Ep. 25: Nagging Lower Back Pain—and How to Fix It
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Lower back pain is one side effect of the pandemic—so we arranged an interview with the world authority on the causal mechanisms of disc and spine issues: Dr. Stuart McGill, the author of Back Mechanic and the founder of Backfitpro. McGill fixed back issues without surgery for NFL superstars, PGA Tour golf coaches and world-record breaking powerlifters. In this episode, he provides easy-to-follow advice on how to address some of the more common pandemic-wrought back problems. Dr. Stuart McGill is interviewed by guest host Stephen Salzmann, Medcan’s director of fitness.
Please subscribe and rate us on your favourite podcast platform. Eat Move Think host Shaun Francis is Medcan’s CEO and chair. Follow him on Twitter @shauncfrancis. Connect with him on LinkedIn. And follow him on Instagram @shauncfrancis. Eat Move Think is produced by Ghost Bureau.
Transcript pasted below. Relevant links:
Dr. Stuart McGill’s book for lay people is Back Mechanic.
He is the founder of Backfitpro.
Dr. Stuart McGill’s “big 3” exercises that are prophylactic for back pain are all over the Internet. Here are further instructions and context on how to do them properly.
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Rough transcript of Stephen Salzmann’s conversation with Backfitpro back mechanic Dr. Stuart McGill:
STEPHEN SALZMANN
I'd like to start by, first of all, again, thank you for making the time. It's an honour. Dr. McGill, I've read many of your books, and your work has been very influential in my own personal training practice in the past and many of the clients that I've worked with. And going through the management stream of the fitness industry, I've tried to infuse your research and the content of your books into the training that I give to personal trainers on a regular basis. And especially with the pandemic going on, and many people being more sedentary, I realized that it was a great opportunity to meet you and get to pick your brain in perhaps a little bit more depth. So with that, and the influence that you've had on me, I've always been curious—what got you into working with backs?
STUART MCGILL
I'm asked that question a lot. And I have to admit that the journey was never planned. Certainly my high school teachers would never have predicted that I would become a professor and all the rest of it. When I finished my PhD, I started at the University of Waterloo and developed a laboratory to measure stresses on the various tissues, the spine tissues. Now I just simply had one question: how does the back work? And it was as simple and almost as naive as that. And we would probe stress concentrations, stability, strength, movement patterns, etc. to see how they linked or impacted with either spine function, health and pain.
And then we developed another laboratory to investigate what happens when you stress specific tissues. So it was a cadaver, spine cadaver lab, and we would measure the stresses on people and then apply them to -- cadaver spines and see what broke. Well, of course, a cadaver is not a human. So then we would work with our various colleagues around the world who were doing human studies and link what we saw in the cadaver and calibrate it to -- to living people. And almost always, if there was tissue damage either at the micro level or the macro level, there's only one way to do it, and it was a stress concentration. Well, we would get invited to speak at different scientific meetings and medical meetings, and I would try and describe what we were discovering about some of these mechanical concepts, and then a clinician would say, "You know, that's interesting. We don't think that way. Would you see a patient with us?" And so slowly, I started to see patients but I was never formally trained as a clinician in the early days. And then since that time, you know, I've been a very -- visiting professor at several medical schools. And then we started to probe well, If these are the mechanisms, how on earth would you assess them in a person?
So that was the beginning of our somewhat unique assessment tests to try and uncover what was causing these -- a person's pains. Then in working with the athletes, I got to work and meet with some of the top coaches and some of the top sports programs throughout the world. I was introduced to some of the Russian science, Eastern European science. And then working in different organizations, the combat athletes and hockey and football which I was somewhat familiar with. Some of the Olympic field sports were all very interesting. I think of someone like Dan Path, who probably has many Olympic medals to his credit in the sprint sports.
And learning all of these things, you know, I think I was one of the first to ever measure some top UFC fighters—who hits the hardest and why? What were the mechanics? And it turned out it wasn't the strong fellas in terms of brute muscle strength, it was those who could create proximal stiffness, a pulse of force, and then let it relax to create closing velocity from the fist in a ready position, and then when they hit the target they pulse again. And when you measure and feel all of this, it's like being hit by a hunk of granite, or by -- you might as well be hit by a Honda. Anyway, my point was in working with the coaches and seeing what they coach to enhance performance and then our investigations of the mechanisms, we're able to enhance that and bring it all around full circle to really optimization. And it started with a) get rid of the pain and now let's get this human to really perform. But when I first started this journey 35 years ago, I never thought in a million years I would end up to where we are today. And I retired from the university three years ago, and I just see patients at our home clinic here in little Gravenhurst, Ontario. But they fly in from around the world. It's amazing.
STEPHEN
Absolutely. That's great. That's a great story. So what has happened with respect to back pain and back rehab in the last six months due to the pandemic?
STUART MCGILL
Well, may I begin with a little bit of a foundational scientific description to really give that answer some context?
STEPHEN
Absolutely. That'd be great.
STUART MCGILL
All right. Well, let's let's start this way, and that is all pain has a cause, and needs a thorough assessment to reveal it. Years ago, when we first started to investigate back pain, we just had a simple question, how does the back work and what are the pathways to pain? And we developed a technology to map stress among the various tissues of the back. And lo and behold, those tissues that bore the highest amount of stress were the ones that became painful. The next principle is that posture change migrates stress from one tissue to another. So you can imagine if I was sitting upright, bolt upright,. II would need muscles to support my upright posture, eventually they're going to become tired, then painful, and then they will go into a pathological state if I held that to extreme. So if I changed my posture and slouched for a little bit, I'd migrate the stress on to that discs and the ligaments, which once again is fine for a short period of time if they are not pain sensitised, but they too will build up cumulative stress.
So now with that background, I can answer your question. I don't think the pandemic has changed people's spines in any way. But what it has changed is their behaviour and their behaviour determines the chronic stress and the postures that they stay in for periods of time. Most likely spending more time sitting, sitting on the computer, and that kind of thing, not going outside and meeting with friends, limiting the amount that they're actually walking and interacting outside and that kind of thing. So it's been a massive shift in human behaviour.
STEPHEN
With working remotely, we are all sitting much, much more and more sedentary. What are some of the less obvious effects of this and what do you recommend we all do to avoid them?
STUART MCGILL
Everyone's source of pain is slightly different. So a thorough assessment will reveal the type of pain mechanism that that person has. So if the person sits for 20 minutes in front of the computer, and that causes their back pain, and then they go for a walk, and that is relieving, and that takes their pain away, you've just identified at least in terms of a movement strategy, what they should stop doing and what they should do, which is take frequent breaks from sitting and going for interval walks throughout the day.
Now I know you have a general interest in broad health, you're not just a spinalphile like myself. And as you know, from a cardiovascular perspective, a hormonal perspective, a psychological perspective, and absolutely from a musculoskeletal and a spine perspective, you cannot argue against frequent walks throughout the day. So there would be the beginning of that conversation. Now to play the other side of the coin, it's more typical for older people to get relief from sitting and walking could -- it would certainly have a higher risk of triggering their back pain. So obviously, they would need a different strategy that would be targeted to their specific pain mechanism.
Stephen
Kind of branching off of your -- of the last question and your answer, besides maybe people experiencing new aches and pains for perhaps the first time because of this all of a sudden onset of much more sedentary lifestyle, you may have other clients who maybe have nagging low back issues creeping back up. And many believe that they have to grow or hypertrophy their back muscles or their entire core to improve the symptoms. What are your thoughts on this approach?
STUART MCGILL
Well, I have been experimenting and probing this question for well over 30 years now. Increasing muscular size and strength is really not linked to reducing back pain as much as people would think. We've done studies on firefighters, police officers, different athletic groups, and strength is not protective at all. In fact, when you look at the -- you said you're in Toronto, we did a study on the Toronto Police Force over five years, those who were the strongest and the highest trained had the highest incidence of back pain. So ...
Stephen
Interesting.
STUART MCGILL
Yes, I hope that dispels the myth a little bit. However, we could get into all sorts of conversations now, probably starting with the notion, it was the way that they were training to gain their fitness and I can really riff on that topic. If you would like me to.
Stephen
Yes, let's hear it. I think that it would be—it could only be useful to perhaps dispel some common notions about low back theory, that people may have.
STUART MCGILL
Right. Well first of all, the spine is not a series of ball and socket joints. The spine discs, which are the movement elements that allow the spine to move actually fall into the category of adaptable fabric. So the ball and sockets are the shoulders and the hips and it's no coincidence that they are either end of the torso. But the torso itself has discs and the discs are made of strands of collagen, and the collagen is held together with a ground substance that sticks them all together, so to speak. So you can imagine grabbing two points on your shirt and working those two points back and forth. Over time, the fibres of your shirt would delaminate and you would create a hole in your shirt. So that was purely motion driven. Now you couldn't do that to a ball and socket joint, the ball and socket joint would just bend and twist and the socket. That's what they're made to do.
So if you take a person's back and bend it back and forth over and over again, and then add load while you're doing it. So where would this occur? It would occur with a person who sat slouched for a while and then they had a young child they reached into their crib, not bending through the hips, but bending through the spine, that added more load. On and off the toilet, in and out of their car, all day long. When you add up the repeated stress strain reversals, it actually loosens the ground substance between the collagen so the next time that they pick up something very heavy bending forward, the nucleus, the gel inside the middle of the disc works its way through the delaminations and the collagen to create a disc bulge. So that is a very common mechanism of people's back pain when they sit for a while, if they didn't have any collagen delamination, they wouldn't have a disc bulge and sitting would be quite tolerable, and there would be no issue.
So there's just an example. Now the next example, because we started this talking about back strength, is that our body forms a linkage, which is a rather unique structure. So think of your arms, your legs and your torso. These are segments with articulated joints holding them all together. Well, in order to get a linkage to move, you have to create what an engineer with called proximal stability. So think of a backhoe, a machine that moves earth. The first thing a backhoe must do is lower the stabilizers down into the ground and it stops the tractor part from moving, it's created proximal stability. That now allows the arm with the bucket and digger on the end to grab earth and move it. But if the base moves, you can't create any power on the bucket. So it's exactly the same for me to stand and then stand on one leg I had -- I had to create strategic stiffness in my spine. Otherwise standing on one leg, say it was my left leg, my right leg and hip would simply fall to the ground. So I had to create that proximal stiffness. But then it's the mobility distally in the hips and the knees and the ankles that then allow me to walk, to push and pull doors and these kinds of things to unleash the shoulder joints in the elbow in the hands. You always have to back that up with proximal stiffness.
So, you know, you may have heard of the old adage, you can fire a gun out of a battleship, but you cannot fire a gun out of a canoe. And that's a very simplistic analogy showing how proximal stiffness is required within the linkage. So now we can go full circle and talk about strength and pain-free function and musculoskeletal health. Instead of creating more strength in the torso muscles, or I believe you used the word core muscles, the key is to build proximal stability. And as you are well aware, we've spent many years converging on what are the best exercises to create and ensure proximal stability and stiffness to protect the back and create very efficient function in a person's body. And those are the modified curl up, the side plank and the bird dog. They are the very best exercises that we've evaluated for ensuring a stable spine and a lessening of stress concentrations. They do so in a very spine-sparing way. We program -- program them in sets and reps to build muscle endurance. Strength comes along, that's for sure, but we don't train strength, we train endurance. And interestingly enough, it's been endurance that has been shown to be prophylactic or protective for future back pain.
We took a group of men at a company in Kitchener actually, Ontario, that chromed car bumpers for a car manufacturer, and we followed those who had episodic attacks of acute back pain throughout the year sufficient to miss work. And then there was another group that never missed work. Now, let me ask you a question. Do you think the ones who never missed work but they were all doing exactly the same job had stronger backs?
Stephen
Stronger? I would say, based on what I know that they weren't necessarily stronger. No.
STUART MCGILL
That's -- you're absolutely correct. In fact, it was the stronger ones who were endurance deficit. And what happened when we measured the injury mechanism and the pain pathway was they would lift the car bumpers using their strength, so bending over and lifting with their backs and that kind of thing, which they did well, for a limited number of lifts and then they got tired and their lifting form broke down. Now even more stress concentrations went onto the discs of their low back and they ended up with discogenic back attacks. The ones who were protected, didn't have as much back strength but they had more muscular endurance and they lifted, maintaining good form for longer. And they didn't create the cumulative stress in their low back discs and didn't miss work or suffer -- suffer the social consequences of debilitating back pain.
So, you know, you may ask what is good form? Well, if the spine is under load, try and bend from the hips like an Olympic weightlifter would do, for example, if you've seen them or the listeners have seen them at the Olympics. They squat down and actually pull with their hips a little bit more than their knees. People say lift with your legs, it's actually lift with your hips would be a more accurate description, and not so much with the back. And in fact, in other studies, we found those who lift closer to world record actually have less load in their back and more load in their hips. So I can go on and on with the evidence. But you're starting to get the idea that lifting with good form is protective. And there's a lot of other strategies that people can use in this special pandemic time as well.
Stephen
Yeah, excellent. So I mean, some of the key takeaways would be to absolutely focus on form, and by focusing on form that would mean maintaining a neutral, low back especially or close to neutral while getting the actual propulsion or locomotion or movement or power generation from things like the hips and in the upper body, the shoulders.
Stephen
So for clarity for our listeners, we mentioned the McGill big three and they are essentially three very, very important exercises that include the side plank, the bird dog, and the McGill curl up. Side plank is a variation of a plank where you are on your side on either your elbow or your hand. The bird dog is where you are on all fours extending opposing arm and leg. So right arm, left leg; left arm, right leg. And the McGill curl up, which is you can think about it like a variation of a crunch where your hands are under your back and you have one leg bent at all times. For more detail on these exercises, we'll put a link in the show notes.
Stephen
Now, when you -- when you come across a back that does have pain and you are going through rehab, is low back rehab something that can be accomplished in a few months, a few weeks or even a few workouts as much as we'd like it to be?
STUART MCGILL
The answer to that is, it's highly variable. And it depends on several things. First of all, it depends on the underlying mechanism of that person's pain. Some conditions are surprisingly quick to wind down with the appropriate intervention, and others are stubborn. They take a long period of time. So I can give you some examples. If we go back to the -- well, the fellows who were chroming car bumpers, when they had an acute attack, it was so acute that they had to lay in bed for two or three days, they were just really locked up with massive back pain, but they were back to work within about a week. So that kind of discogenic back pain can be wound down very quickly. And believe it or not, when we trained the workers, and we've done this with patients time and time again over the years, once they learned and were schooled in what the specific movement flaw was that caused the acute attack, they never had another one.
So let's take another pathway to pain and it would be more in an older person. They've got a little bit of arthritis activity in their backs. The discs are thinning out a little bit, the bone has responded with some bone spurs and these kinds of things, which are narrowing the holes through which the nerves travel. These are conditions of central and foraminal stenosis. If people are familiar with those kinds of diagnoses, they may have had them. These, generally speaking, take a little bit longer to wind down, if at all. And some back conditions really aren't treatable, but we put them in the category of being more manageable. So you manage the symptoms, hopefully to subclinical levels, but hopefully to levels where they don't have impact your life very much. So that's the honest truth. There's a full spectrum of responses there. And obviously, they have to be different because of the spectrum of pain pathways.
Stephen
Interesting. And I think that that's -- that's a -- that's a really good point and something that both personal training clients and personal trainers themselves should keep in mind when deal -- when working with patients or clients who do exhibit low back pain, that it's not a one size fits all and you need to approach each case uniquely, assuming that what may have worked or alleviated some of the symptoms in one client may not necessarily be the correct approach with another.
STUART MCGILL
That's exactly right. As you know, I've written several textbooks for clinicians, but I wrote one for the lay public called Back Mechanic. And the trainers tell me that this is a very consumable book to guide their programming for their clients. And the book guides the reader through a nine-point self-assessment of their pain. The trainers, as I said, find it very helpful because they're based on motions, postures and loads and habits that are either shown to be associated with their pain trigger or not. And then the trainer first and foremost doesn't prescribe exercise. In fact, they train movement patterns. We call them movement hacks, that coach the person how to accomplish tasks of daily living, but in a way that doesn't poke their pain trigger.
So in other words, say tying your shoe was a fairly potent pain trigger or at least set off, you know, back grumpiness for the rest of the day. If you can teach the person how to stand up and instead of sitting on the bench to tie your shoe, stand up and put one foot in front of you in a lunge pattern and then the key is don't bend forward to tie your shoe, it's actually to with the stance leg, bend the knee and take your hips down to the target, and then you can reach forward easily without stressing your back to tie your shoe.
So these movements, they're movement hacks based on squat patterns, lunge patterns, twisting through the ball and socket joints and not through the spine and this kind of thing to enable, you know, pulling heavy doors or pushing things in a way that create movement hacks around their specific spine triggers. And then once the pain is starting to wind down through the movement hacks, then the trainer can create a tuning of the body where they've created this optimality of strategic mobility and stability that we were talking about earlier. They teach some appropriate footwork, for example, on how to move around objects, lift objects, how to walk, how to push, how to lift and lower, etc, and know enough of basics about the various injury mechanisms that they know how to stimulate adaptation and healing. So that's in the Back Mechanic book.
Stephen S.
So I guess jumping right off of that -- that last idea of managing the low back pain, I've met many people, clients, trainers, who -- whose default strategy centres around stretching. And so what does your research say about the effectiveness of stretching to deal with low back pain and can yoga and Pilates be effective?
STUART MCGILL
Yes. Well again, it depends on the specificity of the mechanism of their pain. I have a model that I can show you, a common disc bulge, and I will show you how bending forward causes the disc bulge to grow. So if your stretching routine that's been given by your family doc and the family doc says, or your physical therapist might tell you, before you get out of bed in the morning, pull your knees to your chest, which is a stretch. Now that stretch, there's no question it fires off a stretch reflex which is an analgesic. It will make and trick the person into thinking that they are feeling less pain for the next 20 minutes. What they didn't realize was they caused the disc bulge to become just a little bit more engorged, a little bit more angry. So for the rest of the day, they just irritated it a little bit. So for that discogenic person, pulling the knees to the chest, stretching out the hamstrings usually prolongs their pain. They stretch. Every day they stretch, they've been doing it for a year, they're not getting better.
But now let me play the other side of the coin. There is another subcategory of back pain where neurogenic effects happen. In other words, having back pain and hip pain causes the brain to not use the gluteal muscles. So when a person gets out of a chair, they extend the hips with the hamstring muscles rather than the gluteals. So we've measured this in people. We induced hip and back pain and measured the shift of activation strategy, leave the glutes and substitute in with the hamstrings. But the other half of that, that's gluteal -- sorry, that's neurogenic inhibition. The opposite is neurogenic facilitation. So in the COVID times, people are sitting more. If they have back pain and hip pain when they sit, they may get neurogenic inhibition, but they get neurogenic facilitation of the psoas muscle. The psoas muscle is a hip flexor, and one of the first signs of that is when they get out of a chair, they find it very difficult to achieve an upright position right away because of the perception of tightness down the front of their thighs and in the crease between the leg and the torso.
So now I'm going to argue a very targeted psoas stretch is quite often effective in releasing that neurogenic facilitation. So we can't talk about back pain and say do yoga for your back or do Pilates for your back. However, the psoas stretch is a form of a stretch both in yoga and Pilates.
Stephen
Right.
STUART MCGILL
My point is, if you pull out certain tools from yoga and Pilates and apply them to the appropriate person, very effective. And then the next thing they do is another stretch because it's part of a yoga programme, and that was poison to their mechanism. And yet they just used another yoga stretch to help it. So this non-specificity is a real problem. So the solution is to get a very thorough assessment, understand your pain mechanism, and then you have a roadmap to know exactly what to do. It'd be like going to your car -- your car mechanic and saying, "My car is having problems," and the car mechanic says, "Oh, good. I'll change the engine." So, you know, without diagnostics and an assessment, the mechanic wouldn't have a clue on how to match an appropriate intervention for your car. And it's exactly like that with back pain. Stephen, could we have a conversation about non-specific leg pain?
Stephen S.
Absolutely.
STUART MCGILL
Could you give me an exercise for my leg pain? And I haven't told you whether we've got torn ligaments or a burn or poison ivy or a muscle tear, you know?
Stephen S.
Yeah.
STUART MCGILL
We have to know what's going on.
Stephen S.
Absolutely.
STUART MCGILL
You know, we don't put up with non-specific head pain or non-specific leg pain. We certainly shouldn't be putting up with non-specific back pain.
Stephen S.
Absolutely. And I think that where we may have, or where clinicians, practitioners, trainers may be in getting into a little bit of hot water, a bit of false confidence is where maybe the first time they did by chance hit the nail on the head and saw some improvement, and now they feel as though that's the strategy to apply to everyone, where that very often is not the case.
STUART MCGILL
It happens with every type of clinician, trainers through to therapists, through to -- yeah. You know, when you think about it, it's kind of interesting. There's nowhere in our medical system to obtain a thorough assessment. It is such a systematic impediment in the back pain field. If people -- you know, so a chiropractor provides their specific intervention, the physical therapist provides their specific intervention that they're trained to do and that they're reimbursed for doing.
Stephen S.
Right.
STUART MCGILL
But whether it is the right thing to do or not, that would be solved by having a thorough assessment. So once again, I'm afraid we have to guide people through that or that's why we put on courses for -- for trainers to teach them how to run a -- an assessment. And here's something else that is so interesting. Most back pain can be subcategorized by motions, postures and loads. Bending forward causes your back pain. Arching back and rotating causes your back pain. Or when you run and cut without sufficient core stiffness, you get back pain. In other words, every single one of those is a mechanical intervention. Now who owns those mechanical interventions? It's not the family doc.
Stephen S.
Right.
STUART MCGILL
It's the trainer. The trainer, when you think about it, has the biggest potential to influence that person's lifelong health.
Stephen S.
Right.
STUART MCGILL
Cardiovascularly, hormonally, psychologically and musculoskeletally. You know, you think of the -- all the diseases that people go to their doc with and how many of them are mitigated, modulated, affected by good movement. Who owns -- who owns good movement?
Stephen S.
Right. Hopefully it's us. And you know, if for nothing else, then for the sheer volume of times that the average trainer sees the average client, it's, you know, much more than perhaps many if not all other healthcare professionals that are out there in any other industry. So there's -- there's some power that -- there's some power and responsibility that I believe trainers have or coaches have to really hone their craft and make sure that they are doing what's best for their clients.
STUART MCGILL
That's well said. It's a huge responsibility. To become a master of the craft is a commitment for every trainer.
Stephen S.
Absolutely. Now being a slightly -- maybe a little bit more than slightly, but familiar with your work. I know you'd like to use the term spine hygiene. For those unfamiliar with it, what would you recommend we do every day, especially for those people with low back pain?
STUART MCGILL
Well, first of all understand the mechanism of your pain, and then you will be able to design an appropriate spine hygiene program to wind down that pain. So let's say for example, I had irritated facet joints. So I would -- when I'm standing for example, instead of standing in tension, gripping with my gluteal muscles, locking my knees hard back in extension, which if you place your hand on the client's back, you will find as soon as I lock my knees back, I just drove extension. In other words, unbeknownst to them, their habitual behaviour was picking away at the scab and keeping that extensor pain trigger active. So spine hygiene would be well, let's stand in a way now that takes the stress off the pain mechanism. Give me some jazz knees, relax your knees. Good. And we might do some other interventions. You know, just simple coaching. Can you stand in a way that you don't use any muscle at all? Let your systems go quiet. Place your ears over your shoulders over your hips over your knees over the middle of your foot. Now float. Become a leaning tower back and forth over your ankles. Float over that, soften your knees. And now there is a spine hygiene hack for you to stand without braking to pain sooner.
Stephen S.
Many have been dealing with low back pain for as long as they can remember and, you know, I've come across clients like that. I know trainers on my team have and I'm sure you have. And in some cases, they've been -- they've had imaging, they've been diagnosed with degenerative disc disease or slipped discs, and they believe their back won't be completely fixed without surgery but hesitate to go to that extreme. What advice do you have for that, that subset of the population?
STUART MCGILL
Well, if it's just the lay public, and they've failed in acquiring a very thorough, competent assessment that helps them understand their back pain trigger, I hate to say this, but I have to. That's why I wrote Back Mechanic, to guide them through a self assessment of their pain triggers. Now if they have received a diagnosis—they have degenerative disc disease, there's no such thing. It's a garbage type of diagnosis. It doesn't guide any treatment, and it really doesn't exist. I have white hair. I guess I have degenerative hair disease. So -- but what matters more is -- well, let me just -- I'm going to put a bit of perspective on that as well. People should know that I've got fighters in the UFC, top NHL superstars, people playing professional football. I don't know how many hundreds of Olympic athletes I've worked with over the last 30 years. Most of them have been diagnosed with a degenerative disc disease. They have no disease whatsoever. They've had a disc injury usually or an [inaudible] injury, and the disc is a little bit flatter now.
So, you know, I just cringe when I hear these, and it's so psychologically destructive. I've had patients come in and I tell them, "Oh, we'll do this," and they say, "Well, when will I be in a wheelchair?" And I say, "What do you mean, when will you be in a wheelchair?" And they say, "Well, I've got this degenerative disease." I said, "Well, so do we all, but chances are, let me show you something right away, do something." And whatever it is, it creates their pain. Then immediately when we show them a movement hack, their face changes and they realize they are in total control of their pain magnitude, etc. And then we start building their confidence, showing -- showing them how to wind it down.
And, you know, I got a call yesterday from a top tour tennis player. "I'm back." And he was -- he was diagnosed with degenerative disc disease. He thought his career was over. "Hey, baby, I'm back." It's -- so I -- it's just destructive, irresponsible. I don't know what more words I can put on with that. It's -- it's just a practice that is horrible for a patient to get.
Stephen S.
Understood. And as it relates to -- to back surgery specifically, I'm get -- I'm assuming that that's really really a last resort in many cases, or maybe I won't be so broad, but in a significant number of cases that have been diagnosed that they do need surgery, there is in fact a non-surgical pathway to being pain free.
STUART MCGILL
Yeah. Well, Chapter Four of Back Mechanic is Do You Need Back Surgery? Now I can stand by this statistic, Stephen, because we follow up with every patient that we've ever seen. If they follow the program that we give them in Back Mechanic, I can tell you -- and I'll stand by this number -- those who've been told their last remaining option is spine surgery, we get 95% of them to avoid surgery and then in a two-year follow up, they were glad that they did. So I can stand by that. They didn't need spine surgery. Now that chapter goes through a little bit of an algorithm. What are the indicators for spine surgery? What questions do you ask the surgeon to ensure that the risk is the lowest for the kind of surgery and the kind of back diagnosis? Because they are going to change your anatomy with a knife, you better hope they're cutting the pain out.
But we also encourage them to try virtual surgery. Now let's go back to a principle we discussed half an hour ago. A lot of back surgery works because it's forced rest. Let me give you an example. So we all know the kind of client who you have to motivate to train. But we also know the polar opposite psychological client who's addicted to exercise. They will say, "I have to go to the gym and run on the elliptical 40 minutes every day, otherwise, I'm going to murder my spouse." Or, "It's the way I handle stress."
Stephen S.
Right.
STUART MCGILL
And I'll say, "Yes. But, you know, we've just shown you that that is why you have back pain. You're going to have to let it rest. So we are going to give you a substitute activity, but one that's friendly to your back." Anyway, then I'm going to make a big production out of it. And I'll say, "Good, go have your surgery. However, let me now give you virtual surgery." If you had real surgery, you're not going to get out and go to the gym and ride the elliptical tomorrow are you? No. You're going to rest, get up, short interval walks. Within a week, you've got some strategic mobility and stability starting to be rechallenged and reintegrated. And we build you back in a scientific way, not creating your pain triggers. So through virtual surgery, you will test whether you really need it. So I give several -- again -- hacks and algorithms. But as I said, once the person goes through that, 95 percent of them will avoid surgery. Now there's still five percent. And absolutely, there are times for spine surgery. There's no question. But these are people who usually they've been traumatized, there's some heavy fracturing or tissue disruption that a knife can speed along its structural stability.
Stephen S.
Understood. Thank you for that. And the last question that I have is actually another one that was submitted by the trainer. So maybe a bit of a curveball here. And it is what, if any, is the most impactful technical criticism that you've received on any of your research? And how has it led to changes in your rehab or fitness content moving forward?
STUART MCGILL
You know, I mean, sometimes there are things that can't be fixed and, you know, as much as we try, and we've had some wonderful victories where we didn't give up. I can think of a top level power lifter who was recent. And when you looked at the scans anatomically, they had a very narrow canal for the spinal cord. There wasn't much room there. And the majority of their pain was when they first got out of bed in the morning. And you're -- you're well aware that the discs are hydrophilic and suck up fluid and become turgid and a little bit stiffer and fatter if you will, early in the morning. And we didn't give up on this. And we kept probing it until finally we found a little bit of an inroad, and that was never lay in bed longer than seven hours. And he never got the hydrophilic turgor in his spine. And you know, I go back to the studies we did oh, probably 15 years ago at the university where we put students to bed and measured their spines' swelling, after eight hours all the way through into 30 some odd hours, and the spines go into quite a lot of hydrostatic stress.
So when you lay in bed for eight hours, think of people who have back pain, and they don't get out of bed 'til 10 o'clock in the morning and I -- you know, I'll point this out to them and I say, "You know, you're actually creating us a scenario where you've increased your your spine stress. So anyway ...
Stephen S.
Fascinating. I just want to say thank you for doing this. I've been a fan for many years. I was a little bit beside myself when I got that email saying that we -- you know, we got you. So I don't -- I don't -- not many things make me nervous. I was actually a little bit nervous coming into this. But I had a great time and I learned a lot. So thank you very much for today and what you've done in the past in your work.
STUART MCGILL
Stephen if it -- I'm trying to find the right words here. I was nervous too. And I always am. So it's -- that never goes away.
Stephen S.
Good. All right. Well, thank you again.