plates healthy." And, and they, they wonder about that. You know? Don't damage their j- your joints. [laughs] Uh, as, as you wrote in your book, you, if you damage your knee ligaments, you will now, uh, have, uh, in your last decade, disabled mobility. That's, that's a fact. So it's the same with the spine. If you can look into the nucleus of this model-
- PAPeter Attia
Yeah
- SMStuart McGill
... you will see that there are red vessels-
- PAPeter Attia
Mm-hmm
- SMStuart McGill
... and yellow nerves. Now, there are all kinds of papers, "Oh, there's no nerves inside the disc." And then you'll read another paper, "Oh, there are nerves in the outer third." And then there are nerves all the way through. And the reason is, a healthy virgin disc doesn't have any vascular tissues going into it, nor does it have any nerves. Um, when you d- And the reason is, when you squeeze a disc, you build up tremendous intradiscal pressure that kills any kind of vascular sprouts or neural sprouts. It's a healthy environment containing the pressure.
- PAPeter Attia
Hmm.
- SMStuart McGill
When you damage the disc and you lose the ability to contain the high pressure, now all of a sudden, vascular sprouts grow in and so do nerves. So it's so unfair. You damage the disc, and now the body grows a hardware, more nerves, to feel [laughs] pain even more. And then eventually, uh, this just goes to a very fibrous, gnarly, uh, structure. Um, highly innervated, but now it, it just basically gristles to bone, and all the pain goes away. But you can see where the damage line-- If I can get the contrast there. Do you see those fibers posterolaterally on the right have delaminated? And if I squeeze the disc, then you see this. I'm going to squeeze and flex.
- PAPeter Attia
Yeah.
- SMStuart McGill
Do you see the fibers-
- PAPeter Attia
Yeah
- SMStuart McGill
... delaminating and allowing the nucleus to seep out? But here's the antidote, Peter. Stay stacked and tall, and I'm going to squeeze. The whole disc bulges in a diffuse bulging pattern, but nothing comes out of the delaminated, uh, uh, region. So there's a little bit of an explanation of why some studies will show an innervated disc and others show s- They're not innervated at all. It depends where they-- Think of where you get cadavers from. It's not young, healthy people dying and donating, uh, their body. It's almost always older people. So those discs are, uh, innervated unless they're horribly down the cascade, and they've gristled, and all the nerves have now, uh, disappeared once again. Is, is that what you were looking for in that answer?
- PAPeter Attia
Yeah, that's very helpful, and I, I was totally unaware of that, by the way. So that's, um, a, a, a very interesting and, as you pointed out, almost a very cruel adaptation, um, that is-
- SMStuart McGill
It is
- PAPeter Attia
... that is quite counterintuitive. L-
- 31:30 – 37:20
Why the majority of back injuries happen around the L4, L5, and S1 joints
- PAPeter Attia
l- let's talk a little bit about the curvature of the spine. What is it about the way we interact with the world and the curvature of our spine that tends to produce the majority of injuries at either the interface between L4 and L5 or the interface between L5 and S1?
- SMStuart McGill
Oh, what an interesting question. I'm, I'm thinking of several things that are going through my mind as y- as you, you ask that. Well, first of all, it's the thickest part of the spine. So if I was to take a thin willow branch and bend the willow branch back and forth, no stress. Tissues damage because of one metric, and it's strain, not the force applied, not the pressure, anything. It's just strain on the tissue that is the metric of when it's going to disrupt. So it's thin, the radial distance to the neutral axis, which is the axis down the middle of that thin rod that doesn't go into compression or tension.
- PAPeter Attia
Yep.
- SMStuart McGill
Uh, it's all very low. Now let's take a thicker stick, and we bend it, and it shatters right away because it's much thicker. So the bend-- Uh, and I, I'm gonna digress a moment-
- PAPeter Attia
Mm-hmm, mm-hmm
- SMStuart McGill
... go back to the flexible willow branch. It's wonderful at bending. That's what it's made for. But don't ask it to bear compression because it buckles right away.
- PAPeter Attia
Yep.
- SMStuart McGill
The thicker stick can bear tremendous compression, but it doesn't tolerate bending. So you look at the neck, very thin, uh, uh, small diameter vertebra. It's made for bending and mobility. Fabulous. But as you move down the spine and get to the bottom two, where the thickest is, they do not tolerate bending near as much as they tolerate compression. So there's the first, um, uh, anatomic feature that describes why the bending stresses are greatest at the thicker two joints, which are, uh, at the bottom. The, uh, other things that matter are the shape of the disc. So, uh, some discs are ovoid.
- PAPeter Attia
Mm-hmm.
- SMStuart McGill
And the bigger the skeleton, they tend to go to a limacon. So you have the spinal cord, uh, there and then the two lobes of the limacon. So the bigger the spine, the more limacon the disc becomes. When you twist a limacon, you create a stress riser right on the edge of each lobe. The bigger the person, you will see they don't tolerate sit-ups. L- l- look at YouTube. Who is the man who has the world record for consecutive sit-ups? Do you think he has a thick spine or a thin spine? [chuckles] You know?
- PAPeter Attia
Right.
- SMStuart McGill
You won't be a powerlifter. Uh, and, you know, having worked with, with, with some fa- fabulous powerlifters and, and, and strongmen competitors, uh, uh, not one of them does a sit-up. They, they, they train other things to tune their body and, and make it suitable to that particular, uh, training stimulation. So now we see that shape, thickness, uh, determines, uh, why, uh, L4 and L5 are, are the target. We know that they don't twist, uh, as well as a, uh, slender spine. Um, the facet joints are also very interesting as well. So some facet joints, since you brought those up earlier, uh, are orientated like that in the sagittal plane. Others are orientated more open, as we say. So if you look at a gymnast who, uh, and, and-- but by definition, me, I would never choose to be a gymnast. But you can tell, look at my facets, they're closed. I don't twist very well. However, when you flex forward and pull a load, those facet joints just glide past one another. So a gymnast, by definition, is someone who has a lot of mobility in their spine. You will see that their facet joints tend to be open. Now, if I said to you, "Who among your patients gets spondylolisthesis?" The broken pars bone that holds the facet joint on, basically. You are going to say, "Well, dancers, gymnasts." The very people that had the mechanical advantage to twist, now when they go into extension, their facet joints are like shingles on a roof.
- PAPeter Attia
Hmm.
- SMStuart McGill
They bend the pars bone, creating stress strain reversals, and eventually that bone will, uh, get a stress fracture or a stress reaction, and if they keep going, full-blown spondylolisthesis. So there's all kinds of reasons, uh, I'm, I'm just giving you a few now, uh, as to why those two discs really are the, as an engineer now, stress risers. When I developed our, uh, in my PhD thesis, actually, a very detailed anatomical model of the spine computer model, uh, that, that hit home loud and clear. We did stress maps of real people moving. The pain and the injury was almost always at the site of the highest stress. And remember I said, the metric is strain that actually leads to, uh, uh, damage. Or it actually, if it's below the tipping point, it actually strengthens you. So we can have that conversation as well. What does not kill you makes you stronger.
- PAPeter Attia
Can you,
- 37:20 – 45:12
How the spine responds to forces like bending and loading, and how it adapts do different athletic activities
- PAPeter Attia
um, help folks, um... 'cause I, I [chuckles] there's a risk that you and I talking about this, because we're both engineers, will easily get into the weeds of compression strain, tension strain.
- SMStuart McGill
Right.
- PAPeter Attia
But for people listening to us who might not have that background, can you explain the difference between stress and strain, and what's-- what happens under tensile load, compressive loads, and things like that?
- SMStuart McGill
Yes. Um, l- l- let's not talk about stress and strain. Let's talk about applied load and deformation. So stress and strain are normalized to an area. We won't get into that. So if I apply a force to a structure, it deforms. So I'm applying a force, and I'm getting a deformation. Um, a mature skeletal bone breaks at a certain amount of deformation. A child's bone breaks at a different level of deformation. When you take a long bone and you bend it, the upper surface goes into tension. It's trying to pull apart. The lower surface goes into compression. Some biological structures are stronger in tension than they are in compression. Uh, a child is actually weaker in compression in a bending bone, and then the adult is weaker on the tensile side. So a greenstick fracture or a buckled bone in a young child would be very rare to see in an adult, as an example. So the behavior of biomaterials when you load them and how they deform, uh, explains a lot of injuries. So if you were to put me on the witness stand as, as people do occasionally to explain, "Is the damage that we see, Professor, in this MRI or in the cadaver or whatever, consistent with this particular mechanical alleged scenario, yes or no?" And that's how we reconstruct that. So, so tissues stress and strain, shear, bend, f- uh, tensile pull apart, uh, et cetera, and the, the, the deformation causes very specific types of, uh, damage.
- PAPeter Attia
So, so let's-- I, I'd like to use this example for people. Um, I'd like to use the example of concrete, which is every engineering student's favorite example, right?
- SMStuart McGill
[laughs]
- PAPeter Attia
So concrete is so strong in compression.
- SMStuart McGill
Right.
- PAPeter Attia
And yet in tension, it is so weak that we need to come up with a hack. How can we use this material to allow it to be both strong in compression and tension? Because the example you use is really a good one, right? If you have a bridge made out of concrete and you're driving on top of it, the bridge wants to deform, which means you're putting the top in tension. Well, that's great. It can handle it, but the bottom is in, uh... Oh, sorry. You're putting the top in compression, which it can handle, the bottom in tension, which it can't. So we put rebar in because the steel rebar is, of course, strong in tension. And, you know, the, the saying is the whole purpose of concrete is to hold the rebar in place.
- SMStuart McGill
[laughs] Oh, beautiful.
- PAPeter Attia
So when, when you, when, when you think about the spine, I think it's-- I, I want to dig into this a little bit more if you think it's helpful, right? So we, we take an axial load on the spine, and as you pointed out, the cervical spine is not built for tolerating a big axial load. It's designed more to provide movement. It's a, it's a joint for great flexibility. The lumbar spine, for all the reasons you just explained, is really designed around taking a large compressive load, and it's, in the process, sacrificed the mobility we have in the neck. But now let's talk about load in the context of flench- flec-flexion and extension, where you now do have within the disc, it's not just pure compression. It's actually-- Again, if you're in-- So maybe just even explain to people, flexion is bending forward. Extension is going back. So, um, now if you have an axial load in that position, which you could easily have if you're deadlifting something or squatting something, any given disc in that, especially in that lower spine region, can be under compression and tension at the same time, correct?
- SMStuart McGill
Absolutely. Uh, I, I have a little bit of a story on that, Peter. It's so interesting when, uh, I, I say I'm asked to give a lecture to a group of radiologists, and, and they describe very well all the subcategories of disc bulges and disc deformations and that kind of thing, but they've never been taught what the applied load nor the adaptation was. So let me paint a little picture here of the deadlifter. A deadlifter almost always gets a posterior disc bulge, as you, you may know. So a deadlifter is under tremendous compressive load, and if they, say, get to the bottom of where the hips run out of room, now the femur collides with the pelvis, and thereafter, the rotation takes place in their low back. Because the nucleus is under such enormous compressive pressure, remember this model, I had to bend it forward-
- PAPeter Attia
Yes
- SMStuart McGill
... to get the nucleus to squirt back. So you're creating a center of hydraulic effort-
- PAPeter Attia
Mm-hmm
- SMStuart McGill
... posteriorly. Now let's consider a person who's adapted their spine to do yoga. This is why I say please never mix up deadlifts and yoga. If you adapt your spine to be very flexible, you adapt the type X collagen holding the type one and type two, the heavy gristly collagen and then the elastic collagen, all those fibers together. A powerlifter wants them to be stiff and tough. They even wear an exoskeleton of a lifting suit to add-
- PAPeter Attia
Yeah
- SMStuart McGill
... even more stiffness and toughness. But the yoga master, that would be the kiss of death. They want nice, pliable, flexible spines. They soften the ground substance holding the collagen together. So when they bend forward, in contrast to the disc bulge going backwards, the front of the disc now buckles under, um, compression. So when a powerlifter typically-- Now, of course, there are very odd cases that are the exceptions. The powerlifter bends forward and crushes the disc bulge posteriorly. But when the yoga person or a very flexible spine, when they bend backwards, the collagen under compression buckles. So one gets a disc bulge from extension, and the other gets a disc bulge from flexion. Isn't that interesting? And it all depends on how they'd ada-adapted their spine. But my, my final point in all of that is don't mix up the adaptation schedules. So if you want to be a powerlifter, train your hip mobility, shoulder mobility, uh, but torso stiffness. Uh, try not to throughout the day do a lot of, uh, bending. Versus the yoga master, please stay away from the very heavy loads.
- 45:12 – 48:33
The pathology of bulging discs
- PAPeter Attia
What is the pathologic response to the anterior bulging of the disc? Because when, when you have that posterior bulge-- I guess we, we should have mentioned this earlier, and I guess it's worth stating. The spinal cord stops quite high up. The spinal cord does not run down the entire canal. It stops around L2. So for most of the people experiencing lower, uh, back pain vis-a-vis a herniation, the... fortunately, the herniated disc is not hitting your spinal cord. It is hitting the nerves that emanate from it. But again, there's so much real estate [chuckles] in that area. It's, it's, it's insane, right? Because you don't just have the nerve roots, you have the dorsal roots, you have all of these other tiny little nerves that are going to the facets and to the disc a-and to the vertebral bodies, the surrounding musculature-
- SMStuart McGill
Into your genitals and, uh, and into [laughs] everything that's important, of course.
- PAPeter Attia
That, that's, that's, that's absolutely correct, and I learned that the very, very hard way. Um-
- SMStuart McGill
Yeah [laughs] .
- PAPeter Attia
And, um, but tell me about the ant-
- SMStuart McGill
I'm not laughing, uh, again, uh, I'm, I'm laughing with the-
- PAPeter Attia
Yeah
- SMStuart McGill
... with the concepts here, not at the person [laughs] .
- PAPeter Attia
Yeah. No, no, it's, uh-- Yeah, we could tell some stories if we weren't on the air. Um, and so the, uh... Tell, tell me about the, the manifestation clinically of the anterior herniation in that f-very flexible person who's presumably greatly lacking in any spinal stability.
- SMStuart McGill
There, there probably won't be too much. Uh, they will go along with their merry life and, uh, uh, be flexible. Uh, the anterior bulge is not, as a rule, picking up any nasty nerve root compressions. And, uh, uh, on the grand scheme, Peter, it's probably a non-clinical issue for them.
- PAPeter Attia
Now, do those people still-
- SMStuart McGill
Until they wanted to lift, uh, you know, they, they were in an emergency situation now. They've come across a car wreck. Someone is in the car, and if they don't get them out, the car is going to explode. So we will all be placed into these situations at some point in our life, and, and whether or not we have the physicality to deal with them is, is another issue. But, uh, anyway, that, that's the downside of that particular adaptation and lifestyle perhaps.
- PAPeter Attia
And which of these types of injuries leaves a person more susceptible to the movement of the vertebral bodies in a slipped fashion, where we now get that spondylo-- What-- I, I, I can never remember which spondylo we're talking about. I think we're now talking about spondylolisthesis when the vertebral body on top moves relative to the bottom, correct?
- SMStuart McGill
Yeah, that's the interior one.
- PAPeter Attia
Yeah.
- SMStuart McGill
Sure. The answer is, uh, both. So a very flexible spine can get sheer translations just the way as a, as a stiffer spine can. Uh, so, uh, again, we wouldn't, uh, a priori, uh, judge and, uh, attribute one of those to the symptoms. The as- We, we always go by the assessment, and, uh, it could be either
- 48:33 – 59:36
The pathophysiology of Peter’s back pain, injuries from excessive loading, immune response to back injuries, muscle relaxers, and more
- SMStuart McGill
spine for sure.
- PAPeter Attia
I want to back up for just a second to the, the story I opened with and just kind of dig in a little bit more to the pathophysiology. So that very, very first bout of back pain I had when I was twenty-one years old, um, clearly the previous ni- eight years of-- or whatever, maybe seven years, eight years of really, really, really heavy lifting with kind of a blatant disregard for any technical kno-- Certainly the technical knowledge I have today about how to do these things correctly was completely absent. W- w- if you had to guess, and this is purely speculation, what was the process that led to that injury on that day, that manifestation? You know, if I had had MRIs examining my spine every year starting at the age of 13 until that first real insult at age 21, what would you have seen?
- SMStuart McGill
Well, I've done studies. Do you remember the NHL hockey strike a number of years ago?
- PAPeter Attia
Yeah.
- SMStuart McGill
Uh, so intere-
- PAPeter Attia
That was '94, wasn't it?
- SMStuart McGill
It was... Whatever year it was, uh, I, uh, they-
- PAPeter Attia
No, that was baseball. But anyway, okay. Yeah, anyway.
- SMStuart McGill
Well, whatever year it was, the younger players, they would go to Russia and whatnot and still, uh, make a salary, but the older veterans hung around, and I, I saw quite a few of them. You know, my shoulder colleagues see some [laughs] hurt shoulders. I end up seeing them for low backs. But it was a fabulous natural experiment, Peter, because they brought their MRIs every year. So say they were a 11-year veteran.
- PAPeter Attia
Mm.
- SMStuart McGill
I would look at their MRs from the first year-
- PAPeter Attia
Mm
- SMStuart McGill
... the second year, and then I would watch the cascade, and then I would say, "What happened in the eighth year?" "Oh, that was the year I started with a trainer, and the trainer believed in doing ass to grass squats with heavy weight." Aha. Look what happened to the, to the spine. When was the last time you saw a hockey player do an ass to grass squat in the NHL? In any case, that was a wonderful experiment to do exactly-
- PAPeter Attia
Mm
- SMStuart McGill
... to give us insight in- into what you're describing. And then the, the second layer of evidence that I would add there is I'm probably only of a handful of people in the world. We had a radiology suite in our, uh, cadaver lab, where we, uh, would take cadavers and apply very specific loading scenarios to it, and we would watch the cascade of damage over time. So both of those I'll put together and give an answer to what I expect I would've seen. So we would've seen a lovely young spine in 14-year-old Peter, I think you said you started.
- PAPeter Attia
Yep.
- SMStuart McGill
And then over time, we would've seen delamination from the inside out. So you were accumulating the delamination, but on the outside it was still pristine. Peter never knew. And the delamination would continue to progress layer upon concentric layer until that day when you were 21 or whatever, and the last, uh, layer was breached, and the nuclear gel extruded just a little bit.
- PAPeter Attia
Mm.
- SMStuart McGill
Now, when you were fertilized as a, an embryo or a, a blastocyst, I guess, still at that case, around the end of the first month, that little flat plate rolled, it's called neurulation, as you know, to create your primitive spinal cord. On that day, your mother has not given you an immune system yet. So now it's fused up. That nuclear gel has never seen the immune system yet.
- PAPeter Attia
Mm.
- SMStuart McGill
The end plates are pristine. It's never seen your blood, which is where the immune system is active. So now you're 21. For the first time, that nuclear gel comes out and sees the blood immune environment. It kicks off a hell of an inflammatory response, and you couldn't even move. It locked you up, and that's how strong and powerful that was. Takes two weeks to subside. Now, here's the rub. Uh, I don't know if you've been following some of the recent literature on anti-inflams.
- PAPeter Attia
Mm. I was going to just-- I was gonna ask you, would I have been better off if I had taken a prednisone taper or p- had some local anti-inflammatory therapy? Of course, none of these, uh, were at my disposal as a poor, dumb college kid.
- SMStuart McGill
Of course not, but I can't tell you how much joy I'm having [laughs] speaking with you because your logic is fantastic. And the answer is it could have gone either way.
- PAPeter Attia
Hm.
- SMStuart McGill
So the anti-inflammatory might have cleaned up the immune response and given you faster resolution. Or what the recent literature is showing, there's a purpose for that inflammatory response. It brings in the immune system and all the macrophages, et cetera, and it starts eating up the extruded material. Now, that process can go one of two ways as well.
- PAPeter Attia
Mm.
- SMStuart McGill
It can wall off what's extruded, and I think you've experienced that, into a free-floating body, or it, it, it chews it up, uh, digests it, for lack of a better word. And if-- I wish I knew you then because I bet I could have got you into, "Just lay on your tummy and breathe," and that vacuums in. In fact, we did experiments. We would create partial disc herniations, and then if you traction the spine and give a little bit of motion, all I do is wiggle your legs, you can vacuum in the disc bulge in a matter of two or three minutes. And people will say you, you, you know, you're, you're dreaming. No. [laughs] We've measured it in some types of subcategories. Uh, that's actually possible. So the answer to the, uh, inflams is at least some of the more recent data is showing dispense with the an- anti-inflammatories. Let the inflammatory response give the patient hell for two weeks. It's the best medicine for them in the long term because it is helping to reduce the, uh, the long-term disc bulge.
- PAPeter Attia
W- whether there's any basis to what I'm about to say, uh, I'm, I, I don't know, but I will just say that anecdotally, um, these days when I have A flare-up, and again, to be clear, these are really, really minor, Stuart. They don't interfere with anything I do other than if that were a day when I was gonna lift a little heavier, I would back off. But that's, but, but even that I, given that I don't squat or deadlift or do any heavy stuff like that anymore, it, it's kind of a non-issue. But what I find to be the most efficacious is not any sort of anti-inflammatory, but a light muscle relaxant, like a baclofen. So not a benzo or anything kind of sedating, but just something that c- allows the, uh, paraspinal muscles to sort of relax a little bit. Um, and frankly use that to allow me to do some deep breathing, and we're gonna talk about the three most important exercises that you prescribe at some point today, I'm sure. So it's, it's mostly just a vehicle to break the cycle of tension, but not the inflammation cycle. And, and truthfully, more of that is not because I'm familiar with the literature that you've just spoken of, but frankly because y- you know, there are downsides of taking prednisone as well, and we have to be mindful of those. And I, I don't want to suggest people shouldn't take prednisone, but one needs to be circumspect about the frequency with which they do it.
- SMStuart McGill
Okay. Here's where I think you are now, to answer the first question. I will bet this is where you are now. You've got a little bit of micro movement in a shear mode, so this joint isn't translating as it should. It's lost a little bit of height.
- PAPeter Attia
Mm-hmm.
- 59:36 – 1:12:46
The three most important exercises Stuart prescribes, how he assesses patients, and the importance of tailored exercises based on individual needs and body types
- PAPeter Attia
Um-
- SMStuart McGill
[laughs] Sounds good
- PAPeter Attia
... let's, let's, let's talk about those three exercises, Stuart. There are three exercises. Um, there's two of them that I've done consistently for quite some time. I really, uh, fancy them a bit. Um, the, the, the third one, the bird dog, I, I only do occasionally. Um, but let's go through the three of them. And, um-
- SMStuart McGill
Uh-huh
- PAPeter Attia
... is it safe to say that, that you... And, and just for the listener, we're going to link to videos of these, right? So, uh, you know, you're gonna do your best to explain them and provide the rationale for them, but ultimately a demonstration will be forthcoming through videos we'll link to in the show notes. Um-
- SMStuart McGill
Yeah
- PAPeter Attia
... but, but th- this is kind of like your, I don't know, your core nutrition, right? This is sort of the everybody should be doing this. You don't wait till you have back pain to do this. Is that safe to say?
- SMStuart McGill
No, it isn't. No, that, that, th- this is a, a bit of a myth and something that I've been fighting basically my whole career. Oh, McGill is the big, McGill big three.
- PAPeter Attia
Okay.
- SMStuart McGill
Uh, there are some people that are far too stiff, and this is not the mechanism of their back pain, and we don't need to go there. Um, have you ever seen the type of body build where they have a huge pneumatic cushion in front called a belly?
- PAPeter Attia
[laughs]
- SMStuart McGill
And it, it slaps on their thighs. It's that angelus of this. Do you ever see spine instability in, in, in that type of architecture? I don't.
- PAPeter Attia
Interesting.
- SMStuart McGill
Uh, so probably those people have difficulty getting on and off the floor. The, the big three is not for them.
- PAPeter Attia
Got it.
- SMStuart McGill
So th- there might be ch- ch-... Again, the assessment always leads us To the solution
- PAPeter Attia
Mm-hmm
- SMStuart McGill
And so, uh, no, the big three, uh, eh... Well, l- l- let me-- I, I need to have a discussion of what stability is in terms of creating resilience and performance. Then why are those particular exercises important, and then how to do them. If, if I could follow that logic line, Peter?
- PAPeter Attia
Absolutely. Yeah. Let, let's do it. And then the other thing, Stuart, if you wanna throw it in there, do you want to talk about some of the hallmarks of your assessment wherever it-
- SMStuart McGill
Sure. Yeah
- PAPeter Attia
... fits into that, into that, uh, into those three things? So, so t- ta- take it away. Yeah.
- SMStuart McGill
All right. So remind me, we're gonna talk about non-specific low back pain and how I think it's a myth and it doesn't exist. That will take us into the assessment.
- PAPeter Attia
Okay.
- SMStuart McGill
So let's go back to a basic discussion of stability. So if I was, uh... I might use an example of a backhoe. So a backhoe is a machine with a tractor, and it has an arm on the back to dig earth. The first thing the operator does is put down the stabilizer bars to lock the tractor into the ground because if you don't do that, you can't pull earth, you just pull the machine around.
- PAPeter Attia
[laughs]
- SMStuart McGill
So what's the human equivalent of that? We live in a linkage just like machinery. In other words, let's take the bench press muscle, pec major. Pec major originates on my rib cage, spans my ball and socket joint of the shoulder, and inserts on the humerus. So when I contract and shorten the pec major, it flexes my arm. So if I'm wanting to do a push or a punch, there it is. That's on the distal side of the joint. Proximally, that same muscle shortening collapses my rib cage towards my shoulder joint. So if all I used was the muscle that spans the joint, that isn't a very effective push. All I'm doing is collapsing my own linkage. Or as an engineer, we would say, "Well, we've just created an energy leak." So I'm now going to build proximal stiffness. So I'm going to lock my core, create stiffness through my torso, which is proximal to the joint. So now when I contract the muscle, 100% of the motion is directed distally.
- PAPeter Attia
Mm.
- SMStuart McGill
Now I've got my push. So what is the best, most efficient way to create a proximal stiffness? We searched for years, doing all kinds of tests of, uh, uh, every abdominal exercise you could think of, back exercises, twisting, Paloff presses, throwing things, et cetera. The three exercises that kept bubbling up to the top in the criteria of sparing the spine while you're doing them, because these people are hurting. You, you, you, you don't have carte blanche to load up their spine. Uh, a guaranteed stability or proximal stiffness. And it was later in my career that we found, um, there is a residual stiffness that occurs. So if you do the big three, and you are an NFL football team, if you do the big three prior to practice, you will run and cut just a little bit faster. So you're on the field, you run, and you cut. The stiffer the core when the hips explode into external rotation, you're now creating a, a, a faster directional change. So, uh, what were the muscles or what were the exercises? Um, a, a modified curl-up, which remember [laughs] and now I'm just gonna start a little bit of an assessment. I'm gonna take a patient, I'm gonna have them sit on a stool, and I say, "Do you have symptoms right now?" And let-- humor me and let's say you got. Now I'm going to say, "Drop your chest down. Does that cause your..." "Oh, yeah. My left toe is going numb, and I've got back pain." "Good. Bring your chin down." And they might say that'll increase their pain or decrease it, but the point is that posture created their pain. If that is true, when they lay on their back and they imprinted their back into the floor doing a Pilates roll-up, for example, uh, that would be their specific pain trigger. So it's not much of a therapeutic exercise, but when you say, "Put your hands under your low back as you're laying on the ground, lift your elbows, now hover up your head, neck, and shoulders, and we're going to propel the abdominal contraction. Breathe through pursed lips, and allow the diaphragm to become the athlete inside this barrel." So that was the foundation of the modified curl-up. Now, if the person has a rotator cuff, uh, issue, or we will hack it and make it, uh, tolerable. Um, then I would see people... Well, let's, let's take a, uh, a dumbbell or a kettlebell, and we're gonna raise it up laterally in the frontal plane like this for the side of the core. That would trigger pain in a lot of people, but, uh, I'll demonstrate all this if you want. Uh, but we could then do a side plank-
- PAPeter Attia
Yeah
- SMStuart McGill
... on the floor. The beauty of the side plank is only half the musculature is heavily challenged. The downside is heavily challenged, the upside is not. You've only got half the load on the spine. Very spine sparing. We prescribe it on ten-second intervals. Why? We use the Russian training science to show you build endurance through repeated ten-second exposures, not getting tired to the point where you break form
- 1:12:46 – 1:25:33
The significance of strength and stability in preventing injuries and preserving longevity
- SMStuart McGill
Just to finish that off-
- PAPeter Attia
Yeah
- SMStuart McGill
... Usain Bolt does bird dogs. So, you know, a- again, this is... Bird dogs are beneath people. Really? They should see what I see. [laughs] Anyway, I, I just wanted... That was the end of that story.
- PAPeter Attia
Yeah, no, I, I was just gonna add to it by saying I, I think that w- what, what I've become interested in as I've aged is looking at the greatest performers because I think that, you know, we t- there's no doubt that the best athletes have a remarkable natural talent that the rest of us don't have.
- SMStuart McGill
I've measured it, without question.
- PAPeter Attia
Where I think people miss the talent, what they're missing is a big part of the talent is the natural stability. In other words, it's the force transmission without the energy leakage. And when I contrast really good athletes with myself And I examine my athletic past. What is clear to me is that in everything I have ever done, despite all of my hard efforts, my lack of both natural ability and, at the time, coaching has meant that I have always suffered from an unbelievable amount of energy leakage. Whatever I have done, whether it's been, you know, you, boxing, swimming, power lifting, all of those things, um, what's-- You know, again, there's such a chasm between me and the really good ones, and it's not due to hard work. I'm-- I can promise you it is not due to effort. It is, it is due to probably some combination of natural ability and coaching that has allowed the really good ones to do what you've demonstrated, right? Which is, you know, a great punch begins in the back foot, and it's transmitted through the hip, and it goes into the, the opposite fist. I mean, that's just how-- You know, it's, it's just hard for people to understand how that through line of force can't lose anything along the way. Um, and, and again, you talk about running-
- SMStuart McGill
Stories I could tell you.
- PAPeter Attia
Yeah.
- SMStuart McGill
I was just gonna say, Peter, the stories I could tell you about the number of athletes being detuned by their trainers and coaches violating this principle that you're describing, it, it's astounding to me. You mean you-- Why are you getting them to do that? You just detuned their athleticism. But anyway, so I interrupted you and I, I-
- PAPeter Attia
Well, I think where I wanna go with this is, you know, most people listening to this are not gonna lament the fact that they didn't run as fast as they could have when they were younger or that they didn't punch or swim with as much, you know, prowess as they could have. Where I think we should all care about this is that it's not just that the energy leakage costs you performance. It clearly does. It's that it predisposes you to injury, and that's where I think we have to bring this back, right? Is what... You know, when I exercise today, I don't care about the performance. I care about the preservation and longevity of my body for whatever number of years I have left. So this is really where I think stability matters. It's, you know, what are the exercises I need to be doing? What are the exercises my patients need to be doing? So that as we age and we walk up the flight of stairs or carry something heavy, we don't hurt ourselves because we don't have that core stability that can resist the deformation that's going to allow energy to seep out of the system.
- SMStuart McGill
Well said. A story was coming to mind as you were saying that. I'll be giving a lecture or teaching a class and I'm, and I, and I'll show some data from an elite athlete, and there will be therapists and clinicians in the room who say, "We don't deal with elite athletes. We deal with the elderly, or we deal with sick people." And I think, "What are you thinking? I'm showing you what the human body has the potential to do, and your arrogance won't allow you to learn what is possible?" And I'm gonna give you a, a very emotional, I hope I can get through this, a very emotional story to, to, to show the, the arrogance that exists among some of our colleagues. Occasionally, medical groups, a hospital or whatever will ask, "Would you come out and assess three patients in our auditorium in front of all our medical staff?" I was at this facility, it was in Europe, and they brought out a-- The first person was a, a rugby player. Fair enough, and I had twenty minutes and declared what I thought was going on. The next one was a woman in her early seventies, clearly distraught. You could look at her posture, her carriage. She was defeated by the world. And, uh, uh, she came onto the stage, and I said, "Can you tell me your story?" And she s- she said a little few sentences, and then she said, "But the therapist says that I have to leave my home now. When I get off the toilet, I'm a bit unsteady and she's afraid I'm gonna fall on the floor. I can't get off the floor by myself, and I'm just gonna lay there and no one will discover me. I have to leave my home." She started to cry at this point, Peter. She said, "What, what's gonna happen to my cat?" and all this sort of stuff. And I said, "Really? Would, would someone please bring me out a stool, and this will be our simulated toilet." So an assistant brought out a stool onto the stage. Um, I said, "Okay, pretend that's the toilet and the seat." She turned and, and had no idea how to move and just sort of plopped and collapsed on the toilet. And then I'm just gonna turn this down because I want you to see my lower body kinematics as we're moving here. And then, uh, I said, "Would you get up, uh, off the chair?" And I can't remember whether she was wearing a skirt or pants. Pants, I think it was. But nonetheless, knees together, and she just sort of collapsed, and I had to help her. She was gonna collapse onto the floor. And so I said, "I, I, I want you to humor me now. You're my mirror." And I try-- When I coach, I try and use minimum words. I said, "Do this with your hands. Put your kneecap between your thumb and your hands as you slide your hands down. Good. Now- I want you to be a leaning tower. Leaning tower forward and backwards, and play with the curve of your back. Do you have any pain now?" She said, "No." And I said, "Watch my shoulders. You're shrugged. I want you to anti-shrug." She did that. "Perfect." And now I said, "Pull your hands up your thighs by pulling your hips through. Don't lift with your back. Pull your hips through." Pete, she had it done in three repetitions.
- PAPeter Attia
Yeah.
- SMStuart McGill
That was now her pattern. And I said, "Okay. Think of what we've just done, and sit on the toilet." And I said, "Whoops. Spread your feet apart." And there she went. Slid her hands down. And now I said... And then she put her knees together. And I said, "Now stand up." She was going right back to the incompetent movement that caused her inability and disability before. I said, "Spread your knees apart and pull your heels underneath you. Sniff some air. Now lean forward and do what you now know how to do." And she did a perfect squat. "Do it again." And then-
- PAPeter Attia
[laughs]
- SMStuart McGill
... by the third repetition, big smile came on her face. It was the emotional part. And I said, "What's up with you?" She said, "I don't have to leave my home, do I?" I said, "No." Do you know, many of those hard-baked surgeons and clinicians started to cry as well? For the first time, they realized all I did was teach her weightlifting 101. And remember how this story started, with the arrogance of some of our colleagues who say, "I don't want to hear stories about elite athletes. I deal with old people or sick people"? And that's why they continue to not have the skill set to help their people. All I did was learn from the best weightlifters [laughs] in the world, people who know how to move load, learn what the efficiency was, and turn it into a hack to change a person's life. Anyway, th- th- that's, that's a pretty emotional story, and I, I, I hope we do that quite often. But it's a matter of, you know, I, I know you like cars. Why does Honda race F1 race cars? Well, they don't anymore, but when they did. And the reason was they learned about automotive technology, and the gearshift change in your Honda Civic came from the F1 racetrack. So that's why we work with elite athletes, so I can bring it down. That's not, that's... I, I love working with them, of course. But th- this is the... Th- they just give it away free to us, and yet some of our colleagues are, are just so closed off, they don't want to hear about elite performance.
- PAPeter Attia
L- let's talk a little bit about... First of all, that's a, that's an absolutely beautiful story, Stuart, and, and thank you for sharing that. Um, uh, you know, it's a sadly common story, too, and, and to me, I think the saddest part of that story is how many of those patients don't get the chance to sit on a stage with you for 30 minutes and learn that movement. Um, and, um, I, I, I, I don't... You know, you've been around long enough that I'm sure you have a better sense of this. But I feel maybe optimistically that we are in a place now where people are starting to appreciate the importance of strength and stability, and that we're less afraid of this. You know, there's more discussion of the importance of resistance training, and that it's not a, it's not a young guy thing to do, it's an everybody thing to do. But given the arc of your career, am I, am I being just sort of delusional, or do you really think that, that we're, we're in a, in a, in a, in a, in a coming of age here?
- SMStuart McGill
The way you phrase questions are fabulous. What was going through my mind? Well, I, I mean, I try and answer every question. What's the evidence, and what's the application [laughs] ? So the, the, the evidence, uh, at the university with all our first-year students, one of their first courses they took was on just basic fitness evaluation. Range of motion, strength, hand grip, um, VO2 max. The, some of these markers. And they would measure each other, and we kept the scores year after year of the incoming class. The students got terribly soft, and I can prove it based-
- PAPeter Attia
Yeah
- SMStuart McGill
... on that data, and we would graph it. Now, whatever year was the year where the students had grown up with the personal computer, it was right at the very late '90s, I think. All of a sudden we saw the incoming class fitness plummet.
- PAPeter Attia
Mm.
- SMStuart McGill
But then something happened. They were a soft bunch for about five years. And then slowly, to your point, they started to come back. And so I think your perception is, is right on. There, the, the, the... It did go to a terrible state however many years ago, uh, that was, 15 or, or 20 years ago. Uh, but it, but it is coming back, uh, now. And among our colleagues, and, and... Uh, but having said that, I, I think some of them are terribly misguided as well. You know, they think, "Oh, you're not a, a real woman," because I heard this on, uh, social media, "until you can deadlift twice your body weight." Well, wait a second. If, if, if, uh, they could come here and see the number of people who've been caused by overzealous trainers and going bonkers on, on deadlift magnitude, uh,
- 1:25:33 – 1:37:08
Stuart’s take on squats and deadlifting: potential risks, alternatives, and importance of correct movement patterns
- SMStuart McGill
you know.
- PAPeter Attia
Yeah. Where, where... Let, let's talk a little bit about that because I have to tell you, Stuart, I'm a bit conflicted personally, and I, and I'll explain why. Um, I obviously have no desire to do anything that I deem stupid anymore, right? So the, my days of gritting through painful Anything are long over. Um, I know the difference between discomfort that is worth pushing through and pain that is not. But when I, when I think about in particular squats and deadlifts, I'll, I'll tell you where, especially around the deadlift, which I-- is an exercise I really, really enjoy, where I feel conflicted. On the one hand, I feel like now that I'm so tuned in to how to do this movement correctly, it's a really wonderful audit for my stability system. Right? Again, I, I, I'm embarrassed to tell you how much I didn't know when I was deadlifting. At no point did I understand the importance of tension in the arms, intra-abdominal pressure, you know, the, the variability in foot pressure on the ground. Like, none of that stuff, right? It was just pure bute- brute force stupidity. Today, as I know those things, it allows me to modulate force and to, on a good day, kind of push the envelope a little bit in what I perceive as safe. So on the one hand, I think, "Yeah, I should be deadlifting my whole life." Not-- I don't need to deadlift four hundred pounds anymore, but I should be deadlifting because it's this great audit. And on the days that I don't feel it, I back off. And then on the other days, I say, "Peter, you don't need to do this anymore because honestly, you can still get the same or nearly the same activation for all of the muscles involved using other movements." Single leg movements in particular, where you don't have a fraction of the axial loadering, loading. And yeah, you might need to do two exercises instead of one, but at the end of the day, th-th-there's a, there's a lower risk approach to get it. And in other words, deadlifting is, is valuable, but you have a narrow operating window in which you can potentially hurt yourself. So I continue to go back and forth on this, Stuart, and as, as such, here I am telling you, I still will go periods of my life where I'll deadlift every week, and then I'll take three months off f-feeling like I don't wanna push it. W-w-wh-- h-how would you advise a middle-aged person or even a non-middle-aged person, um, who's sort of thinking through this particular issue?
- SMStuart McGill
Again, I have so many thoughts going through my mind. It's interesting when we have a back pain fifty-year-old coming here and I'll say, "What are your goals?" "Oh, I wanna set a personal best in deadlift." And I said, "Really? Okay. Um, let me tell you some stories. Let, let's, let's talk about Ed Coan." Do you know Ed Coan? The, the-
- PAPeter Attia
I sure do. Yeah
- SMStuart McGill
...greatest powerlifter of all time. I was with Ed a couple of weeks ago. I'll tell you a funny story about him if you like in a minute. But anyway, Ed, when he would set a personal best, he'd take a couple of months after, off afterwards. To, to set a personal best is so demanding of your body. There are actually... If, if you set a true personal best, most people experience microfracturing just underneath the end plate of the trabecular bone. Um, if you look at the great strength athletes, they train deadlift, uh... And, and again, if you go to our website, look at the testimonials at the bottom, the number of world-class deadlifters who are on there. So, you know, I've, I've worked with, with quite a few of these people through their injuries. Now, those microfractures could be a good thing or a bad thing. The professional powerlifter will take a week off. They train heavy deadlifts or squats once a week, uh, because it takes a week for the bone callus to not only attach through the chemical electro attraction, but to really scaffold on. Ta-takes a week. If you deadlift it in another three or four days, the way some trainers, they might deadlift a client three times a week, that allows those microfractures to accumulate until finally you've got a full-blown end plate fracture or whatnot. So these are the people that, that, that come here. And then I say, "H-how about this for a goal? Do you have kids?" "Yeah." "Do you have grandkids?" "Yeah." "How about this?" And, uh, I've since learned about your Centurion, uh, decathlon, which I love by the way. Um, I'll say, "Would you rather, as your goal, have the ability to play with your grandchildren on the floor when you're eighty and get off the floor and pick them up?" And they pause for a minute and they'll say, "Yeah, I like that goal." And I say, "Well, you can't have both. If you think you're gonna continue having deadlift, uh, personal bests, you will not-- you will have artificial hips [laughs] and all of these other things because how many old powerlifters do you know? Do you really wanna be like that group of athletes?" So I can talk them into changing their long-term goals. Now is the time to get on the program and make sure you get there. If that's the case, we eliminate deadlifts. Um, we had an athlete here yesterday and, uh, they're, they're at the, uh, end of their career, and I took them out and we went for a ten-minute walk to a hill that we have. And I'll say, "Here's why you're not gonna do deadlifts, but here's what I want you to do." I showed them a monster walk. "Okay, monster walk. Now we're going to the bottom of the hill, and I want you to lean back into the hill and we're walking backwards. You're going to align your foot, ankle, knee, and hip and push through the knee, through the knee, through the knee, backwards up the hill." Do you know after thirty meters they were absolutely done. Here they are doing all this deadlifting, and they don't even have the leg strength endurance to walk backwards thirty me- meters. It's totally inappropriate stimulation of their athleticism to make it through to eighty. So good. "Poor you. Let's do it again." We walked down the hill. We did three sets. They could hardly walk. And then we played the neurological trick, which I like to do a lot of. Now I said, "Walk forwards up the hill, but pretend you have $100 in your butt cheeks. Don't let anyone take it."
- PAPeter Attia
[laughs]
- SMStuart McGill
"Now walk forwards up the hills." And they say, "I've never felt this before." The brain perceives exhausted quads. It now has to go and get the glutes. It's the only thing left. So quite often we'll, we'll do a, uh, a, an exhaustion, uh, focus to stimulate the thing that we really want to [laughs] , uh, stimulate. And I convinced that person after that what they're going to do and train now to get a well-rounded and sustainable athleticism that will spare their joints, still have great training capacity, um, but I think their athleticism is gonna go through the roof. And, you know, I've taken some very accomplished powerlifters, and we've taken out all the squats and just do squat, uh, sled work, backwards walking up hills, some of these old time techniques. And their joints settle down. They get a sustainable fitness. They lose this idea of maximum effort, uh, squats and deads, and now they're thinking of the word sufficient strength, sufficient mobility, sufficient endurance. And, uh, we've been doing this long enough now that we've tracked them, and those are the ones that are getting through. Uh, eh, you know, again, you, I mean [laughs] you... Let's go get any one of our colleagues who are orthopedic surgeons. "Tell us who you're replacing the hips of." "Well, uh, 50-year-old Caucasian women who have done yoga for 30 years." "Okay." Uh, and, uh, men around 50 who've, uh, done deadlifts all their lives. [laughs] Who are you not? The middle of the road moderates. Not the ones who've rusted out and not the ones who've worn out, but the ones in the middle are the ones who are... So this idea of sufficient fitness, um, because I still believe we are all called upon to do things in life at certain times. I hope we're already enabled. And, uh, it's more fun, too, just to be able to continue to do those things. So I'm like you. I don't do deadlifts, but, uh, I pick up, uh, 100 pound bucked up logs, as an example. Big oak log. So, so that's my stone lift. [laughs] Load that into the log splitter and, uh, still split my wood. I've... Uh, people comment on my hands. This athlete who came yesterday, I, I shook his hand when he came to the door, and, uh, he couldn't fit his hand around mine. And, uh, he said, "Whoa, whoa!" [laughs] When we were young, we, we, we didn't have dumbbells. My dad would give us a cinder block. [laughs] Cinder blocks.
- PAPeter Attia
Yeah.
- SMStuart McGill
That's how you develop a... Anyway, as you know, the importance of, of grip strength, I will take any day over how much you deadlift.
- PAPeter Attia
Yeah. Uh, people often ask me, "Stuart, why do you think grip strength is such a great proxy for longevity?" And, um, I, I say it's the same reason I think VO2 max is a great proxy for longevity. Those are probably the two best biomarkers we have. It sounds crazy, by the way, that your VO2 max and your grip strength are better predictors of how long you're gonna live than whether or not you smoke, drink, uh, what your family history is for cancer. Like, those things all matter, but it's amazing how dwarfed they are by those two. And m- my best explanation for it is that those are the best two integrators for the work you've done, right? So, you know, you can't cram for a VO2 max the week before. Like, if you have a high VO2 max, you have done the work to get it. If you have a strong grip, you didn't just buy little grip squeezers on Amazon and-
- SMStuart McGill
[laughs]
- PAPeter Attia
... and filter away at them while you were, you know, on, on calls on Zoom. Like, you had to do the work. You had to be carrying heavy things, you know, whatever it be, chopping wood, carrying cinder blocks, doing farmer carries. And, um, and of course, that also speaks to stability, right? That speaks to the stability that you have to be able, uh, to, to transmit force from the torso right to the hand. So, um, so
- 1:37:08 – 1:46:59
Helping patients with psychological trauma from lower back pain by empowering them with the understanding of the mechanical aspects of their pain
- PAPeter Attia
agree completely. L- let's pivot for a moment to talk a little bit about, um, the, the amount of psychological trauma that exists in the patient with lower back pain. And I'm, I'm thinking very specifically even about some of my own patients or friends who have been in the throes of lower back pain. And, um, i- if, if nothing else, Stuart, I take a great degree of comfort from the injury, the third injury that I had, the one in 2000. Because it lasted so long and because it was so debilitating and because I'm here today without pain, my confidence around small recurrences is so high that I don't tend to awfulize about it and work myself up. But I have great empathy for a person who doesn't have that knowledge and instead I don't know how to help someone sometimes because I can't tell what is mind and what is body at this point, and I suspect that there's a significant interplay. So c- can you speak more about this phenomenon and w- what those of us who want to help these patients can do?
- SMStuart McGill
I'm certainly much more conscious of the point you're making now than I was 30 years ago. Absolutely. I'm gonna start with a little story, but I-- th- th- this happens very often. You mentioned earlier how MRIs don't show you the mechanism of pain, and I can give all kinds of reasons why. But let's, let's take this patient. He came to see me, and, uh, he said, "Uh, hi, doc, I hear you're different."
- PAPeter Attia
[laughs]
- SMStuart McGill
"Um, I've got this pain that... I've, I've been everywhere. I went to the pain clinic, they gave me narcotics, and now they say the pain is in my head. I can live with the physical pain. I cannot live with someone telling me the pain is in my head 'cause that means I'm crazy. And if I'm crazy, I don't deserve to live. You've got two weeks, and in two weeks, I'm blowing my brains out." Now, there's a heavy psychosocial [laughs] challenge and a little bit of a story of what the system does to people and, and it's not unusual for someone to come here suicidal. So I said, "All right. Uh, you don't appear to have pain right now." And he says, "No, I don't." And I said, "Okay, what causes your pain?" And he said, "Well, it's when I do a certain movement that I get a flash of pain, and it feels like someone has broken a beer bottle and have ripped open my hamstring muscles. It's awful." And I said, "Oh. Ca- ca- can you show me the pain?" And he said, "What? You, you, you want me to show you how I create the pain?" And I said, "It's the only chance I have to understand it." I said, "You've been to 15 different clinicians. Has no one ever asked you to show them the mechanism of your pain? Has anyone ever touched you?" He says, "No." I said, "Well, it's the only way I know." Peter, I put on my instrumentation, which was muscle EMG over the torso, the glutes, et cetera. We put on the spine motion monitor, 3D motion spine monitor. And then I said, "All right. Let, let, let's, let's see what causes this." So he stood there, and he did a very weird thing. And he said, "All right. Well, here you go." And he wound himself around in a circle like this. And when he got to ten, top dead center, "Argh." Now, at that time, I heard like a little cavitation, little pop come out of his back, and that was the trap of the sciatic nerve, and he was in a bad way. You know, I, I laid him prone on a table, tried to give him a bit of decompression, and he went home, and I said, "I know exactly what the mechanism of your pain is. Here's what you should do over the next three days, but I want you to come back, but promise me you aren't gonna do anything silly." Remember what the threat was hanging over us. He said, "I promise." I called him that night. I called him the next day just to make sure. Then he came back, and I said, "I know exactly what your mechanism is." As-- and, and here's what the data showed. As he was winding himself around, he was using muscle. Muscle is stiffening and stabilizing. It's centrating of the joints. And as he got to top dead center, he shut all his muscles off. He completely relaxed, and then there was a little sheer translation or a clunk. And that's what we heard, and that's what trapped the sciatic root.
- PAPeter Attia
Mm.
- SMStuart McGill
I said, "Okay, you have no pain. Push my fingers out. Harder. Good. Hold that. Now talk to me and keep talking to me with that controlling." A- and we coached him through this in, in a minute. Very simple. I said, "Oh, keep the tone now, and we're going through." And as he came to top dead center, you could see him, "Ah, ah, ah, ah, ah, ah." I said, "We're there. Do it again. Hold on. Keep control." He didn't clunk. Now, it took him about four months to wind down the ache, but he never had another clunk or a trap. Ten years later, he brought his daughter to me, and, uh, I saw her for back pain, and he brought me a case of beer.
- PAPeter Attia
Hmm.
- SMStuart McGill
And, uh, and, uh, he said-- I said, uh, "You know, I did my one-year follow-up with you, but, but how have you been?" He says, "Fabulous." I said, "Did you ever get another episode?" "Never had one." Now, some people will think that that's a, a, a fantastic, impossible story. Pete, after that [laughs] one coaching lesson we gave him, he was so coachable, and he got it. He understood. He was a mechanical mind. You know, he never had another acute episode, ever. And, uh, so think of a, a suicide case from the medical system not having a sufficient evaluation procedure to really get at what the mechanism of his pain was to a point where they defaulted and said, "We've tried everything with you. It's not working. Therefore, the pain is in your head." Now, think of the psychological, uh... Anyway, to, to, to coach him, and the key was to prove to him immediately that he had the ability. It's just he had to be shown how. So it was a process of understanding the mechanism, giving him a strategy to address the mechanism, and the psyche just changes. It empowered him. I'm, uh-- May I give you one more story?
- PAPeter Attia
Absolutely.
- SMStuart McGill
Okay. I was giving a lecture in England, and there was a fella off to the side, and he was slumped down. Now, if you get a, a, a clinical psychology textbook, the picture of depression is this: knees together, slumped down in that demeanor. Now, if you have a posterior disc bulge, that is [laughs] not a good position to be. So there we're starting with clinical depression feeding a disc bulge. Two don't go together. And he just sat there. And then in the break, he came over to me, very, very quiet, uh, spoken fella, and he said, "I, I, I hear what you're saying. D- do you have 30 seconds for me to tell you my story?" And I said, "Sure." He said, "I used to be a police officer. I, uh, hurt my back. I went through the NHS system. Uh, the, the, they only gave me exercises that hurt me more. Finally, they gave me a pamphlet, How to Live With Your Back Pain." And he said, "That book destroyed me."
- PAPeter Attia
Hmm.
- SMStuart McGill
"What? You mean I have to live the rest of my life with my back pain, and no one's ever touched me or shown me any of this?" And I said, "Oh." And then you'll remember that-
- PAPeter Attia
Hmm
- SMStuart McGill
... squat procedure that we went with the, with the older woman that I described earlier. I simply showed him that, and he went back, and he sat down on the chair, nice and tall. And then at the end of the lecture, I went over to him and I said, "How's your pain?" And he stood up, and he said, "It's gone," and he started to cry because he realized now what the system had done to him. In the meantime, he lost his job, and he realized that he'd been stolen from, and those are his words. He said, "They stole my career from me, giving me that book, How to Live With My Back Pain. Why didn't anyone show me what my pain was like you just did in 30 seconds?" And it was just... I've been watching this pattern for so many years, you could see it a mile away. Anyway, those are two stories to link the mechanics. And ultimately, what we're trying to do is to empower people in showing them they have the ability within themselves. They just need to understand the mechanism. And most of the time, they are able to mitigate the cause and then build a robust foundation. So
- 1:46:59 – 1:56:08
Empowering patients through education and understanding of their pain through Stuart’s clinic and work through BackFitPro
- SMStuart McGill
I wrote Back Mechanic, and people would come. I, I started the experimental research clinic at the University of Waterloo. We were the only clinic... Maybe you've heard of this, but I've never heard of another clinic where f- they follow up with every single patient that they ever saw. We did a two-year follow-up with every single patient who came in, and we sub-categorized them because we assessed everyone into the mechanism of their, uh, pain pathway. We gave them an appropriate exercise prescription. We followed up to see did they even comply, because some people didn't, uh, and then how are you doing after two years? If you were in the sub-category that everything has failed, you've been told you need surgery. So you're at the end of the road now. You're a surgery case. In the two-year follow-up, following the plan that I just described for you with this thing called virtual surgery, which is part of it, 95% reported that they avoided surgery, and they were glad that they did. So that's my efficacy to the empowerment and psychology issue. It, I don't know if that answers your question. Sometimes I get a little bit... I, I try and create a logic flow. I hope that worked.
- PAPeter Attia
Y- yeah. I'll, I'll tell you what stands out to me the most in those stories, Stuart, is your kind of, um, consistent, adamant drive towards understanding the mechanism of the pain. So it's a, um, you know, how do we break this down into a physics and biology problem? And, um, it... I, I guess my question is wh- where, where-- which type of healthcare providers are most in line with that, right? So your training is in... Is it k- d- Is your PhD through, through the School of Kinesiology?
- SMStuart McGill
Yes.
- PAPeter Attia
And, um, so, so we can-
- SMStuart McGill
Well, well, I, I, I should back that up. Yeah, there's a, a lot of mechanical engineering in there and, uh... But, but nonetheless, yeah, basically.
- PAPeter Attia
But when we think of all the different practitioners that interact with patients who have lower back pain, ranging from neurosurgeons, orthopedic surgeons, chiropractors, physical therapists, kinesiologists. I mean, there are so many people, and I never want to suggest that the profession determines the, the school of thought. Like, I really think that individ- there are great people and there are lousy people within all of those categories. But-
- SMStuart McGill
Agreed
- PAPeter Attia
... what are the characteristics, um, uh, you know, that you see driving that type of search for a true mechanistic understanding of the pain? Because I'll, I'll be honest with you, like, in all of my back i- bouts of m- m- you know, misery, nobody-
- SMStuart McGill
Right
- PAPeter Attia
... ever explained to me what was going on. I mean, nobody said to me, "This is happening." Even as a medical student, yes, I could look at the MRI. I could see the fragment. It clearly had to come out, presumably, uh, given that I was in such excruciating pain, and the thing wasn't... You know, it might have taken months for the thing to have been resorbed. Um, but But there wasn't a sort of, we need to understand the why this is happening so that-
- SMStuart McGill
Right
- PAPeter Attia
... we're going to fix the underlying behavior that's causing it. Th- that's the thing that strikes me as the most interesting, um, of those stories. And is that, I guess what my long-winded, apologies, question is, is that a function of the individual or of the school of training?
- SMStuart McGill
Both. So the elephant in the room here is there is no billing code that exists for an assessment of back injury mechanism. Doesn't exist. You can't bill an insurance company and say, "Well, I assessed the person's back pain." When I started the experimental research clinic, I set aside two hours to see a back pained person.
- PAPeter Attia
Hmm. Wow.
- SMStuart McGill
And I'm that guy. That's all I ever saw, two hours. My medical colleagues who'd been through medical school training, which I had not, I'd only have, have ever been a guest professor at a medical school, but I sure didn't graduate from one. And, um, my medical colleague said, "Two hours? What are you gonna do for two hours?" Well, I've been spending 30 years figuring out how I'm going to test shear, tolerance to compression, pulling a nerve root one way, pulling it the other way. Is it flossing? Is it friction? Is it stuck? Um, et cetera. Um, uh, I'm probably, again, I said a, a handful of people in the world that would take cadaveric spines and create the injuries [laughs] so I knew how to measure them and, and, and what to look for in terms of, uh, the, the full pattern. But that, that's the first political impediment to all of this. There's no billing code. Therefore, you're left with clinicians who are billing for a procedure that they've been trained to perform. Well, if you have non-specific back pain, it's an absolute crapshoot whether a manipulation for mobility, uh, an exercise prescription for stability, um, [coughs] just a movement tool, not to create a stress riser or a stress concentration on the tissue that is sensitized. Simple as that. So wh- where I've arrived at with all of this, um, we have to train our own clinicians, and that's what I've been doing through, uh, Backfitpro. And I do not care if you come from a chiropractic, physical therapy, coaching, training, physiatry, neurology, uh, radiology even, uh, background. All I care is that you have passion. And we then, uh... It's, it's a 50-hour online course of me going through anatomy, physiology, neurology, psychology, uh, biomechanics, uh, et cetera, and then the probably 100 subcategories of, of pain mechanisms, and then how do you test for all of these? And then, uh, how do you coach them? And then after all of that, we have three days together where we do hands-on skills training at a, at a table. So again, there's no subcategory in the medical rubric-
- PAPeter Attia
Mm-hmm
- SMStuart McGill
... that trains how to assess, uh, back pain from the perspective of biomechanics, psychology, neurology, physiology, et cetera. They don't exist. So that was my challenge and, and what the only-
- PAPeter Attia
Stuart, what's the, what's the name of that course?
- SMStuart McGill
It's called The Summit course, and you can read it, uh, read about it on backfitpro.com.
- PAPeter Attia
And is it only for practitioners, or is there a variant of that course that an individual can take to become sort of a master of their own domain?
- SMStuart McGill
Okay. Good question. It's mostly for clinicians. Uh, it's only been clinicians that I know of that have ever registered for it. Uh, I'm, I, we, uh, I don't think we would stop a member of the lay public, because some of them are very savvy, uh, from taking it. However, the gatekeeper of all of this is there's a fairly extensive exam at the end. It is a written exam. There's a practical exam where the person must assess a real patient, usually online, with one of our examiners. Uh, they have to come up with a written explanation of the pain pathway and then a program of what they're going to do with the person, and then they have to coach elements of it.
- PAPeter Attia
Hmm.
- SMStuart McGill
So they have to see the coaching skill as well. So that, that's sort of the gatekeeper at the end that I think would only be for, uh, clinicians. But, uh, that's the, the only way that I've found, uh, possible. And, and having s- said that, it, you know, I, I, I'm like you. I, I'm very agnostic in, in terms of preparation. There are fabulous chiropractors, and there's the absolute opposite. There's fabulous-
- PAPeter Attia
Yeah
- SMStuart McGill
... therapists, fabulous... And there, there were fabulous professors and terrible professors. Uh, it's just the way it is. But, uh-
- PAPeter Attia
Yeah
- SMStuart McGill
... anyway, I, I don't know if... It, it... Does that answer?
- PAPeter Attia
Yeah. No, that's a, that's a very interesting course. It's almost something I wonder... Uh, I'd love to figure out a way to make the time. So it's 50 hours online plus three days in person is what it sounds
- 1:56:08 – 2:05:48
When surgical interventions may be appropriate, and “virtual surgery” as an alternative
- PAPeter Attia
like?
- SMStuart McGill
Correct.
- PAPeter Attia
Yeah.
- SMStuart McGill
Yep.
- PAPeter Attia
Um, let's talk about the cases where you think surgery is really the best course of action. And again, I think it should always be stated that, you know, surgery without understanding how you got there and then making sure you correct it post-surgically is not what we're talking about. So it should always be assumed that you want to understand what got you there. But- What are the indications in your mind for where a patient is better off ge-getting a surgical procedure? And we could talk about the different, you know, whether you-- you know, what do you, what do you think are the best indications for discectomy, fusion, et cetera, um, versus when you think-- where would you take a contrarian approach where many people would say, yes, surgery, and you would say, let's push a little bit harder before?
- SMStuart McGill
Wow. L- uh, a lot of elements there, so I'll just, uh, start at the beginning and hope I can create a, a logic story. I did mention the follow-up that we did where ninety-five percent of people who were told they needed surgery in fact avoided it. And what we did there was I anointed them and said, "There is your virtual surgery." This worked really well on people who-- I'll paint a picture of let's take a, uh, stay-at-home mom with two young kids. Uh, every day has to go to the gym and ride the elliptical for twenty minutes, do something else as a stress reliever, otherwise she's gonna murder us. [chuckles] You know, you've heard that story before. And, uh, I'll say, "Good. Go get your surgery. Are you gonna do that tomorrow? No. You are going to lay in bed. You're gonna behave like a post-surgical person. You're gonna get out of bed and go for a pee three times. That is your total workload tomorrow. And slowly you're gonna build yourself back. In other words, surgery may work for you because it's forced rest."
- PAPeter Attia
Mm.
- SMStuart McGill
"Now I'm gonna give you a tool that will mimic the forced rest. It's called virtual surgery. Tomorrow, here's the plan, here's how you're gonna behave. We are going to desensitize strategically the pain mechanism as we've measured it, and we're going to retune your body with strategic mobility and stability, plus movement skill, so we don't replicate [clears throat] the stress concentrations that caused your problem in the first place. Let's see how you are." Now, if they can do that, ninety-five percent will avoid surgery. So there's my first little story for [coughs] people in that, uh, category, just, uh...
- PAPeter Attia
And, and Stuart, just to be clear, are-- what are the patients who you would not offer that virtual surgery to? Give me an indication-
- SMStuart McGill
Well-
- PAPeter Attia
... where you would say, "You know what? We, we-- this is too pressing."
- SMStuart McGill
Obvious red flags, which before we see a patient, we don't take patients, uh, off the street, never. They always come through physician referral. So I'm hoping they've been checked for red flags. Do you know how many have not? Even though we state in the referral directions to the referring medic. We've had cases of, uh, uh, uh, aortic aneurysm, lung embolism, cancerous tumors, metastasized, um, all sorts of things that somehow these poor people got through the system, and we were the ones that found them-
- PAPeter Attia
Mm
- SMStuart McGill
... and, uh, saved their lives. So I, I wish that wasn't the case. But all of those, obviously, are surgery, uh, cases, and they should never have come to us in the first place. So obvious red flags is number one. Number two is when the pattern doesn't fit. So I was smiling when you were telling your original story, only because it was such a familiar, spot-on pattern consistency. You fit the pattern. I knew exactly what it was. When the pattern doesn't fit, I'll say, "No, something's not right. I need you to go back to your doc, and here's the reason why. There is, you know, a turgidness under your liver. Uh, we're not able to move that pain by moving stress concentrations around your spine, so it's not a nerve. It's nothing vertebral or facet. The pattern doesn't fit. It's something else." So there is a person where we refer back and say, "Something, uh, needs further investigation." But now the last part of your question was about the need or when we would say for a person, "You're not our person. You need to see a surgeon." Surgeons-- And by the way, we see far too many post-surgical patients who they went through-- Maybe the surgery was botched. When I see a horrible scar on the outside of the skin, I think, man, if that's the pride that the surgeon took on the outside, what carnage has gone on the inside?
- PAPeter Attia
Mm.
- SMStuart McGill
Or sometimes it's a shit happens story. The nerve scarred in and adhered. Oh, that's, that's rough, you know. Or, uh, the post-rehab was terrible. Here's a person, they went to a fabulous surgeon, and the surgeon says, "Oh, well, go do PT. That's your rehab." And the PT goes and gives them toe touches or something [chuckles] after they've just had a microdisk surgery. And guess what? They're reherniated again, and now we're seeing them. Um, but wh-wh-when would we say, "No, you're not for us here, y-here, here"? The surgeons are at their best in cases of a real heavy stenosis. So there's not much room in the, in the neural canal. The facet joints are thick in behind, so you've got encroachment from behind. You've got a, a calcified disc bulge coming from the front. Uh, so a, uh, you know, a, a couple level laminectomy to give the, the, the nerve some space. That really is When the surgeons are at their best. Uh, some of the spondylomyelopathies that we'll see in the neck, you know, [laughs] I think of a, a, a lead, a lawyer in, uh, uh, in the courtrooms, and the judges would ask him, "Sir, are you drunk?" And he said to us, "Well, when I, I, I stand, I start my presentation, I'm fine," he says, "but after two or three minutes, I'm losing my balance and falling over." And the judges think he's, he's drunk. And then we found it. It was a cervical spondylomyelopathy that was also, uh, co-presenting with back pain, but no one had figured this out. Uh, so that-
- PAPeter Attia
Hmm
- SMStuart McGill
... that was a, uh, a surgery case, obviously. So it's either, uh, post-trauma, and then that one's obvious. They, they've got the... They need a little bit of hardware to, uh, stabilize their spine. Um, but it may also be, uh, spondylolisthesis. The listhesis, or the shear translation, is just choking off the, uh, cauda equina or a- another nerve. Um, it's, it's best to, uh... And then, uh, we, we recommend surgeons who, who we have really good luck with.
- PAPeter Attia
And in that situation, the, i- if the spondylo- if the spondylolisthesis is significant enough, is the only treatment a fusion?
- SMStuart McGill
I'm go- I'm going to say yes. Yeah.
- PAPeter Attia
There's no amount of stability you can generate in the paraspinal muscles, in the-
- SMStuart McGill
Oh
- PAPeter Attia
... QL, in the psoas to compensate for that? I mean, I realize that, because... You have to forgive me because I'm not an orthopedic surgeon, but I would assume that there's some threshold, right? One millimeter of spondylolisthesis might be tolerated, and at some level they would say, "No, it's too un- unstable." But, y- you know-
- SMStuart McGill
No, no, I wouldn't agree with that, Peter.
- PAPeter Attia
Okay.
- SMStuart McGill
It's not the distance at all. You go with the assessment. And the, again, the evidence I offer there is we're coming down to the next Olympics now. So I don't know how many Olympians and people who are tapering now for the Olympic trials we've had here over the past year, but this is every four years [laughs] we're inundated with these-
- PAPeter Attia
Yeah
- SMStuart McGill
... these, uh, types of athletes, and they come in pairs, where we might have two young women who are, uh, competing for a place on the US Olympic team, uh, in gymnastics. Both have the same spondy. Uh, one, uh, will say, w- we need six months off here, uh, of gymnastics, and here's what we're gonna do. We're gonna do a heavy stabilization program. The next one says, "Oh, no, we really gotta make the, the trials. We're just gonna keep going with, uh, going to gym." And I can almost predict with 100% accuracy who's gonna make it. So I wouldn't say at all that, uh, we, we don't try, uh, a heavy exercise stability program, uh, regardless of the amount of, uh, slippage, and I've done that with, you know, people trying to make, uh, the, uh, Special Forces in the US. You gotta do a speed sit-up test. You gotta do [laughs] all of these things. "Oh, but you got a heavy spondy." "Okay, here is the program to try and get there. You might make it." Uh, anyway, uh,
- 2:05:48 – 2:11:21
Weakness, nerve pain, and stenosis: treatments, surgical considerations, and more
- SMStuart McGill
so in-
- PAPeter Attia
What about, what about nerve pain? What about patients who, um, are either having weakness, such as a foot drop-
- SMStuart McGill
Right
- PAPeter Attia
... or significant, uh, pain like the pain I had, where, uh, in-
- SMStuart McGill
We have them all the time
- PAPeter Attia
... in the very first-
- SMStuart McGill
Yep
- PAPeter Attia
... case where it was... Yeah, okay, so yeah, take, take that away.
- SMStuart McGill
Yeah, we, we have them all the time, Peter. Uh, if I can get the nerve pain, pain to move on the assessment, uh, please don't have surgery. Let us have a try at it.
- PAPeter Attia
Got it.
- SMStuart McGill
Most of the time, the, they will be, uh, pleased.
- PAPeter Attia
Wow. And what you're basically doing is-
- SMStuart McGill
But, but we have to play, play with certain rules.
- PAPeter Attia
And give me, give me an example of some of those. So let's say your assessment comes out that this person who's having intermittent sciatic pain-
- SMStuart McGill
Right
- PAPeter Attia
... um, and, um, and, and you do an assessment and you say, "Look, there is no doubt that you have a ruptured, uh, annulus here. You've got a protruding, um, segment of, of disc, and it is clearly at times, depending on your activity, getting nearer to the nerve root. It's driving that sciatic pain." But it... But during your assessment, I assume what you're getting at is through some of those positional things, such as laying the person on their front, manipulating the legs, getting the, uh, the herniation to retreat into the annulus. If... So you're saying if you can demonstrate resolution under a changing movement pattern, that gives you enough confidence that this is-- this doesn't need to be removed surgically.
- SMStuart McGill
Not, not resolution. Can I move the pain a little bit?
- PAPeter Attia
Oh.
- SMStuart McGill
Can I make it worse, and can I make it better? Now I'm starting to understand the variables that make it worse, make it better, and I play with those.
- PAPeter Attia
I see.
- SMStuart McGill
Now, here's, here... Uh, and again, I'm, I, I'm, I'm trying not to sound boastful. I'm, I'm trying to be scientific here. There was a, a day not that long ago. I'm losing track of time. It was probably, uh... Well, it was the NHL playoffs, so there's our time marker. I just, I don't watch TV really, but for some dumb reason, it was Saturday, I flipped on the TV. Uh, it was the NHL playoffs, and I listened to the announcer. The name, "Oh, that's my patient." [laughs] And then I... Next player, my patient. Two of my patients are now in the NHL, uh, playoff series. A little bit later, I flip over to TSN, uh, tour tennis. Uh, what, what, um, what's, what's the big professional t- tennis tour? I look at that, my patient. And then that night, the UFC comes on. There's my patient again. [laughs] So in one day, [laughs] I see three different pro sports. Every single one of them had sciatica when they came to me. And so that's some evidence that I can offer. Now, let's take-- I remember one of those, uh, players in the NHL, um, if he fully flexed, he would stir up sciatica and increase the risk of a full-blown acute attack, as you know, you and I know very well. So we got him to move well. He, uh, played hockey, mindful of a skating style that he didn't get too flexed up.
- PAPeter Attia
Mm-hmm.
- SMStuart McGill
We didn't allow him to tie his own skates. He said, "Tying my own skates really set my back up."
- PAPeter Attia
Hmm.
- SMStuart McGill
I said, "Good." Now, NHL players are very particular how they tie their skates, but they coached one of the training staff to tie his skates for him. Now, I know some people will laugh at that, but that was all part of the plan to keep the capacity as high as he could-
- PAPeter Attia
Mm-hmm
- SMStuart McGill
... to utilize in the game. How he sat on the bench was also, uh, instructed. Uh, the, uh, fellow in the, uh, UFC, this is no slouch. Uh, jujitsu really put his spine in a place where it could fire off an acute attack. You do not wanna be in the cage fighting for your life and having an acute attack. [laughs] That's the last thing you want. Um, we would limit the mat time, uh, on jujitsu. He would do stand-up, all kinds of things to minimize the accumulative stress on the disc bulge causing sciatica. And, uh, he competed. And, again, I, I wish I could tell you who he was and what he did that night. So I'm not afraid of nerve irritation, sciatica, uh, et cetera, and it certainly doesn't fall into the category of you need surgery. We've proven that far too many, uh, times. Um, but as I said, heavy instability. And when we fail to arrest the shearing movements, uh, trapping nerves, uh, it's gone on for, for q- quite a, a time. We can't hack our way around it. It's best to see, uh, a surgeon. Uh, stenosis-
- PAPeter Attia
Yeah, and stenosis as well. Yeah.
- SMStuart McGill
It's-- Yeah.
- PAPeter Attia
Stuart, how-
- 2:11:21 – 2:13:34
Tarlov cysts: treatment and surgical considerations
- SMStuart McGill
out. Um, another one is, uh, you know, I know a lot of our medical colleagues say, "Well, a Tarlov cyst, a neural cyst, well, they don't cause pain." Really? I will prove to you very quickly whether or not that's causing pain by pulling the nerve root one way or the other. Y- you know, I, I can-- A typical pattern recognition might be a physio might do a slump test, which is you straighten one leg and you flex the spine and neck. But the net stress in the middle of the cord is zero. You're pulling it one way. You're pulling it the other way. It just goes into a little bit of tension. If that's a Tarlov cyst, that won't be triggered. A Tarlov cyst doesn't like being pulled one way. So that patient on exam might say, "Well, I don't get pain with a, uh, a, uh, slump test, but I can't stand driving my car." "Oh, tell me about your car." "Well, I sit upright, put my head back, and extend my leg to push on the accelerator." "You're pulling the nerve root one way. Where's the pain?" "It's in my big toe." "Aha."
- PAPeter Attia
Hmm.
- SMStuart McGill
I am now going to inform my inspection of the MRI 'cause the radiologist missed it. They're not gonna find a Tarlov cyst distal on the fifth root. But I know that the symptom and the assessment took me there logically to say, "I know there's something hanging up there that's directionally specific. It's not a friction. It's a direction-specific tension." There's the Tarlov cyst. I found it. Now, boy, what's the surgical procedure there? Typically, they'll try and drain the cyst, and it comes right back again. Typically. But there's a, there's a doc in Dallas who, uh, we send all our Tarlov cyst, uh, patients to, and he, he has a reasonable, uh, rate, at least better than anyone else in, in dealing with those pes- pesky cysts that we've just proven is... So there, there's another y- you know, [laughs] bit of an off the wall. I can't do a damn thing about that cyst. It's, it's eroding the bone. They're, they're pesky little things, but here's a surgical referral. Sorry. Is-- That was a bit long-winded too, but-
- PAPeter Attia
No,
- 2:13:34 – 2:18:40
The evolution of patient assessments and the limitations of MRI
- PAPeter Attia
no, that's, that's, that's great. Stuart, how often, um, I mean, uh, i- if you're doing a two-hour assessment on a patient, I assume you're also looking at an MRI.
- SMStuart McGill
Let me stop that. After the first year of the experimental research clinic running two years, I changed it to a three-hour consult.
- PAPeter Attia
[laughs] Wow.
- SMStuart McGill
Yeah. I needed even more time. So now I, uh, you know, there's our-- I, uh, if, if they're an old athlete and they still have, uh, films on the film. Remember how we used to get MRIs? I read them on the reader, or I put them up on the screen there. So yeah, no, full medical images we, uh, go through.
- PAPeter Attia
What are the things you're looking for in the MRI that, that maybe Aren't as readily apparent. In other words, where-- what are you looking at in an MRI that isn't obvious to the radiologist? 'Cause presumably, y- you know, you c- yeah, you can maybe explain to somebody what the MRIs are showing, but you're, you're, you know, you're getting axial cuts, you're getting coronal and sagittal cuts.
- SMStuart McGill
Right.
- PAPeter Attia
They're T1 weighted, they're T2 weighted, so s- you know, they highlight the disc. A nice healthy disc looks white on the MRI. Of course, mine are jet black. Um, w- what are things you're-
- SMStuart McGill
Don't worry about it.
- PAPeter Attia
Yeah, what are, what are things you're picking up on that MRI read?
- SMStuart McGill
Well, all of the things that you've mentioned. Um, but the la-- I don't know if you looked at my CV and the number of papers and the topics that we covered over the years, but the very last study that I ever published as a professor was exactly that, and we took a cohort of whiplash patients. I didn't do very much cervical spine specific work. Most of mine was lumbar. But, uh, just to, to, just to answer your, your question, we took whiplash patients. Every single one of them had been denied compensation because they're now more than two years post-whiplash. They still continue to have symptoms. The medical profession and the legal system was declaring them pain magnifiers. They were exacerbating their pain for financial gain. Terrible. The MRs said there's no reason for your pain. Really? The MR is a static picture. What do you expect? So we took video fluoroscopy, which you know is a real-time moving X-ray. So we're watching the bones move now, and we would have them move through their pain. And their pain wasn't very rarely at the end range of motion. It was actually somewhere in the middle of the range, and they would move their head like this, and then the spine would clunk. And then they'd go, "Ugh!" And then they'd continue to move through. On the video fluoroscopy, we'd watch the rotations occurring between e- every vertebra, but we know what instability is. It's when the rotation stops and the shear begins. So the ratio of rotation and shear is the marker of that cervical instability. So if I can just show with my hands, here would be the neck moving, rotating well, and then it would clunk. It was the clunk that corresponded one hundred percent with the shot of pain. Now, you and I both know that the muscles-- when a muscle contracts, it does two things. It creates force, but it also creates stiffness. The body uses stiffness to control motion. Okay, so if you just want to observe me now, and you can play along and do this if you like, I want you to lightly, uh, stack your ears over your shoulders and have a pitch to your head that's neutral. Stare straight ahead. Now, lightly touch yourself under your, your jaw, just above your Adam's apple. Don't retract. Don't be-- you're too stiffy. Relax. Now, push your tongue hard to the roof of the mouth behind your front teeth. You felt the deep flexors activate. Now, corners of your mouth grimace down. Do this to your neck. Now, keep that. Imagine the person who's rotating and then has the clunk. Keep that controlling stiffness and repeat the offensive movement. Would you believe in most people, the clunk was arrested? It was gone. Proving that the MR had no ability to pick up that dynamic pain trigger. We just proved what their pain trigger was. You can imagine the psychological relief that they had to know that it isn't in their head, the medical profession was wrong, and, uh, finally they're empowered now because they have a strategy to start learning just a little bit of a strategy to take the clunk out. If you arrest the clunk, over time, the joint will stiffen. The bad news is you don't move so well through that joint. The good news is the pain clunk is gone.
- 2:18:40 – 2:26:49
Pain relief related to stiffness and muscle bulk through training
- SMStuart McGill
So we all experience this, and you're going to be experiencing this now over the next fifteen years, particularly if you're in your early fifties. Things are gonna be stiffening in your body. The good news is your pain will go. The little... Y- y- you know who really gets this? I, I've worked with a-
- PAPeter Attia
Hmm
- SMStuart McGill
... a couple of former Mr. Olympias. That's the top professional level of bodybuilding. They put a lot of mileage on their joints. They don't really get joint pain when they're competing because the muscles are so big, so bulky. They have enormous wrench handle moment arms, and the stiffness holds the joints together. When we work with them tapering down back to civilian life, some of them don't look that different than you and me [laughs] . Believe it or not, what they look like in their former glory, they ache like hell. All their joints have these shearing translations to them now. So the cure is getting a little bit of the muscle bulk back to add some controlling stiffness, and all their aches go away. So anyway, these are all sort of fun stories, but, uh, I, I don't know if, if that's really answered your question on instability, sciatica, brachial plexus nerve traps, numb thumb and first finger, uh, whatever. Th- they're, they're not indicators for surgery at all. Try some of these voluntary skills and, uh, let nature take its course. And, uh, most of the time, and I can with confidence, prove it and say most of the time, uh, it will work out well with some patience and skill
- PAPeter Attia
One of the really good spine surgeons I know, and you can always tell a, a great surgeon by talking to them, and maybe I'm fortunate because having trained as a surgeon, you, you sort of learn what the signs are of the hacks and the, and the good ones and, and, uh, you know, as, as we can all attest to in our own respective profession, we're, we're pretty good at picking up who the, who the good ones are and the bad ones are. But y- you know, in speaking to this spine surgeon, you know, it's just really clear she's a really good surgeon. And one of the signs of a really good surgeon is the surgeon who's really happy to not operate. The really good surgeons are really happy to not operate on somebody. They're... You know, partly what makes them so good is their, their judgment. It's their knowing who to operate on and who not to. Um, we did a really fun exercise one day where we went through my MRI, um, and I... Every time I get an MRI for another reason, if it's gonna get any sort of back cut, I just send it to her, even if it's not a dedicated spine MRI, and I say, "What do you think of this? Does it look any worse?" And again, we're always collectively amazed at how bad my spine looks on MRI relative to the fact that I don't have any symptoms. And, um, one of the discussions we had prompted her to, to, to contrast my back with that of another patient she had who has no obvious disc pathology and yet is in debilitating pain. And, um, she said, "Look at the difference," and, and again, I'm not saying this just to be boastful, but I'm just trying to make the contrast. She goes, "Look at the difference in the musculature of your psoas, your QL, your erector spinae. Like, these are big, beefy muscles here. And now compare it to this other patient. They look... The-- First of all, the muscles are about half the size, and they look like Wagyu. They're very fatty." And, you know, w- the way she was explaining it to me, she goes, "There's a-- This is a person who's never lifted anything in their life, and they don't have any of the disc pain. You know, they don't have the-- Their discs haven't been decimated like yours have, but they're more debilitated."
- SMStuart McGill
Right.
- PAPeter Attia
"Their inactivity has led to instability and tremendous pain." Can you speak to... Uh, you, you've already sort of alluded to this, where we've agreed that the, the, the, the, y- you know, the, the deadlift till you drop strategy and the do nothing strategy are both bad, but can you speak a little bit to why that person might be in pain? And... 'Cause what I don't want anybody to come away from this podcast feeling is, "Oh, I better not lift weights." Right?
- SMStuart McGill
Oh, okay.
- PAPeter Attia
'Cause that's clearly the wrong message.
- SMStuart McGill
100%. Okay, I'm so glad you brought this up. I would love to talk to her, and I'd say, "Tell me about your training program or your daily routine or your life in physical terms." I will bet she's a mobility monster, and she keeps pushing the end range, softening the joints even more. So on MRI, they look plump and pristine, but if... I, I bet if we put her under a load or we put her in bed and she had this instability that I've showed earlier and she lays in bed and the joints just fall like that a little bit, she'll get a hell of an ache to her back. My first question would be, "When you roll over in bed, do you ever have a sharp pain?" Pete, that's a beautiful, uh, follow-up question. It is so indicative of-
- PAPeter Attia
Mm
- SMStuart McGill
... if, if she has nice plump discs but micro movements. How many pillows do you go to bed with at night? That is a wonderfully telling question. The more the pillows, the more the joint instability. [laughs] It's quite, uh, high correlate.
- PAPeter Attia
Mm.
- SMStuart McGill
Anyway, uh, I'd love to have that conversation with her, and I will bet we will get some real insight from that versus, uh, the person who has a mature strength history and the joints are held together. Uh, a little bit of arthritis, and people are gonna nail me for this one, but a little bit of arthritis is good for adding certain amount of joint stability and holding it all together. Uh, I, uh, had a, uh, fracture of C4 as a young fella, and, uh, oh, I would have some terrible episodes checking my blacks-- backs, uh, my, my blind spot or craning my neck-
- PAPeter Attia
Mm
- SMStuart McGill
... to back a trailer up or something. I have zero, uh, pain now. My neck is bulletproof again. It looks horrible [laughs] on a CT or an MR, but my, my, my point is the arthritis has now stabilized the joint. All the pain's gone. Now, I, I don't move it very well, but, uh, I don't worry about it. My, my sister's a vet. She sends me MR-- uh, not MRs, but, uh, X-- just X-rays of a dog. Terrible. And y- as you know, uh, spine arthritis and, uh, nerve compromise in dogs, which is very breed specific as well, um, but they, they lose their hind end.
- PAPeter Attia
Mm.
- SMStuart McGill
And, uh, it, it just atrophies just, just like in a person. But anyway, she'll send me this X-ray of a dog. She says, "What do you think th- this dog's doing right now?" And I said, "Well, it's just laying in its bed." She goes, "No, that just won the Frisbee championship." [laughs] The Frisbee catching championships. So, um, again, it... I just keep coming back to the assessment. Uh, and between you and I, I don't ever wanna see another MRI of my spine until the pattern doesn't fit and I can't move the pain anymore.
- PAPeter Attia
Mm.
- SMStuart McGill
Only time I ever wanna see an MR of my own back. Uh, I'm like you. Doesn't look so good. However, I've got a few miles on my back, and I'm the person I am today because of that, and, uh, I, I do everything I, I- Want to do, uh, with certain guidelines. You know, I'm not 16, and I don't have infinite capacity, so I, I, I play with that tipping point all the time. But, uh, does, does that answer the-
- 2:26:49 – 2:39:24
Advice for the young person on how to keep a healthy spine
- PAPeter Attia
Absolutely. Uh, l- let me ask you a- a- another question. D- let's, um... What would you say to the person who's watching or listening to us right now? And I realize that there's a pretty good chance that by now, 'cause we're a couple hours into this podcast, if you have never experienced back pain, you might not be listening anymore. 'Cause the truth of it is there's gonna be a lot of people listening, because if you've experienced back pain, especially if it's happened more than once or if it lasted more than, you know, a week or so, you know, this is a riveting discussion. But if you were talking to a person of any age who had yet to experience it, but in particular maybe a young person.
- SMStuart McGill
Right.
- PAPeter Attia
Someone in their 20s or 30s, um, what would you say to them, and how would you counsel them with respect to what they could do to maximize the longevity of their spine?
- SMStuart McGill
Right. What a fabulous question. If I was to say to you, a young fella comes into your office with a cigarette hanging out of his mouth, what would you say to him that he hasn't already heard? And, uh, you know, I would love to take you over to the cancer ward at the hospital, and I wanna show you how your last days are gonna look. That might, uh, convince a few of them on the lunacy of what they're doing to themselves. Uh, but you know, it won't be 100% effective, and I would hazard a guess it wouldn't be close to 100%. Their friends and peer pressure is, is far more important for them now, and that's how I'm going to answer the question you just asked of me. I don't have very good luck when I see, uh, someone who's just all balled up. [laughs] A kid called me-- Not a kid, a 30-year-old called me last week, and, uh, this guy was all balled up like this, and he said, "Oh," he says, "whenever I do exercise, I'm just exhausted." I said, "Oh, yeah?"
- PAPeter Attia
[laughs]
- SMStuart McGill
And, uh, I, I, I said, uh, "Would you move away from your, your desk a little bit, and would you ask someone to come in and hold your cell phone up so I can see all of you?" And there he was. And I said, "All right. Would you now sit at your stool, your chair? Sit upright for me. Do you have pain?" And he goes, "No." And I said, "Good. Drop your chest down and slouch and lower your head. Do you have pain?" He says, "Yeah, I do." [laughs] And the whole thing, I just proved to him what, uh, what caused his pain, and I said, um... He, he said, "Well, I've heard that before. I've, I've, I've sat like a cashew," and that was his exact words-
- PAPeter Attia
[laughs]
- SMStuart McGill
... "since I was 14." And I said, you know, "But I ca..." To, to, to, to... I, I coached him, "Okay. Sit up. Lay on your tummy for a little bit. Let this thing calm down. And, uh, by the way, what do you do when you get up in the morning?" "Uh, well, I go down and I, I get a coffee." And I said, "How do you get to work?" He says, "I drive." And I said, "Tomorrow, I want you to get up half an hour early and go for a walk in that beautiful s..." And it was snowing here, so I said, "It's snowing outside. You live in LA. Get your you know what out of bed and go for a walk for half an hour tomorrow morning before you get in your car." Do you know he was bucking me on that? So to your point, I don't think I changed his behavior one little bit, and he's gonna have to suffer a little bit more before he comes to a realization that he does have the power to do something. And you know, I, I know your thesis loud and clear in Outlive. We're identical. We're trying to get people on a program now when he's 30, and not wait to have more misery and more misery. It's so hard to motivate someone. May- maybe you have a, a, a hint for me.
- PAPeter Attia
No. I, I, I, I share your sentiment exactly, and that's why I've often referred to that third bout of back pain that I had, the one that lasted for a year, as the best worst experience of my life. Uh, it was, it was the worst experience in that I wouldn't wish that duration or depth of pain on anyone. But what was so good about it is that it lasted for so long that it created a lifelong change in behavior and an appreciation for something. Which is, without that experience, this idea of a centenarian decathlon wouldn't exist, because you have to sort of see what a life looks like with immobility and pain. Because even though I was only 27, I lived that year as though I was 87, and a year is long enough that it imprints, right? If it was only a week, no matter how bad it is, I don't think it would've imprinted. But a year of that really imprinted in me. I've, I've said this before many times but, you know, to this day, I still enjoy parking as far away as possible in the parking lot, even if there are plenty of spots close to the grocery store or wherever, because I remember what it was like to not be able to walk from the car to the grocery store. So, um, unfortunately, that's probably the nature of, of our species in that it's very difficult to make a short-term sacrifice for a long-term objective without a more pressing reason. So instead, I'll turn my attention to who I think is the larger population listening to us, which are the people who have experienced either personally or through watching someone they care about perhaps. Um, let's start with this. What are the best online resources we can point people to that can help with the types of exercises, maybe some do's and don'ts around lower back pain? Um, and again, I, I love that you even clarified around the big three, which is, hey, the big three are great if you need stability, but, you know, we-- if you need mobility, we might need some different exercises. So, so how can, how can people sort of navigate their way through that?
- SMStuart McGill
All right. I challenged myself with exactly the same issue, uh, fifteen years ago, just as the internet was, was getting going. But here's the thing. There is no such thing as nonspecific back pain. And if that's what the person operates on in their strategy, this nonspecific thing, it will only be dumb luck if they're able to come up with a strategy to mitigate it. They have to have an assessment. Well, they can go and see someone who is very knowledgeable in converging on an understanding of their pain most of the time. Well, short of that, I wrote Back Mechanic. Now, it's not on the internet, and the reason is they have to have some background understanding of how their back works and then go through a series of self-tests. That's what the book does. The first thing is it just says, "Draw a table. What are activities that cause you pain? What are activities that either take your pain away or are neutral? Write them all out." Now, here is how you pattern recognize those. All of those activities involve you bending backwards. Guess what? Change a light bulb overhead that triggers your pain, we're starting to learn a little bit about what could the candidates be. Then we take them through some physical tests. Sit on a chair, slouch, extend, drop one shoulder back, hold five pounds out at front with arms straight. So that's a compression test. Then we do a, a few self-sheer tests. Then we do some nerve tensioning postures to start converging on subcategories of their pain. Then we say, "If you have this subcategory, if you have..." Uh, uh, let's do a real simple one. You get pain when you sit in front of your computer. Going for a walk is relieving. The next person sitting in the computer is their relief, and they go for a walk, and that causes their pain. Probably more in the stenosis older person kind of category. The other one is a, a younger dynamic disc bulge. Okay, sit with a lumbar support, number one. Uh, number two, we are now going to have a strategic exercise session. Uh, you're going to do it every day. You're going to do the big three. We'll mobilize the hips. Um, you're not going to sit longer than an hour at your computer. You just cannot reach a stage of sufficient health if you continue with that behavior, um, et cetera. So that's why you won't find it on the internet. You are going to be-- You're, you're gonna find a lot of people who do not have the expertise, "Oh, here's the quick fix for your back pain." Well, good luck with that. So [laughs] that's my answer to your question and, uh, the solution. Um, and, and just going back to, to listening to you, uh, j-just as you started to answer that question, I, I, I've got s- a little bit of good news for you, uh, in terms of your own back. And by the way, I know who I'm talking to, so I know you get this, but this is for the readership listening or the listenership. I retired early. I retired when I was sixty. I reached a stage where I realized what I'm-- what my job was. I got to... Uh, when I s- I started as a professor in nineteen eighty-six, student meetings meant students came to see you, and we would get up, and we work through things, and we do things in the laboratory and whatnot. And then the students started to migrate to this idea, "Oh, sir, could we have a, uh, an online call for student hours?" "No, you can't. You get down here. [laughs] We're going to work through this problem." In other words, my job got turned into a sitting job, and it was killing me, and I realized that my health was declining, my fitness was declining. I still walked to the university. I strategically bought a home right on the edge of campus, so I would have a twenty-minute walk to and from my office and laboratory. Still, I was declining. So I walked away. I shut the door on my office. I said to the graduate students, "There's all my books. Go take them." To all the other professors, "There's my lab. Go take it. I'm, I'm..." And I just walked away, never thinking that anyone would ever ask me again 'cause I'm not producing new data anymore. I was sort of wrong on that estimate. But anyway, my point is, Peter, I'm healthier now than I ever was in the latter fifteen years of my computerized work life. I hardly go on the computer. It's fabulous. Uh, I can talk about my life now if, if you want and what I do. But, uh, my point in this story is I think you're gonna look forward to a resurgence, uh, of your health. Maybe you've got it dialed in with your seeing patients and traveling and everything else. Maybe you don't. But trust me, when you retire, and that doesn't mean leaving your whole medical family and expertise. I mean, I'm sort of working right now. Uh, I still see patients two days a week. It's, it's, it's a wonderful marker for my week. I love it. But the other five days, I, I, I, I, I live a healthy li- Anyway, my point in all of that is things are gonna get really better for you. [laughs] They're not gonna decline more. I've heard you say that, and I think, "Pete, come over with me, man. Spend a couple of days and, and, and you'll, you'll see how y- y- y- you're not on this decline as, as you think, as a fait accompli."
- 2:39:24 – 2:45:19
Resources for individuals dealing with lower back pain
- PAPeter Attia
Well, you, you just said something a moment ago that I was gonna ask you about. So, um, uh, at the risk of overwhelming you, because I know that there are gonna be so many people listening to us who are gonna say, "You know what? I am not happy with the assessment or lack thereof that I've received. I'm not happy with the care that I'm receiving with respect to my lower back injury. I need to go and see Dr. McGill." What is involved in arranging that type of a consultation with you?
- SMStuart McGill
And again, I, I feel, uh, awkward saying this, but that's why I wrote Back Mechanic. So well, I don't see anybody until they've read the book.
- PAPeter Attia
Hmm.
- SMStuart McGill
And most of them say, "I don't need to see you now." So they've been through the self-assessment. They've got enough out of it. Now, if they're not getting enough out of it, uh, on, on our website, backfitpro.com, we have two layers of clinicians. We have the, uh, certified clinicians who've taken that 50-hour course. They've gone through the, uh, hands-on skills training. They've written the exam. But I've never worked with them personally. But they are all there on a, on a, on a page. Uh, then we have a different level called master clinicians. I have worked with every single one of those people and trained them. I've seen patients with them. They have my confidence now that, uh, I can send them, uh, any, any patient, and they will subcategorize them and know pretty well what to do with them. I continue to train those, uh, individuals. I, I seek out stars or people who have the passion and the skill, and I go to them and say, "Would you now study with me? And I'd like you to become a, o- one of our master clinicians." So that's my, uh, answer to that dilemma, which-
- PAPeter Attia
And, and how many, uh, how many master clinicians are there in North America, Stuart?
- SMStuart McGill
Not many. I, I don't know. A dozen, 15 maybe, something like that.
- PAPeter Attia
But they're all identifiable on the website, which was backfitpro.com?
- SMStuart McGill
Yes, they are. Correct. And the certified, that, that's growing all the time. There's maybe 30 or 40 of them. Uh-
- PAPeter Attia
Okay
- SMStuart McGill
... we add to that every, oh, maybe one or two, uh, every couple of months.
- PAPeter Attia
Okay.
- SMStuart McGill
But, uh, a- a- anyway, the, the, the... S- I, I think people, in reading that book, it's a v- it's quite a quick read. It was a very difficult book to write, uh, as, as you can imagine. I was-- I've written my medical textbooks for my medical colleagues. Those are easy to write. You put in the references. You make your points. You show the strength of evidence, e- et cetera. But you can't do that with the public. Uh, y- you have to give them enough of the truth to guide a effective strategy, but you can't overwhelm them with jargon and all of that. So that, that's why th- those things are so difficult to write. But people tell me that Back Mechanic, in any case... I, I sent you a copy. I, I hope you got it.
- PAPeter Attia
I not only got it. I greatly appreciated the inscription in it. Thank you.
- SMStuart McGill
Oh, yeah. Okay. That was special. [laughs] Heartfelt. Uh, in any case, uh, that is my solution to that conundrum, and that's why going to the internet, as you know, it's the Wild West. You can get screwed up as much as you can, uh, be helped.
- PAPeter Attia
Yeah. Well, Stuart, this has been a really, um, enlightening discussion for me. And given how much I've thought about this topic, uh, I think that says something. But it tells me that, more than anything else, a lot of people listening to this, uh, which again, I think is a lot of people who can relate to what we're talking about personally, um, I, I think this, I hope, offers a more than just a glimmer of hope, um, and, and also a set of resources that people can look to. And I will take you up on this offer the next time I'm in Toronto. Um, we'll, we'll make that trip up to, to Gravenhurst. Uh, apologies for my poor Canadian geography. I always thought Gravenhurst was just outside of Toronto. I didn't realize it was that far north. But, uh-
- SMStuart McGill
Yeah. Br- Huntsville, Bracebridge, Gravenhurst, if you know that area. Right in the heart of Muskoka.
- PAPeter Attia
So j- just from, like, Aurora, we're talking, like, what, 90 minutes, two hours?
- SMStuart McGill
Uh, we'd be, uh, a good hour north of... No, about an hour and ha- an hour and a half north of Aurora.
- PAPeter Attia
Okay. Yeah. Um, all right. Well, we'll, we'll make that happen.
- SMStuart McGill
Okay. I-- Well, I hope so. Peter, I've looked forward to this day for, uh, ever since we scheduled it a couple of months ago. Uh, the leadership that you've provided, uh, is, is fabulous. I, uh, have spent many hours listening to your podcasts and getting wisdom from, uh, your guests. And, and the level that you take all these issues to is, uh, just the foundation I need for, uh, a lot of the things that, uh, I think about. So for all you do, thank you so much. And, uh, the, the way you posed your questions today were, uh, not really typical, so I appreciate that very much. But, uh, again, thanks for all you do.
- PAPeter Attia
Thank you for what you do 'cause that's, uh, that's where I'm learning today. So thank you, Stuart.
- SMStuart McGill
Okay. My pleasure. [upbeat music]
Episode duration: 2:45:19
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