The Peter Attia Drive - #287 ‒ Lower back pain： causes, treatment, and prevention of lower back injuries and pain

00:00:00.000 Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:16.540 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

00:00:21.520 into something accessible for everyone. Our goal is to provide the best content in health and

00:00:26.720 wellness, and we've established a great team of analysts to make this happen. It is extremely

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00:00:53.200 of the subscription. If you want to learn more about the benefits of our premium membership,

00:00:58.020 head over to peteratiyahmd.com forward slash subscribe. My guest this week is Stuart McGill.

00:01:06.700 Stuart holds the title of Professor Emeritus at the University of Waterloo, where he has dedicated

00:01:11.480 40 years of overseeing his laboratory and research clinic dedicated to advancing the understanding of

00:01:17.020 back pain. Currently, he serves as the Chief Scientific Officer of BackFit Pro, where he specializes

00:01:23.020 in evaluating complex cases of lower back pain from across the globe. He has authored 245 scientific

00:01:30.260 articles and multiple textbooks. I wanted to have Stuart on for the obvious reason that very few

00:01:37.480 people listening to this will have not had their lives impacted by lower back pain, even if it's just

00:01:43.820 a short bout that lasts for only a few days. And sadly, many of you have had far greater impact

00:01:50.700 resulting from lower back pain, lower back pain that has perhaps plagued you for many years. In this

00:01:56.780 episode, we do a deep dive into all things that pertain to lower back pain. We begin by discussing the

00:02:02.820 anatomy of the lower back and how the spine works, the pathophysiology of back pain, and where people

00:02:08.660 can have issues as it relates to their back. We talk about why Stuart believes there is no such thing as

00:02:14.080 non-specific back pain and why he is so adamant about finding a causal relationship between an injury

00:02:21.400 and pain. And by injury, I mean a physical reason for the pain, not necessarily an acute injury that

00:02:29.180 resulted in it. We talk about ultimately why people who are experiencing back pain should be empowered

00:02:35.220 to do something about it. In other words, Stuart really believes that nobody should suffer endlessly

00:02:40.380 because of back pain. I'm very excited about this episode because I know even just looking at the

00:02:47.100 relatively small sample population of my patients, I know this is a topic that many people will find

00:02:53.860 value in. And if you're not finding value in it today, it might be a podcast you want to come back to

00:02:59.200 when you do experience lower back pain, though I hope that never happens. Lastly, this is an episode

00:03:05.820 where Stuart shows off a variety of models and positions to better explain what we're covering

00:03:11.660 in the conversation. So while the show notes will have all of the images, this may be an episode you

00:03:18.020 want to watch on video. So without further delay, please enjoy my conversation with Stuart McGill.

00:03:24.320 Hey, Stuart, thank you so much for joining me today. Wish we were doing this in person because there's so

00:03:35.020 much I'd love to get into. But I have a feeling we're going to be able to do a pretty good job remotely. And I

00:03:41.160 get the sense that you're very well versed at communicating your ideas in two dimensions rather than three. So

00:03:48.780 great to make your acquaintance today.

00:03:50.580 Same here, Peter. I've been looking forward to this day for quite a long time. At some point,

00:03:57.000 I'm going to thank you for writing your book. You are one of the few people on this planet who,

00:04:06.880 A, I allowed and B, I did change my behavior. So thank you very much for that. Let's see where we go today.

00:04:15.900 You're going to leave me hanging with that. I'm curious to know what it was. Were you a smoker who

00:04:20.020 somehow stopped? No, I'm kidding. What was it?

00:04:23.980 Well, a couple of years ago,

00:04:26.380 my family doc right now is one of my former students. This may bring a smile to your face.

00:04:31.440 I don't remember this, but apparently when he was an undergrad and he asked me to write the letter of

00:04:36.760 recommendation for medical school, I told him,

00:04:39.440 of course, I'm going to write this because one day I'm going to need a good doc when I'm an old man.

00:04:44.120 Well, wouldn't you know? Anyway, so we did my blood and I was just on the edge of what the

00:04:53.100 cardiology association is saying, needing Crestor or Lipitor or something like that.

00:04:59.320 And this doc knows me well enough. He said, let's run the experiment. We're doing it for three months.

00:05:06.980 It's I'm living Peter Attia's life. And then I love to work hard physically and finish it off with

00:05:13.620 a beer, which of course, six days out of seven, I'm denying myself of that. But long story short,

00:05:20.200 I have my blood done again in two weeks and we'll see if this three month experiment has paid off.

00:05:26.340 He says, no, it's in your genetics. You're not going to move the marker. But my sister says,

00:05:31.300 oh, no, you will. She did. Anyway, thanks and no thanks. But I think I'm sleeping a little bit

00:05:38.000 better. I think I'm a little more mentally sharp, but we'll see over the next hour if that's true.

00:05:46.460 We can revisit this. I'll reserve the right to come back and say,

00:05:49.980 maybe you don't have to be quite as restrictive. I don't necessarily believe in denying all the

00:05:56.240 pleasures of life. And I don't deny them myself.

00:05:58.720 There were some paragraphs in your book that just burned into my memory that you allowed

00:06:03.600 yourself some French fries. And I thought, oh, OK, I'm going to stay with the plan come

00:06:07.420 hell or high walk. But anyway, there you go.

00:06:11.700 I'm going to start with a story, Stuart. It's a story that some of the listeners might know,

00:06:15.380 but you probably don't know in this level of detail. And it sets the stage for why this is a

00:06:20.440 topic that is of great interest to me personally. And of course, by extension, I suspect that there are

00:06:26.160 very few people who are going to listen to us today who can't relate to the subject at hand.

00:06:32.280 The very abridged version of the story is I grew up doing all sorts of really aggressive things and

00:06:38.740 really took to powerlifting when I was probably 14 and found myself reasonably strong for a little

00:06:46.120 scrawny kid. And between about the ages of 14 and 19, I really, really pushed, couldn't bench press to

00:06:52.580 save my life, but seemed pretty strong in a squat and deadlift and kind of ignored any claims my parents

00:06:59.460 made that maybe I was doing a little too much. Truthfully and sadly, had no formal instruction.

00:07:06.460 I was just watching the other grown men in the gym who were insanely powerful and sort of just trying

00:07:12.800 to replicate what they were doing, but truthfully had no sense of what I was doing.

00:07:16.200 Anyway, fast forward, I am 21 years old. I'm rowing at the time. So rowing crew. And for the first time

00:07:26.320 in my life, I experienced lower back pain. This really rocked my world because I always thought

00:07:31.620 that people who got lower back pain were people who did nothing. I never really thought someone who

00:07:36.000 was as active as I was could get it. And for about two weeks, Stuart, it completely disabled me.

00:07:43.340 I could sort of get around, but barely. And being a college student, I didn't really have any

00:07:48.780 resources. I didn't know what to do. This was actually, I think it occurred during the summer.

00:07:52.780 So I didn't have classes, but I had to stop rowing. I remember that. And otherwise I was able to work.

00:07:59.600 It went away and I thought everything was fine. And I never thought about it again until the summer

00:08:03.660 three years later when I was 24 years old. And I remember exactly where I was. I was in San Diego

00:08:10.300 riding my bike up the steepest hill in San Diego, which is a certain patch of a mountain called Mount

00:08:16.620 Soledad. There's a section of this thing where you make a sharp right turn. And at that moment,

00:08:21.920 it's about a 25 degree pitch. I experienced this very sudden pain in my lower back and like a typical

00:08:29.940 idiot, just kept on pushing and climbing to the top and finished my ride, but then went on to experience

00:08:36.220 the exact same thing, Stuart. For two weeks, I was debilitated. Couldn't do a thing other than sort of

00:08:45.260 lay around and walk. But then it got better and I kind of just forgot all about it. And then fast

00:08:51.540 forward to the big one. I'm doing pattern recognition here, Peter. So the big one occurred in my third year

00:08:58.400 of medical school. I'm now 27 years old and the remarkable consistency of this is not lost on me. It is

00:09:05.040 every three years by the summer, the summer of 94, 97 and 2000. And I'm riding my bike from class to the

00:09:13.520 gym. I get to the gym, hop off my bike to lock it up. And all of a sudden I feel that same familiar,

00:09:22.640 horrible pain in my back. But this time it's a little worse than the previous two bouts. And it was

00:09:28.780 so bad that I did something I'd never done before, Stuart. I decided not to go into the gym.

00:09:34.260 And so I just slowly got back on the bike and limped my way back to my apartment and wasn't

00:09:42.580 able to do anything other than just sort of lay in bed. I assumed I'd be fine the next morning and I

00:09:49.120 woke up the next morning and actually couldn't get out of bed. Luckily, my roommate and I each had

00:09:54.240 separate phone lines. So I was able to call him from my room. So began a really painful journey over

00:10:00.740 the next couple of weeks where the only place I could find relief was bent at 90 degrees forward,

00:10:08.520 where I would basically stand and bend over the nurse's station. By this point, I was doing my

00:10:13.620 clinical rotations. And as every good gunning medical student knows, there was no way I was

00:10:19.560 going to miss a day of this. So I would drag myself into the hospital each day and somehow managed to get

00:10:26.020 through this. The nurses took pity on me and so did the residents and they were injecting me full of

00:10:31.580 Tordal. And this went on for a month and it got so bad that eventually the pain progressed from just

00:10:39.680 being debilitating in my lower back to a nerve pain that felt like my foot was being skinned.

00:10:46.760 And it was interesting in that the pain in my lower back started to subside as it was replaced

00:10:51.880 by the feeling of my left foot being skinned from the bottom. I'm not going to go into the more

00:10:57.940 details of the story because it gets worse and worse before getting better. But needless to say,

00:11:02.480 I have a graduate degree in back pain. There's a happy ending to this story, Stuart, which is

00:11:07.980 after this bout, which occurred when I was 27, which took a year to resolve, I made it a mission

00:11:15.040 to figure out what was going on. And I'm not suggesting that I have, but I know so much more

00:11:20.660 now than I did then. And fortunately, anytime I've had back pain since then, it has been a very,

00:11:27.260 very short-lived experience. I'll plant one last seed before we jump into this, just for both you

00:11:32.680 and the listener so that we can come back to it. If you are to look at an MRI of my spine today,

00:11:39.660 you would ask yourself, maybe not you because you're so well-versed, but a reasonable person would

00:11:44.980 look at an MRI of my spine today at the age of 50 and say, how does he walk? This person must be

00:11:51.580 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.

00:11:58.300 Occasionally, I get a little tight in my lower back musculature, but I don't have

00:12:03.580 radicular pain. I'm not limited in anything I do. Again, suggesting that the correlation

00:12:09.200 between the image of my back on an MRI and my symptoms is pretty light. So with all that as a

00:12:15.060 backdrop, the fact that you're smiling so much as I tell you this story tells me not that you're

00:12:21.680 taking pleasure in my pain, but rather the familiarity of my story. Exactly. I've been doing pattern

00:12:27.900 recognition. There's only one thing that would account for the repeated acute episodes. In the

00:12:36.780 interim between each one, you were quite fine. Then it shifted to a radicular pain. And now you're

00:12:43.620 at the stage of your life where it's more an occasional grumpiness when you cross what we call

00:12:48.820 the tipping point. Did the pain go to your foot, Peter? Yes. Big toes or little toes? No, it was actually

00:12:55.580 really interesting. It was burning pain that was like the bottom of the foot was being skinned.

00:13:00.660 I should have, there's one detail I should have shared with you that might explain this.

00:13:04.260 When I finally did have surgery, it turned out I had a free fragment that was about five centimeters

00:13:10.520 long from the L5 S1 disc. So that free fragment had broken off. Well, I was going to guess this for

00:13:18.500 you, actually. I was going to ask you which foot, so the fifth root goes to your big toe. But anyway,

00:13:23.880 you carry on. Yep. So basically, the really, really unbearable pain I was having presumably

00:13:29.160 was because that free fragment was parked on the S1 nerve root. And even though it ended up taking

00:13:34.980 two surgeries to get that out, and those surgeries ended up causing more damage that needed more repair

00:13:40.920 that turned into a journey of a thousand cuts, I was on the road to recovery. But the radicular pain

00:13:46.820 seemed to be directly a result of the S1 nerve root.

00:13:49.940 Well, if you want me to react to that story a little bit, I'm smiling because you told me

00:13:58.060 exactly what the pain mechanism was. I knew it was a disc with an open fissured disc bulge.

00:14:06.960 It would be on the side of your foot, right or left. What foot was it?

00:14:11.480 It was left.

00:14:12.060 Okay. So you had a posterior left-sided biased open fissured disc bulge that would open and close

00:14:19.920 as a function of the flexion postures, bending down to lock your bicycle. You just gave it to

00:14:26.480 me every single time. And then you were able to vacuum that in. It lasted for a couple of weeks.

00:14:33.440 Now you're in the unstable. Do you want me to show you a couple of mechanisms?

00:14:37.480 What I was going to suggest, even before we get into that, this is exactly where I want to go,

00:14:42.840 Stuart, is let's walk people through the anatomy of the back. Now, I understand that there are some

00:14:48.260 people who are going to be listening to us. So whenever possible, do your best imagining somebody

00:14:53.080 can't see us. But I think there's also going to be enough people watching on video. And we'll

00:14:57.300 certainly refer people to the video, at least for this section, in addition to some diagrams.

00:15:01.640 But let's really explain to people what this remarkable structure of the human back is.

00:15:08.460 The stability, the flexibility, the mobility, the amount of nerves, muscles, and ligaments

00:15:13.260 that are involved. You could almost argue it's a miracle we don't get more injured, even though

00:15:18.280 the frequency with which we do is intense. Take us through the anatomy.

00:15:23.480 I would almost argue the opposite, Peter. There was a television show that they were producing and

00:15:29.420 asking various experts around the world, if you got to re-engineer your particular area,

00:15:35.040 me being the spine guy, and they had a cardiac person, an endocrine system person, how would

00:15:41.420 you re-engineer it and make it better? And every expert said they couldn't. It was perfect.

00:15:48.660 So everything in terms of systems in your body comes with a trade-off, and there are rules that

00:15:56.160 manage the trade-off. So with that, I can start the anatomy. The spine is a series of vertebra,

00:16:04.940 as you know, forming a flexible rod. This allows us to dance and move and procreate, tie our shoes,

00:16:11.700 and do all of these wonderful things. But at some point, you now, say, are picking your child out of

00:16:18.240 the crib. You reach across the crib, gather your child, pull them in. If you had a flexible rod,

00:16:24.420 consider a series of stacked oranges, it would fall apart. So you need a flexible rod that you

00:16:33.160 can then stiffen to bear load. You cannot push rope, but you can push stone, or in this case,

00:16:39.700 an eye beam to bear load. So all of these things are necessary to have a functional spine.

00:16:46.460 What else can I say? Let's look at the structure of the discs, which are the fabric. The disc actually

00:16:56.280 forms the subcategory of a biological fabric. It's not a ball and socket joint. Could you imagine

00:17:01.800 if we had vertebra with ball and socket joints? You would need an enormous musculature around that

00:17:09.520 flexible rod to control all the ball and sockets. You would need an enormous motor cortex to coordinate

00:17:16.020 all of these. You would be so wide, you couldn't walk, you couldn't run, etc. But we have this very

00:17:21.600 slender torso because we have discs. Now, the stress strain curve of a disc starts out with a little bit

00:17:29.880 of a neutral zone in the neutral range. And as you approach the end range, the disc provides stiffness,

00:17:35.660 a mechanical stop to motion. Fabulous. I didn't need all this complex musculature to do so.

00:17:42.140 So the disc creates tremendous evolutionary efficiency in your spine. Either end of the torso

00:17:51.820 strategically is a ball and socket joint. The ball and socket joints of the hips and shoulders are

00:17:59.000 designed to create power. Power is force times velocity. So if you were to watch a sprinter sprint,

00:18:06.060 the extensor muscles explode like a hammer hitting a stone, a stiffened structure. If they hit rope,

00:18:14.240 the hips would pulse and you couldn't run anywhere. You can't even walk without sufficient stiffness

00:18:19.700 in the core. So I can get into an interesting discussion of how stability works proximally

00:18:29.660 to unleash and enable this distal athleticism. So in terms of anatomy, we have a flexible disc that is a

00:18:38.780 fabric. That great advantage is the efficiency of your dimensions that I'm talking about. We're light,

00:18:48.600 narrow in the waist, we can run, etc. The price that you pay though, is being a structure of many

00:18:57.340 collagen fibers. Let's take my shirt, which is a fabric. If I wanted to delaminate the fibers,

00:19:05.420 I would have to create stress strain reversals back and forth and slowly we would debond the fibers.

00:19:12.960 This is what happens to people's discs. They debond the fibers with too much load and motion

00:19:19.860 simultaneously. And this is what you must have done as a younger fellow. But the concentric rings of

00:19:27.540 collagen that are held together with collagen type X, the binding substance, they hold a pressurized

00:19:35.440 gel, which is this incompressible hydraulic fluid that creates the ball. That gets pressurized,

00:19:42.640 but it's always seeking the weakness in the wall. If you delaminate the collagen fibers,

00:19:49.680 then the nucleus seeps through. And in some situations, the fibers are pulled together and

00:19:59.080 they create a fragment, as you described earlier. Or if it's an open fissure and contained underneath

00:20:05.660 the posterior longitudinal ligament, there's a good chance it's going to get vacuumed back in and off

00:20:11.220 you go for another two or three years. I can talk about the nerves, I suppose. If you have a disc

00:20:17.880 bulge, there is the spinal cord centrally behind the vertebra and at each lumbar or spinal joint is a

00:20:27.220 pair of nerve roots. Maybe one thing we can talk about before that, Stuart, is the other point of

00:20:32.620 fixation, which are the facet joints. So if anteriorly this structure is bounded and the vertebral

00:20:39.660 bodies are stuck together through their sharing of the disc. On the back, we have these other joints

00:20:47.520 that come from each of them called these facet joints. So yeah, why don't you talk a little bit

00:20:52.500 about that? I don't know if you can see those, but the facet joints are guiding of motion. So you can

00:21:01.780 see as I'm flexing and extending and twisting this model spine, these are articular joints in the back

00:21:08.860 that are guiding motion. What you will find, I know what I'm going to find if I look at your MRI,

00:21:15.620 at the level of the disc bulge, the facet joints will now be getting a little thicker, a bit more

00:21:21.240 gnarly looking. Am I right? Because the facets almost always, two or three years after a major disc

00:21:29.280 injury, they take much more load. Think of air in your car tire. If you let a little air out of your

00:21:37.520 car tire, it bulges on the road. It gets a bit sloppy to drive your car. You have to tune the

00:21:43.460 pressure. This is exactly what happens with your body. So when you lose the controlling stiffness of

00:21:49.980 the disc, you get more work performed on the facet joints, and they wear a little bit faster than the

00:21:57.940 adjacent joints, and they grow thicker. And facet pain is very different from disc pain. It's more of

00:22:05.260 an ache. It comes on a bit more slowly. If you have a wound up facet joint, it can take two or three

00:22:11.660 months to wind it down versus a disc that, as you described, you can wind down in a couple of weeks.

00:22:17.300 But if I can show this as a model now, this disc is normal. This bottom disc, L5, is normal. L4 has

00:22:25.760 been damaged. I'm just going to apply a torque to this spine. Do you see how the majority of the

00:22:31.940 motion now is occurring at the joint that's lost stiffness? Think of it like a knee that has a

00:22:38.080 damaged ACL ligament. It no longer has the guidance, and the rotation motion of the knee, which is normal,

00:22:45.820 is now substitute with shearing motion. So shearing motion indicates it's the metric for instability.

00:22:53.800 So now you can see the shearing instability, and now look at the work being performed by the facet

00:23:00.820 joints at the level of the disc being damaged and losing stiffness. Now those will get grumpy,

00:23:08.200 and they will wear a little bit faster if you continue with the behavior that you did prior to.

00:23:16.200 So injury and this cascade changes the rules a little bit. So initially, the goal was to create

00:23:24.780 power in the shoulders and the hips and transfer it through a controlled spine. But now the game has

00:23:32.540 changed a little bit. You're 50 years old. You will have a little bit of joint instability. It's more

00:23:39.120 important now to create a muscular girdle around the joint that has lost a bit of stiffness. And for the

00:23:48.100 next little while, do your core exercises, develop a bit more muscular control, arrest the shearing

00:23:56.080 motions. And by the time you and I are very similar, by the way, so I'm in my late 60s now, my pain is

00:24:05.040 gone. So the joint has become so stiff, I can still do everything I want to do. But the joint itself has

00:24:13.860 stiffened up. Professor Kirkcaldy Willis, the famous Canadian spine surgeon, wrote a book called

00:24:20.560 Managing Low Back Pain. And he described very well, the process that most of us go through the

00:24:27.380 instability and the very acute episodes that come every two or three years that are very debilitating

00:24:34.220 to a muscular ache. And you wake up in the morning on one side with this ache in your back. But if you

00:24:40.580 push one heel away or put a pillow under your waist or something like that, you can get rid of the ache.

00:24:46.680 And then if you live a little bit longer and behave by the new rules, I don't have any back pain.

00:24:53.760 And I can encourage that you will seek that relief as well.

00:24:59.380 Stuart, give us a sense of the prevalence of acute lower back pain episodes. Is an acute lower back

00:25:05.500 pain episode defined as one that lasts up to some period of time, two weeks or something like that?

00:25:10.420 No, I don't define it that way at all. You'll be surprised. I'm not the guy who can

00:25:16.540 give you those statistics. I don't worry about those sorts of things. All I worry about is the

00:25:21.820 people who come here and ask for help with their back pain. I'm not out there doing population

00:25:27.840 studies to crack incidents. And even having said that, when I used to study that as a younger scientist,

00:25:36.340 what is back pain? What's an acute episode? Is it sufficient to be debilitating so you don't have

00:25:42.840 to work? I was a professor. I could have an acute attack and go to work. If I was a construction

00:25:48.160 worker, I couldn't. So even the definition of whether it was disabling or not gets lost. So

00:25:54.120 I didn't really get into those statistics. But having said that, I don't categorize pain as being

00:26:02.820 acute lasting a certain period of time and chronic lasting a longer period of time. Because when we

00:26:09.440 measure people here with back pain, very rarely do we find chronic back pain. It's almost always due to

00:26:19.820 them repeatedly insulting their back with many acute attacks and offenses all day long. So they think

00:26:29.020 they have chronic pain because it lingers. When we show them a strategy or whatever the treatment happens

00:26:36.240 to be, to stop the insults that occur throughout the day, all of a sudden their pain goes. And then

00:26:42.680 they realized, you know, I never did have chronic back pain. So chronic back pain to us is pain that is

00:26:50.500 intransigent, unrelenting. Their brains have changed. They've been traumatized. That is chronic pain

00:27:00.220 and not always having a strong mechanical trigger. That's how we separate chronic and acute. But the

00:27:08.600 pattern that you described of the two-week disabling, terribly disabling pain you had,

00:27:15.200 there's only one thing that that could be. And that was an open fissure disc bulge.

00:27:19.320 So let's talk about the mechanism of the discomfort. For example, is that disc actually innervated?

00:27:26.820 Is the pain that's being perceived due to sensory fibers of the disc? Or is it the response of the

00:27:35.740 body sensing that damage going into some sort of protective mechanism that is seizing all the

00:27:42.720 muscles within the proximity of it? Stretch. Or it could be both. So here's how I would answer that.

00:27:50.220 A healthy disc. By the way, all these models that I'm using, highly biofidelic models are made by

00:27:58.180 dynamic disc designs. So when a disc is healthy, people say, well, what's the number one thing you

00:28:06.360 can do to keep a healthy spine? And I will say, keep your end plates healthy. And they wonder about that.

00:28:12.400 Don't damage your joints. As you wrote in your book, if you damage your knee ligaments,

00:28:18.040 you will now have in your last decade disabled mobility. That's a fact. So it's the same with

00:28:26.540 the spine. If you can look into the nucleus of this model, you will see that there are red

00:28:34.360 vessels and yellow nerves. Now, there are all kinds of papers. Oh, there's no nerves inside the disc.

00:28:42.380 And then you'll read another paper. Oh, there are nerves in the outer third. And then there are nerves

00:28:46.820 all the way through. And the reason is a healthy virgin disc doesn't have any vascular tissues going

00:28:54.580 into it, nor does it have any nerves. And the reason is when you squeeze a disc, you build up

00:29:00.820 tremendous intradiscal pressure that kills any kind of vascular sprouts or neural sprouts.

00:29:07.920 It's a healthy environment containing the pressure. When you damage the disc and you lose the ability to

00:29:14.280 contain the high pressure, now all of a sudden, vascular sprouts grow in and so do nerves. So

00:29:21.480 it's so unfair. You damage the disc and now the body grows a hardware, more nerves to feel pain even

00:29:29.460 more. And then eventually, this just goes to a very fibrous, gnarly structure, highly innervated,

00:29:38.200 but now it just basically gristles to bone and all the pain goes away. But you can see where the

00:29:44.920 damage line, if I can, the contrast there, do you see those fibers posterior laterally on the right

00:29:52.220 have delaminated? And if I squeeze the disc, then you see this, I'm going to squeeze and flex.

00:30:00.840 Do you see the fibers delaminating and allowing the nucleus to seep out? But here's the antidote,

00:30:07.400 Peter, stay stacked and tall, and I'm going to squeeze. The whole disc bulges in a diffuse

00:30:14.960 bulging pattern, but nothing comes out of the delaminated region. So there's a little bit of

00:30:24.460 an explanation of why some studies will show an innervated disc and other shows they're not

00:30:31.580 innervated at all. Think of where you get cadavers from. It's not young, healthy people

00:30:36.340 dying and donating to their body. It's almost always older people. So those discs are innervated

00:30:43.460 unless they're horribly down the cascade and they've gristled and all the nerves have now

00:30:49.100 disappeared once again.

00:30:51.140 That's very helpful. And I was totally unaware of that, by the way. So that's a very interesting

00:30:55.980 and, as you pointed out, almost a very cruel adaptation that is quite counterintuitive.

00:31:01.940 Let's talk a little bit about the curvature of the spine. What is it about the way we interact

00:31:08.300 with the world and the curvature of our spine that tends to produce the majority of injuries at

00:31:15.860 either the interface between L4 and L5 or the interface between L5 and S1?

00:31:21.640 Oh, what an interesting question. I'm thinking of several things that are going through my mind

00:31:29.280 as you ask that. Well, first of all, it's the thickest part of the spine. So if I was to take

00:31:35.300 a thin willow branch and bend the willow branch back and forth, no stress. Tissues damage because

00:31:43.560 of one metric and it's strain. Not the force supplied, not the pressure, anything. It's just

00:31:49.760 strain on the tissue that is the metric of when it's going to disrupt. So it's thin, the radial

00:31:55.360 distance to the neutral axis, which is the axis down the middle of that thin rod that doesn't

00:32:00.740 go into compression or tension. It's all very low. Now let's take a thicker stick and we bend it and

00:32:07.580 it shatters right away because it's much thicker. I'm going to digress a moment, go back to the flexible

00:32:13.480 willow branch. It's wonderful at bending. That's what it's made for, but don't ask it to bear

00:32:19.120 compression because it buckles right away. The thicker stick can bear tremendous compression,

00:32:24.300 but it doesn't tolerate bending. So you look at the neck, very thin, small diameter vertebra.

00:32:31.820 It's made for bending and mobility. Fabulous. But as you move down the spine and get to the bottom

00:32:36.500 too, where the thickest is, they do not tolerate bending near as much as they tolerate compression.

00:32:42.920 So there's the first anatomic feature that describes why the bending stresses are greatest

00:32:50.800 at the thicker two joints, which are at the bottom. The other things that matter are the shape of the

00:32:57.640 disc. So some discs are ovoid and the bigger the skeleton, they tend to go to a limacon. So you have

00:33:05.360 the spinal cord there and then the two lobes of the limacon. The bigger the spine, the more limacon

00:33:13.460 the disc becomes. When you twist a limacon, you create a stress riser on the edge of each lobe.

00:33:21.880 The bigger the person, you will see they don't tolerate sit-ups. Look at YouTube. Who is the man

00:33:27.600 who has the world record for consecutive sit-ups? Do you think he has a thick spine or a thin spine?

00:33:33.080 He won't be a powerlifter. Having worked with some fabulous powerlifters and strongmen competitors,

00:33:40.300 not one of them does a sit-up. They train other things to tune their body and make it suitable to

00:33:47.420 that particular training stimulation. So now we see that shape thickness determines why L4 and L5 are

00:33:58.560 the target. We know that they don't twist as well as a slender spine. The facet joints are also very

00:34:07.220 interesting as well. So some facet joints, since you brought those up earlier, are orientated like

00:34:15.460 that in the sagittal plane. Others are orientated more open, as we say. So if you look at a gymnast who,

00:34:24.860 by definition, me, I would never choose to be a gymnast. But you can tell, look at my facets,

00:34:31.420 they're closed. I don't twist very well. However, when you flex forward and pull a load,

00:34:39.540 those facet joints just glide past one another. So a gymnast, by definition, is someone who has a lot

00:34:46.080 of mobility in their spine. You will see that their facet joints tend to be open.

00:34:50.240 Now, if I said to you, who among your patients gets spondylolisthesis? The broken PARS bone

00:35:00.420 that holds the facet joint on, basically. You are going to say, well, dancers, gymnasts,

00:35:09.360 the very people that had the mechanical advantage to twist. Now, when they go into extension,

00:35:15.640 their facet joints are like shingles on a roof. They bend the PARS bone, creating stress strain

00:35:21.500 reversals. And eventually, that bone will get a stress fracture or a stress reaction. And if they

00:35:28.560 keep going, full-blown spondylolisthesis. So there's all kinds of reasons. I'm just giving you a few now

00:35:37.000 as to why those two discs really are the, as an engineer now, stress risers.

00:35:44.900 When I developed, in my PhD thesis, actually, a very detailed anatomical model of the spine,

00:35:51.340 computer model, that hit home loud and clear. We did stress maps of real people moving.

00:35:58.800 The pain and the injury was almost always at the site of the highest stress. And remember,

00:36:06.280 I said, the metric is strain that actually leads to damage. Or it actually, if it's below the tipping

00:36:13.640 point, it actually strengthens you. So we can have that conversation as well. What does not kill you

00:36:18.740 makes you stronger. There's a risk that you and I talking about this, because we're both engineers,

00:36:23.320 will easily get into the weeds of compression strain, tension strain. But for people listening

00:36:29.620 to us who might not have that background, can you explain the difference between stress and strain

00:36:34.400 and what happens under tensile load, compressive loads, and things like that?

00:36:38.780 Let's not talk about stress and strain. Let's talk about applied load and deformation. So stress and

00:36:46.540 strain are normalized to an area. We won't get into that. If I apply a force to a structure,

00:36:53.320 it deforms. I'm applying a force and I'm getting a deformation. Mature skeletal bone breaks at a certain

00:37:04.920 amount of deformation. A child's bone breaks at a different level of deformation. When you take a long bone

00:37:16.740 and you bend it, the upper surface goes into tension. It's trying to pull apart. The lower

00:37:23.580 surface goes into compression. Some biological structures are stronger in tension than they are

00:37:30.060 in compression. A child is actually weaker in compression than a bending bone. And then the adult

00:37:36.360 is weaker on the tensile side. So a green stick fracture or a buckled bone in a young child would be

00:37:43.280 very rare to see in an adult as an example. So the behavior of biomaterials when you load them and

00:37:50.560 how they deform explains a lot of injuries. So if you were to put me on the witness stand, as people do

00:37:58.900 occasionally to explain, is the damage that we see, professor, in this MRI or in the cadaver or whatever

00:38:10.000 consistent with this particular mechanical alleged scenario. Yes or no. And that's how we reconstruct

00:38:18.140 that. Tissue stress and strain, shear, bend, tensile pull apart, etc. And the deformation causes very

00:38:29.220 specific types of damage. I'd like to use this example for people. I'd like to use the example of concrete,

00:38:36.140 which is every engineering student's favorite example, right? So concrete is so strong in compression

00:38:43.480 and yet in tension, it is so weak that we need to come up with a hack. How can we use this material

00:38:51.240 to allow it to be both strong in compression and tension? Because the example you use is really a

00:38:56.220 good one. If you have a bridge made out of concrete and you're driving on top of it, the bridge wants to

00:39:01.520 deform, which means you're putting the top in compression, which it can handle, the bottom in tension,

00:39:05.940 which it can't. So we put rebar in because the steel rebar is of course strong in tension. The

00:39:13.080 saying is the whole purpose of concrete is to hold the rebar in place. When you think about the spine,

00:39:19.780 I want to dig into this a little bit more if you think it's helpful. So we take an axial load on the

00:39:25.440 spine. And as you pointed out, the cervical spine is not built for tolerating a big axial load.

00:39:31.400 It's designed more to provide movement. It's a joint for great flexibility. The lumbar spine, for all the

00:39:39.560 reasons you just explained, is really designed around taking a large compressive load and it's in the

00:39:47.140 process sacrificed the mobility we have in the neck. But now let's talk about load in the context of

00:39:54.420 flexion and extension where you now do have within the disc, it's not just pure compression. Maybe just

00:40:02.340 even explain to people, flexion is bending forward, extension is going back. Now, if you have an axial

00:40:09.420 load in that position, which you could easily have if you're deadlifting something or squatting something,

00:40:15.460 any given disc, especially in that lower spine region, can be under compression and tension at the

00:40:22.180 same time, correct? Absolutely. I have a little bit of a story on that, Peter. It's so interesting

00:40:29.800 when, say, I'm asked to give a lecture to a group of radiologists and they describe very well all the

00:40:37.540 subcategories of disc bulges and disc deformations and that kind of thing, but they've never been taught

00:40:43.200 what the applied load nor the adaptation was. So let me paint a little picture here of the deadlifter.

00:40:51.240 A deadlifter almost always gets a posterior disc bulge, as you may know. So a deadlifter is under

00:40:59.960 tremendous compressive load and if they, say, get to the bottom of where the hips run out of room,

00:41:07.420 now the femur collides with the pelvis and thereafter the rotation takes place in their low back.

00:41:13.740 Because the nucleus is under such enormous compressive pressure, remember this model, I had to bend it

00:41:22.040 forward to get the nucleus to squirt back. So you're creating a center of hydraulic effort posterior.

00:41:30.740 Now let's consider a person who's adapted their spine to do yoga. This is why I say please never mix up

00:41:39.620 deadlifts and yoga. If you adapt your spine to be very flexible, you adapt the type X collagen

00:41:50.780 holding the type 1 and type 2, the heavy gristly collagen and then the elastic collagen, all those fibers

00:41:57.820 together. A powerlifter wants them to be stiff and tough. They even wear an exoskeleton of a lifting suit

00:42:04.620 to add even more stiffness and toughness. But the yoga master, that would be the kiss of death. They want

00:42:11.240 nice, viable, flexible spines. They soften the ground substance holding the collagen together. So when they

00:42:19.060 bend forward, in contrast to the disc bulge going backwards, the front of the disc now buckles under

00:42:25.780 compression. So when a powerlifter typically, now of course there are very odd cases that are the

00:42:33.540 exceptions. The powerlifter bends forward and crushes the disc bulge posteriorly. But when the yoga person or

00:42:43.500 very flexible spine, when they bend backwards, the collagen under compression buckles. So one gets a disc bulge

00:42:51.980 from extension and the other gets a disc bulge from flexion. Isn't that interesting? And it all depends on how

00:42:58.660 they'd adapted their spine. But my final point in all of that is don't mix up the adaptation schedules.

00:43:06.800 So if you want to be a powerlifter, train your hip mobility, shoulder mobility, but torso stiffness.

00:43:15.000 Try not to throughout the day do a lot of bending versus the yoga master. Please stay away from the very

00:43:23.180 heavy loads. What is the pathologic response to the anterior bulging of the disc? Because when you have that

00:43:31.140 posterior bulge, we should have mentioned this earlier, and I guess it's worth stating, the spinal cord stops

00:43:37.140 quite high up. The spinal cord does not run down the entire canal. It stops around L2. So for most of the people

00:43:43.520 experiencing lower back pain vis-a-vis a herniation, fortunately, the herniated disc is not hitting your spinal cord.

00:43:53.000 It is hitting the nerves that emanate from it. But again, there's so much real estate in that area.

00:44:00.400 It's insane because you don't just have the nerve roots. You have the dorsal roots. You have all of

00:44:06.660 these other tiny little nerves that are going to the facets and to the disc and to the vertebral

00:44:12.380 bodies. It's running musculature. And to your genitals and everything that's important, of course.

00:44:17.180 That's absolutely correct. And I learned that the very, very hard way.

00:44:21.220 Yeah. Yeah. We could tell some stories if we weren't on the air. Tell me about the manifestation

00:44:27.660 clinically of the anterior herniation in that very flexible person who's presumably greatly lacking

00:44:35.200 in any spinal stability. There probably won't be too much. They will go along with their merry life

00:44:41.900 and be flexible. The anterior bulge is not, as a rule, picking up any nasty nerve root compressions.

00:44:51.460 And on the grand scheme, Peter, it's probably a non-clinical issue for them.

00:44:56.340 Until they wanted to lift, they were in an emergency situation now. They've come across a car wreck.

00:45:02.560 Someone is in the car. If they don't get them out, the car is going to explode.

00:45:05.480 So we will all be placed into these situations at some point in our life. And whether or not we have

00:45:12.180 the physicality to deal with them is another issue. But anyway, that's the downside of that particular

00:45:19.740 adaptation and lifestyle, perhaps.

00:45:23.480 Which of these types of injuries leaves a person more susceptible to the movement of the vertebral

00:45:31.780 bodies in a slipped fashion, where we now get that spondyloth? I never remember which spondyla

00:45:38.400 we're talking about. I think we're now talking about spondylothesis when the vertebral body on top

00:45:42.880 moves relative to the bottom, correct?

00:45:44.640 Yeah, that's the anterior one. The answer is both. So a very flexible spine can get sheer

00:45:52.920 translations just the way as a stiffer spine can. So again, we wouldn't a priori judge and attribute

00:46:04.200 one of those to the symptoms. We always go by the assessment. It could be either spine, for sure.

00:46:11.220 I want to back up for just a second to the story I opened with and just kind of dig in a little bit

00:46:15.700 more to the pathophysiology. So that very, very first bout of back pain I had when I was 21 years old,

00:46:22.920 clearly the previous eight years or whatever, maybe seven years, eight years of really, really,

00:46:29.760 really heavy lifting. Certainly the technical knowledge I have today about how to do these

00:46:34.320 things correctly was completely absent. If you had to guess, and this is purely speculation,

00:46:40.040 what was the process that led to that injury on that day, that manifestation? You know, if I had had

00:46:45.980 MRIs examining my spine every year, starting at the age of 13 until that first real insult at age 21,

00:46:54.420 what would you have seen?

00:46:56.160 Well, I've done studies. Do you remember the NHL hockey strike a number of years ago?

00:47:01.780 Yeah. That was 94, wasn't it?

00:47:04.220 It was whatever year it was.

00:47:06.920 No, that was baseball. But anyway, okay. Yeah.

00:47:09.920 Well, whatever year it was, the younger players, they would go to Russia and whatnot and still

00:47:15.120 make a salary. But the older veterans hung around and I saw quite a few of them. You know,

00:47:19.960 my shoulder colleagues see some bridge holders. I ended up seeing them for low backs. But it was a

00:47:25.020 fabulous natural experiment, Peter, because they brought their MRIs every year. So say they were

00:47:31.520 11-year veteran. I would look at their MRs from the first year, the second year, and then I would

00:47:37.500 watch the cascade. And then I would say, what happened in the eighth year? Oh, that was the

00:47:42.760 year I started with a trainer and the trainer believed in doing astagrass squats with a heavy

00:47:48.120 weight. Aha, look what happened to the spine. When was the last time you saw a hockey player do an

00:47:53.920 astagrass squat in the NHL? In any case, that was a wonderful experiment to give us insight

00:48:00.880 into what you're describing. And then the second layer of evidence that I would add there is

00:48:05.540 I'm probably only of a handful of people in the world. We had a radiology suite in our cadaver lab

00:48:15.520 where we would take cadavers and apply very specific loading scenarios to it. And we would watch the

00:48:24.620 cascade of damage over time. So both of those I'll put together and give an answer to what I

00:48:30.860 expect I would have seen. So we would have seen a lovely young spine in 14-year-old Peter. I think

00:48:38.000 you said you started. And then over time, we would have seen delamination from the inside out. So you

00:48:47.900 were accumulating the delamination, but on the outside, it was still pristine. Peter never knew.

00:48:53.820 And the delamination would continue to progress layer upon concentric layer until that day when

00:49:02.040 you were 21 or whatever. And the last layer was breached and the nuclear gel extruded just a little

00:49:10.980 bit. Now, when you were fertilized as an embryo or a blastocyst, I guess still at that case,

00:49:19.540 around the end of the first month, that little flat plate rolled, it's called neuralation, as you know,

00:49:28.540 to create your primitive spinal cord. On that day, your mother has not given you an immune system yet.

00:49:37.760 Now it's fused up. That nuclear gel has never seen the immune system yet. The end plates are pristine.

00:49:47.080 It's never seen your blood, which is where the immune system is active. So now you're 21. For the

00:49:55.300 first time, that nuclear gel comes out and sees the blood immune environment. It kicks off a hell of an

00:50:04.580 inflammatory response and you couldn't even move. It locked you up. And that's how strong and powerful

00:50:10.700 that was. Takes two weeks to subside. Now, here's the rub. I don't know if you've been following some

00:50:17.320 of the recent literature on anti-inflams. I was going to ask you, would I have been better off

00:50:23.620 if I had taken a prednisone taper or had some local anti-inflammatory therapy? Of course,

00:50:30.980 none of these were at my disposal as a poor, dumb college kid.

00:50:34.820 Of course not. But I can't tell you how much joy I'm having speaking with you because your logic is

00:50:41.840 fantastic. And the answer is, it could have gone either way. The anti-inflammatory might have cleaned

00:50:49.800 up the immune response and given you faster resolution. Or what the recent literature is

00:50:56.460 showing, there's a purpose for that inflammatory response. It brings in the immune system and all

00:51:04.060 the macrophages, etc. And it starts eating up the extruded material. Now, that process can go one of

00:51:11.100 two ways as well. It can wall off what's extruded. And I think you've experienced that into a free

00:51:16.180 floating body. Or it chews it up, digests it, for lack of a better word. And I wish I knew you then

00:51:24.840 because I bet I could have got you into, just lay on your tummy and breathe. And that vacuums in.

00:51:31.480 In fact, we did experiments. We would create partial disc herniations. And then if you traction the spine

00:51:38.240 and give a little bit of motion, all I do is wiggle your legs. You can vacuum in the disc bulge in a

00:51:43.800 matter of two or three minutes. And people will say, you're dreaming. No, we've measured it in some

00:51:48.820 types of subcategories. That's actually possible. The answer to the inflams is, at least some of the

00:51:56.300 more recent data is showing dispense with the anti-inflammatories. Let the inflammatory response

00:52:02.800 give the patient health for two weeks. It's the best medicine for them in the long term,

00:52:07.500 because it is helping to reduce the long-term disc bulge.

00:52:12.100 Whether there's any basis to what I'm about to say, I don't know. But I will just say that

00:52:17.500 anecdotally, these days when I have a flare-up, and again, to be clear, these are really, really

00:52:24.520 minor, Stuart. They don't interfere with anything I do other than if that were a day when I was going

00:52:31.560 to lift a little heavier, I would back off. Even that I, given that I don't squat or deadlift or do

00:52:36.060 any heavy stuff like that anymore, it's kind of a non-issue. But what I find to be the most

00:52:41.720 efficacious is not any sort of anti-inflammatory, but a light muscle relaxant like a baclofen. So

00:52:47.800 not a benzo or anything kind of sedating, but just something that allows the paraspinous muscles to

00:52:55.740 sort of relax a little bit. And frankly, use that to allow me to do some deep breathing. And we're

00:53:04.260 going to talk about the three most important exercises that you prescribe at some point today,

00:53:08.500 I'm sure. So it's mostly just a vehicle to break the cycle of tension, but not the inflammation

00:53:15.260 cycle. And truthfully, more of that is not because I'm familiar with the literature that you've just

00:53:20.020 spoken of, but frankly, because there are downsides of taking prednisone as well. And we have to be

00:53:25.620 mindful of those. And I don't want to suggest people shouldn't take prednisone, but one needs to be

00:53:29.720 circumspect about the frequency with which they do it.

00:53:31.920 Here's where I think you are now to answer the first question. I will bet this is where you are

00:53:39.200 now. You've got a little bit of micro movement in a sheer mode. So this joint isn't translating

00:53:45.400 as it should. It's lost a little bit of height. And those are the things that are causing the low-grade

00:53:50.860 aches, not kicking off the heavy acute attacks that you used to have as a younger man.

00:53:55.640 Now, test number one. I understand your brother has a farm up around here somewhere and you

00:54:02.440 occasionally visit. If you want to spend an extra day, come on by the Gravenhurst and we'll have some

00:54:08.760 fun. But anyway, what I would do with you is I would get you to stand just as you are. And I will

00:54:16.180 bet you stand differently when you get out of that chair after doing this podcast for a bit versus of you

00:54:23.060 just walking around. So there would be a focal lean and intelligent. And if I palpated your

00:54:28.500 erector spinae, they would be active. And I would have to coach you to open up your hips a little bit,

00:54:35.080 ears over your shoulders, shoulders over your hips. And now all of a sudden, we've achieved that

00:54:40.860 muscular relaxation that you're after. So next time, before you think you need to take the relaxant,

00:54:50.200 humor me, lay on your tummy. Again, I don't know your spine well enough, but I would lay on your

00:54:57.240 tummy, maybe put your hands, palms up under your hips, maybe make a fist. Again, I don't know where

00:55:01.860 you are, but we would find a nice little relaxation place. And then I want you to melt into the table

00:55:09.120 every time you exhale. Keep doing that. And tell me, A, if that doesn't remove the ache,

00:55:16.300 and we will play with your hands to realign that little shearing micro movement. And then stand up.

00:55:24.480 We might open up your hips a little bit with a psoas-specific stretch. And then you will monitor

00:55:31.280 your back muscles and see if you've shut them down. But then if I said, poke your head forward,

00:55:37.960 muscles on, pull your chin back, muscles off. Soften your knees a little bit. Some people,

00:55:44.120 they will stand with a strategy of ramming their knees back into heart extension. Feel your erector

00:55:50.580 spinae. Maybe it's just simply jazz knees and soften your knees. In other words, those little

00:55:56.680 postural cues, I have a sneaky suspicion, and I've seen you enough moving on YouTube and whatnot,

00:56:05.300 that I bet we could hack our way around that. So there's our challenge. Let's see if we can do that

00:56:10.480 without the med. You got yourself a deal. I will happily add an extra day to my next

00:56:16.820 Toronto trip when I'm up at my brother's farm. And I'm sure my brother will want to join as well.

00:56:22.440 We'll take you up on that. Fabulous.

00:56:24.920 Let's talk about those three exercises, Stuart. There are three exercises. There's two of them that

00:56:30.740 I've done consistently for quite some time. I really fancy them a bit. The third one, the bird dog,

00:56:37.320 I only do occasionally, but let's go through the three of them. And just for the listener,

00:56:42.940 we're going to link to videos of these. So you're going to do your best to explain them

00:56:47.900 and provide the rationale for them. But ultimately a demonstration will be forthcoming through videos

00:56:54.480 we'll link to in the show notes. But this is kind of like your core nutrition. This is sort of the

00:57:01.720 everybody should be doing this. You don't wait till you have back pain to do this. Is that safe to say?

00:57:07.420 No, it isn't. This is a bit of a myth and something that I've been fighting basically my

00:57:13.020 whole career. The McGill Big Three. There are some people that are far too stiff and this is not the

00:57:20.360 mechanism of their back pain and we don't need to go there. Have you ever seen the type of body build

00:57:29.200 where they have a huge pneumatic cushion in front called a belly? It slaps on their thighs. It's that

00:57:36.380 pendulous of this. Do you ever see spine instability in that type of architecture? I don't. Those people

00:57:43.300 have difficulty getting on and off the floor. The big three is not for them. Again, the assessment

00:57:49.620 always leads us to the solution. I need to have a discussion of what stability is in terms of creating

00:57:58.800 resilience and performance. Then why are those particular exercises important and then how to do

00:58:06.580 them? If I could follow that logic, Peter? Yeah, let's do it. Then the other thing, Stuart,

00:58:11.700 if you want to throw it in there, do you want to talk about some of the hallmarks of your assessment

00:58:16.680 wherever it fits into those three things? Take it away. Yeah.

00:58:20.240 All right. Remind me, we're going to talk about non-specific low back pain and how I think it's

00:58:26.240 a myth and it doesn't exist. That will take us into the assessment. Let's go back to a basic

00:58:33.500 discussion of stability. I might use an example of a backhoe. A backhoe is a machine with a tractor

00:58:42.980 and it has an arm on the back to dig earth. The first thing the operator does is put down the

00:58:47.900 stabilizer bars to lock the tractor into the ground because if you don't do that, you can't

00:58:53.700 pull earth. You just pull the machine around. So what's the human equivalent of that? We live in a

00:59:00.920 linkage just like machinery. In other words, let's take the bench press muscle pec major. Pec major

00:59:08.800 originates on my rib cage, spans my ball and socket joint of the shoulder, and inserts on the humerus.

00:59:15.660 So when I contract and shorten the pec major, it flexes my arm. So if I'm wanting to do a push or a

00:59:24.120 punch, there it is. That's on the distal side of the joint. Approximately, that same muscle shortening

00:59:32.060 collapses my rib cage towards my shoulder joint. So if all I used was the muscle that spans the joint,

00:59:40.460 that isn't a very effective push. All I'm doing is collapsing my own linkage. Or as an engineer,

00:59:47.580 we would say, well, you've just created an energy leak. I'm now going to build proximal stiffness.

00:59:54.160 I'm going to lock my core, create stiffness through my torso, which is proximal to the joint.

01:00:01.800 So now when I contract the muscle, 100% of the motion is directed distally. Now I've got my push.

01:00:09.500 So what is the best, most efficient way to create a proximal stiffness? We searched for years doing

01:00:19.100 all kinds of tests of every abdominal exercise you could think of, back exercises, twisting,

01:00:26.880 pal-off presses, throwing things, et cetera. The three exercises that kept bubbling up to the top

01:00:33.920 in the criteria of sparing the spine while you're doing them, because these people are hurting.

01:00:39.740 You don't have carte blanche to load up their spine. A guaranteed stability or proximal stiffness.

01:00:46.440 And it was later in my career that we found there is a residual stiffness that occurs. So if you do the

01:00:56.040 big three and you are an NFL football team, if you do the big three prior to practice,

01:01:02.540 you will run and cut just a little bit faster. So you're on the field, you run and you cut.

01:01:09.540 The stiffer, the core, when the hips explode into external rotation, you're now creating a faster

01:01:16.840 directional change. So what were the exercises? A modified curl up, which remember,

01:01:25.040 I'm now I'm just going to start a little bit of an assessment. I'm going to take a patient,

01:01:29.300 I'm going to have them sit on a stool and I say, do you have symptoms right now? Humor me and let's

01:01:33.580 say they don't. Now I'm going to say, drop your chest down. Does that cause you? Oh yeah.

01:01:39.120 My left toe is going numb and I've got back pain. Good. Bring your chin down. And they might say that

01:01:45.420 will increase their pain or decrease it. But the point is that posture created their pain.

01:01:51.800 If that is true, when they lay on their back and they imprinted their back into the floor doing a

01:01:59.400 Pilates roll up, for example, that would be their specific pain trigger. So it's not much of a

01:02:05.980 therapeutic exercise, but we can say, put your hands under your low back as you're laying on the

01:02:11.760 ground, lift your elbows, now hover up your head, neck and shoulders. And we're going to propel the

01:02:18.880 abdominal contraction, breathe through pursed lips and allow the diaphragm to become the athlete

01:02:26.280 inside this barrel. So that was the foundation of the modified curl up. Now, if the person has a

01:02:32.820 rotator cuff issue or we will hack it and make it tolerable, then I would see people, well, let's

01:02:39.880 say a dumbbell or a kettlebell and we're going to raise it up laterally in the frontal plane like this

01:02:44.580 for the side of the core. That would trigger pain in a lot of people. I'll demonstrate all this if

01:02:50.420 you want, but we could then do a side plank on the floor. The beauty of the side plank is only

01:02:57.080 half the musculature is heavily challenged. The downside is heavily challenged. The upside is not.

01:03:03.900 You've only got half the load on the spine. Very spine sparing. We prescribe it on 10 second

01:03:10.800 intervals. Why? We use the Russian training science to show you build endurance through repeated 10

01:03:19.660 second exposures, not getting tired to the point where you break form, nor do you develop a neural

01:03:26.360 fatigue and you get a much higher tolerable training level with this, what we call the Russian descending

01:03:32.460 pyramid. And then for the back muscles, look at the beauty of the bird dog where you extend one leg,

01:03:39.180 the opposite arm. One half of my low back is active. One half of my upper back is active on the other

01:03:45.860 side. We're developing a nice DNF pattern. We're creating stiffness and stability in the core. We're

01:03:52.680 teaching the brain to disassociate ball and socket joint motion of the shoulders and hips with only half

01:04:01.360 the spine load of, say, a Roman chair extension or something like that. So that bubbled up to be

01:04:08.040 a fabulous exercise. Then we did experiments where we would train people. We would just have a single

01:04:17.380 session exposure. We would measure the core stiffness prior to doing the big three. They'd do the big

01:04:25.860 three on the Russian descending pyramid, and then we would remeasure their torso stiffness. Peter,

01:04:31.720 they were stiffer. And some of my muscle physiology colleagues said, well, you've added a turgidness

01:04:37.620 to the muscle. I don't think so. I think the brain created a lasting neural stiffness. And in some

01:04:46.880 people, it lasts about 20 minutes. Some people, it lasts longer. So you will see some patients who say,

01:04:52.360 you know, when I do the big three, I don't have pain for the next hour. Fabulous. What you're going to do

01:04:58.840 is mid-morning, do a 12-minute big three session, mid-afternoon, do a 12. So these are the little tricks

01:05:05.500 and hacks to slowly wind a person down out of pain. That was the pain side of the big three. Then we started

01:05:16.760 to look at the performance side. If you train a group of athletes versus graduate students, the typical

01:05:24.080 university experiment, not much difference was found in the athletes. But in the graduate students,

01:05:33.020 we would see an increase in stiffness over a six-week training trial. Now, really interesting

01:05:39.980 things started to happen. If you do isometric holds in the manner I've described, you punch harder.

01:05:47.460 We took a group of Muay Thai athletes. And when they did the big three and we measured the

01:05:55.820 punching impulse, it was greater after they trained for six weeks. When we did dynamic core exercises,

01:06:06.520 it increased the closing velocity. So the closing velocity is when you first get the first muscle

01:06:12.980 pulse, boom, and then you relax closing velocity. And then you strike with the second pulse, boom,

01:06:18.760 boom. The closing velocity was faster with dynamic core exercises, but the strike force, boom, in the end

01:06:26.220 was greater the isometric big three. Again, talk about performance. I know you're a bit of a pugilist.

01:06:34.840 I certainly study combat techniques. If we were to take three styles. Let's take Joe Frazier. And you would

01:06:46.340 see him just always on forward progression. But the punches came from his body weight behind them. He

01:06:54.980 would create a beautiful thrust line straight, but his body rotated and he lent his weight into them. And

01:07:01.940 that was his footwork. Wasn't the greatest for getting hit because that means you get hit a lot.

01:07:07.920 Mike Tyson, different body type, very compact type of a body, but contrast his footwork. Oh,

01:07:15.180 it was just beautiful. He would drop step, drop step, drop step, hook the liver, come back very quickly,

01:07:23.600 hook, boom, and cross. And there was the knockout. Again, all coming from the hips, drop step,

01:07:31.600 boom. You see, it's all hips. You know this. And then Ali breaks all the rules, little Ali shuffle.

01:07:39.300 And then he would turn, rotate, hang on to it. And then at the end, look at it. Beautiful thrust line

01:07:46.260 all through the stick and core. I can go through athlete after athlete. I saw the other day,

01:07:52.960 I've never worked with Mick Jagger, but there is Mick Jagger doing the bird dog in his training.

01:07:58.660 Usain Bolt, the fastest man on the planet, does the bird dog, creating extensor pulsing power

01:08:09.180 into a stone. Or just to finish that off, Usain Bolt does bird dogs. Bird dogs are beneath people.

01:08:18.720 Really? They should see what I see. Anyway, that was the end of that story.

01:08:23.020 I was just going to add to it by saying, I think that what I've become interested in as I've aged is

01:08:29.960 looking at the greatest performers. There's no doubt that the best athletes have a remarkable

01:08:36.900 natural talent that the rest of us don't have. I've measured it without question.

01:08:41.900 Where I think people miss the talent, what they're missing is a big part of the talent is the natural

01:08:49.620 stability. In other words, it's the force transmission without the energy leakage.

01:08:56.640 And when I contrast really good athletes with myself, and I examine my athletic past,

01:09:03.940 what is clear to me is that in everything I have ever done, despite all of my hard efforts,

01:09:10.560 my lack of natural ability, and at the time coaching, has meant that I have always suffered

01:09:17.760 from an unbelievable amount of energy leakage. Whatever I have done, whether it's been boxing,

01:09:24.800 swimming, power lifting, all of those things, there's such a chasm between me and the really

01:09:31.920 good ones. And it's not due to hard work. I can promise you it is not due to effort. It is due to

01:09:38.160 probably some combination of natural ability and coaching that has allowed the really good ones

01:09:43.140 to do what you've demonstrated, which is a great punch begins in the back foot, and it's transmitted

01:09:51.360 through the hip, and it goes into the opposite fist. It's just hard for people to understand

01:09:57.660 how that through line of force can't lose anything along the way.

01:10:02.860 The stories I could tell you about the number of athletes being detuned by their trainers and coaches

01:10:13.000 violating this principle that you're describing. It's astounding to me. Why are you getting them

01:10:19.440 to do that? You just detuned their athleticism. I think where I want to go with this is most people

01:10:26.160 listening to this are not going to lament the fact that they didn't run as fast as they could have

01:10:32.400 when they were younger, or that they didn't punch or swim with as much prowess as they could have.

01:10:39.840 Where I think we should all care about this is that it's not just that the energy leakage costs you

01:10:46.920 performance. It clearly does. It's that it predisposes you to injury. And that's where I think we have

01:10:53.180 to bring this back. When I exercise today, I don't care about the performance. I care about the

01:11:01.780 preservation and longevity of my body for whatever number of years I have left. So this is really

01:11:09.900 where I think stability matters. It's what are the exercises I need to be doing? What are the exercises

01:11:16.300 my patients need to be doing? So that as we age and we walk up the flight of stairs or carry something

01:11:25.940 heavy, we don't hurt ourselves because we don't have that core stability that can resist the

01:11:33.800 deformation that's going to allow energy to seep out of the system. Well said. A story was coming to mind

01:11:41.580 as you were saying that. I'll be giving a lecture or teaching a class and I'll show some data from an

01:11:48.640 elite athlete. And there will be therapists and clinicians in the room who say, we don't deal with

01:11:56.240 elite athletes. We deal with the elderly or we deal with sick people. And I think, what are you

01:12:04.860 thinking? I'm showing you what the human body has the potential to do. And your arrogance won't allow

01:12:14.280 you to learn what is possible. And I'm going to give you a very emotional, I hope I can get through

01:12:20.940 this, a very emotional story to show the arrogance that exists among some of our colleagues. Occasionally,

01:12:29.900 medical groups, a hospital or whatever will ask, would you come out and assess three patients in

01:12:35.900 our auditorium in front of all our medical staff? I was at this facility. It was in Europe. The first

01:12:42.060 person was a rugby player, fair enough. And I had 20 minutes and declared what I thought was going on.

01:12:48.180 The next one was a woman in her early 70s, clearly distraught. You could look at her posture,

01:12:55.520 her carriage. She was defeated by the world. She came onto the stage and I said, can you tell me

01:13:01.680 your story? She said a little few sentences. And then she said, but the therapist says that I have

01:13:11.540 to leave my home now. When I get off the toilet, I'm a bit unsteady and she's afraid I'm going to fall

01:13:17.680 on the floor. I can't get off the floor by myself and I'm just going to lay there and no one will

01:13:22.720 discover me. I have to leave my home. She started to cry at this point, Peter. She said, what's going

01:13:29.060 to happen to my cat and all this sort of stuff? And I said, really, would someone please bring me

01:13:34.220 out a stool and this will be our simulated toilet. So an assistant brought her stool onto the stage.

01:13:40.080 I said, okay, pretend that's the toilet. Have a seat. She turned and had no idea how to move and just

01:13:47.500 sort of plopped and collapsed on the toilet. And then I'm just going to turn this down because I

01:13:52.640 want you to see my lower body kinematics as we're moving here. And then I said, would you get up

01:13:59.140 off the chair? And I can't remember whether she was wearing a skirt or pants. Pants, I think it was,

01:14:04.420 but nonetheless, knees together and she just sort of collapsed and I had to help her. She was going

01:14:10.700 to collapse onto the floor. And so I said, I want you to humor me now. You're my mirror. When I coach,

01:14:19.660 I try and use minimum words. I said, do this with your hands. Put your kneecap between your thumb and

01:14:26.460 your hands as you slide your hands down. Good. Now, I want you to be a leaning tower, leaning tower

01:14:34.540 forward and backwards and play with the curve of your back. Do you have any pain now? She said, no.

01:14:40.740 And I said, watch my shoulders. You're shrugged. I want you to anti-shrug. She did that. Perfect.

01:14:47.720 And now I said, pull your hands up your thighs by pulling your hips through. Don't lift with your

01:14:53.300 back. Pull your hips through. She had it done in three repetitions. That was now her pattern.

01:15:00.780 And I said, OK, think of what we've just done and sit on the toilet. And I said, whoops, spread your

01:15:08.780 feet apart. And there she went, slid her hands down. Then she put her knees together. And I said,

01:15:15.940 now stand up. She was going right back to the incompetent movement that caused her inability

01:15:21.740 and disability before. I said, spread your knees apart and pull your heels underneath you.

01:15:28.100 Sniff some air. Now lean forward and do what you now know how to do. And she did a perfect squat.

01:15:36.020 Do it again. And then by the third repetition, big smile came on her face.

01:15:42.940 It was the emotional part. I said, what's up with you? She said, I don't have to leave my home,

01:15:49.520 do I? I said, no. Do you know, many of those hard-baked surgeons and clinicians started to cry

01:15:56.300 as well. For the first time, they realized all I did was teach her weightlifting 101.

01:16:03.460 And remember how this story started with the arrogance of some of our colleagues who say,

01:16:09.980 I don't want to hear stories about elite athletes. I deal with old people or sick people.

01:16:15.780 And that's why they continue to not have the skill set to help their people. All I did was learn from

01:16:25.200 the best weightlifters of the world, people who know how to move load, learn what the efficiency was

01:16:31.580 and turn it into a hack to change a person's life. Anyway, that's a pretty emotional story. And

01:16:37.860 I hope we do that quite often. I know you like cars. Why does Honda race F1 race cars? Well,

01:16:46.300 they don't anymore, but when they did, and the reason was they learned about automotive technology

01:16:52.880 and the gear shift change in your Honda Civic came from the F1 racetrack. So that's why we work

01:17:02.120 with elite athletes so I can bring it down. I love working with them, of course, but they just give

01:17:08.100 it away free to us. And yet some of our colleagues are just so closed off. They don't want to hear

01:17:12.480 about elite performance. That's an absolutely beautiful story, Stuart. And thank you for sharing

01:17:17.240 that. It's a sadly common story too. And to me, I think the saddest part of that story is how

01:17:22.680 many of those patients don't get the chance to sit on a stage with you for 30 minutes and learn that

01:17:29.980 movement. You've been around long enough that I'm sure you have a better sense of this, but

01:17:34.360 I feel maybe optimistically that we are in a place now where people are starting to appreciate the

01:17:41.840 importance of strength and stability and that we're less afraid of this. There's more discussion

01:17:49.420 of the importance of resistance training and that it's not a young guy thing to do. It's an everybody

01:17:55.680 thing to do. But given the arc of your career, am I being just sort of delusional or do you really

01:18:01.780 think that we're in a coming of age here? The way you phrase questions are fabulous.

01:18:07.500 What was going through my mind? I try and answer every question. What's the evidence and what's the

01:18:12.760 application? The evidence at the university with all our first year students, one of their first

01:18:19.560 courses they took was on just basic fitness evaluation, range of motion, strength, hand grip,

01:18:27.620 VO2 max, some of these markers. And they would measure each other. And we kept the scores year after

01:18:35.860 year of the incoming class. The students got terribly soft and I can prove it based on that

01:18:42.900 data. And we would graph it. Now, whatever year was the year where the students had grown up with

01:18:48.820 the personal computer? It was right at the very late nineties, I think. All of a sudden we saw the

01:18:54.460 incoming class fitness plummet. Then something happened. They were a soft bunch for about five years.

01:19:02.000 And then slowly, to your point, they started to come back. And so I think your perception

01:19:08.840 is right on. It did go to a terrible state, however many years ago that was, 15 or 20 years ago.

01:19:17.300 But it is coming back. Now, among our colleagues, and having said that, I think some of them are

01:19:23.280 terribly misguided as well. You know, they think, oh, you're not a real woman because I heard this on

01:19:28.180 social media until you can deadlift twice your body weight. Well, wait a second. If they could

01:19:35.220 come here and see the number of people who've been caused by overzealous trainers and going bonkers on

01:19:41.080 deadlift magnitude. Let's talk a little bit about that because I have to tell you, Stuart,

01:19:46.120 I'm a bit conflicted personally, and I'll explain why. I obviously have no desire to do anything

01:19:51.520 that I deem stupid anymore. My days of gritting through painful anything are long over. I know

01:20:00.460 the difference between discomfort that is worth pushing through and pain that is not. But when I

01:20:06.880 think about in particular squats and deadlifts, especially around the deadlift, an exercise I

01:20:13.640 really, really enjoy, where I feel conflicted. On the one hand, I feel like now that I'm so tuned in

01:20:21.740 to how to do this movement correctly, it's a really wonderful audit for my stability system.

01:20:30.040 I'm embarrassed to tell you how much I didn't know when I was deadlifting. At no point did I

01:20:35.960 understand the importance of tension in the arms, intra-abdominal pressure, the variability in foot

01:20:42.260 pressure on the ground, like none of that stuff, right? It was just pure brute force stupidity.

01:20:46.760 Today, as I know those things, it allows me to modulate force and to, on a good day,

01:20:54.480 push the envelope a little bit in what I perceive as safe. So on the one hand, I think, yeah, I should

01:21:00.000 be deadlifting my whole life. I don't need to deadlift 400 pounds anymore, but I should be deadlifting

01:21:04.900 because it's this great audit. And on the days that I don't feel that I back off. And then on the other

01:21:10.220 days, I say, Peter, you don't need to do this anymore because honestly, you can still get the

01:21:16.720 same or nearly the same activation for all of the muscles involved using other movements,

01:21:24.900 single leg movements in particular, where you don't have a fraction of the axial loading.

01:21:29.380 And yeah, you might need to do two exercises instead of one, but at the end of the day,

01:21:33.540 there's a lower risk approach to get it. In other words, deadlifting is valuable,

01:21:40.040 but you have a narrow operating window in which you can potentially hurt yourself. So I continue to

01:21:46.020 go back and forth on this, Stuart, as such, here I am telling you, I still will go periods of my life

01:21:53.160 where I'll deadlift every week. And then I'll take three months off feeling like I don't want to push

01:21:58.480 it. How would you advise a middle-aged person or even a non-middle-aged person who's thinking

01:22:04.660 through this particular issue? Again, I have so many thoughts going through my mind. It's interesting

01:22:11.640 when we have a back pained 50 year old coming here and I'll say, what are your goals? Oh, I want to set

01:22:18.420 a personal best in deadlift. And I said, really? Okay. Let me tell you some stories. Let's talk about

01:22:25.000 Ed Cohn. Do you know Ed Cohn? I sure do. The greatest powerlifter of all time. I was with

01:22:29.920 Ed a couple of weeks ago. I'll tell you a funny story about him if you like in a minute. But anyway,

01:22:34.240 Ed, when he would set a personal best, he'd take a couple of months off afterwards.

01:22:40.020 To set a personal best is so demanding of your body. There are actually, if you set a true personal

01:22:49.240 best, most people experience micro-fracturing just underneath the end plate of the trabecular bone.

01:22:57.940 If you look at the great strength athletes, they train deadlift. And again, if you go to our website,

01:23:05.320 look at the testimonials at the bottom, the number of world-class deadlifters who are on there. So I've

01:23:11.980 worked with quite a few of these people through their injuries. Now, those micro-fractures could be a

01:23:17.660 good thing or a bad thing. The professional powerlifter will take a week off. They train

01:23:23.340 heavy deadlifts or squats once a week because it takes a week for the bone callus to not only

01:23:31.100 attach through the chemical electro attraction, but to really scaffold on. It takes a week. If you

01:23:37.220 deadlift in another three or four days, the way some trainers, they might deadlift a client three times

01:23:42.480 that allows those micro-fractures to accumulate until finally you've got a full-blown end plate

01:23:49.820 fracture or whatnot. So these are the people that come here. And then I say, how about this for a

01:23:55.000 goal? Do you have kids? Yeah. Do you have grandkids? Yeah. How about this? I've since learned about your

01:24:01.660 centurion decathlon, which I love, by the way. I'll say, would you rather, as your goal, have the ability

01:24:10.440 to play with your grandchildren on the floor when you're 80 and get off the floor and pick them up?

01:24:15.660 And they pause for a minute and they'll say, yeah, I like that goal. I say, well, you can't have both.

01:24:21.180 If you think you're going to continue having deadlift personal bests, you will have artificial hips

01:24:27.740 and all of these other things. Because how many old powerlifters do you know? Do you really want to be

01:24:36.600 like that group of athletes? So I can talk them into changing their long-term goals. Now is the time

01:24:47.480 to get on the program and make sure you get there. If that's the case, we eliminate deadlifts.

01:24:53.440 We had an athlete here yesterday. They're at the end of their career. And I took them out and we went

01:24:59.720 for a 10-minute walk to a hill that we have. And I'll say, here's why you're not going to do deadlifts,

01:25:05.060 but here's what I want you to do. I showed them a monster walk. Okay, monster walk. Now we're going

01:25:11.560 to the bottom of the hill and I want you to lean back into the hill and we're walking backwards.

01:25:17.780 You're going to align your foot, ankle, knee, and hip and push through the knee, through the knee,

01:25:23.880 through the knee, backwards up the hill. Do you know after 30 meters, they were absolutely done.

01:25:31.020 Here they are doing all this deadlifting and they don't even have the leg strength endurance to walk

01:25:36.540 backwards 30 meters. It's totally inappropriate stimulation of their athleticism to make it

01:25:42.760 through to 80. So good for you. Let's do it again. We walked down the hill. We did three sets they could

01:25:49.540 hardly walk. And then we played the neurological grip, which I like to do a lot of. Now I said,

01:25:56.720 walk forwards up the hill, but pretend you have a hundred dollars in your butt cheeks. Don't let

01:26:03.060 anyone take it. Now walk forwards up the hills. And they say, I've never felt this before. The brain

01:26:09.480 perceives exhausted quads. It now has to go and get the glutes. It's the only thing left. So quite often

01:26:16.960 we'll do a exhaustion focus to stimulate the thing that we really want to stimulate. And I convinced

01:26:25.680 that person after that, what they're going to do and train now to get a well-rounded and sustainable

01:26:33.700 athleticism that will spare their joints, still have great training capacity, but I think their

01:26:40.620 athleticism is going to go through the roof. I've taken some very accomplished power lifters and we've

01:26:48.340 taken out all the squats and just do sled work, backwards walking up hills. Some of these old time

01:26:55.860 techniques, their joints settle down, they get a sustainable fitness. They lose this idea of maximum

01:27:05.600 effort, squats and deads. And now they're thinking of the word sufficient strength, sufficient mobility,

01:27:14.840 sufficient endurance. And we've been doing this long enough now that we've tracked them. And those

01:27:21.440 are the ones that are getting through. Let's go get any one of our colleagues who are orthopedic

01:27:27.280 surgeons. Tell us who you're replacing the hips of. Well, 50 year old Caucasian women who have done

01:27:35.360 yoga for 30 years. Okay. Men around 50 who've done deadlifts. Who are you not? The middle of the road

01:27:45.380 moderates. Not the ones who've rusted out and not the ones who've worn out, but the ones in the middle

01:27:51.660 are the ones who are. So this idea of sufficient fitness, because I still believe we are all called

01:27:59.980 upon to do things in life at certain times, I hope are already enabled. It's more fun too, just to be

01:28:07.320 able to continue to do those things. So I'm like you. I don't do deadlifts, but I pick up a hundred

01:28:15.780 pound bucked up logs as an example, big old glob. So that's my stone lift. Load that into the log

01:28:22.880 splitter. Still split my wood. People comment on my hands. This athlete who came yesterday, I shook his

01:28:28.840 hand when he came to the door. He couldn't fit his hand around mine. He said, whoa. When we were

01:28:36.060 young, we didn't have dumbbells. My dad would give us a cinder block, cinder blocks. Anyway, as you know,

01:28:44.040 the importance of grip strength, I will take any day over how much you deadlift. People often ask me,

01:28:50.020 Stuart, why do you think grip strength is such a great proxy for longevity? And I say it's the same

01:28:55.540 reason I think VO2 max is a great proxy for longevity. Those are probably the two best biomarkers

01:29:01.480 we have. It sounds crazy by the way, that your VO2 max and your grip strength are better predictors of

01:29:07.180 how long you're going to live than whether or not you smoke, drink, what your family history is for

01:29:12.060 cancer. Like those things all matter, but it's amazing how dwarfed they are by those two. My best

01:29:18.300 explanation for it is that those are the best two integrators for the work you've done. You can't

01:29:25.980 cram for a VO2 max the week before. If you have a high VO2 max, you have done the work to get it.

01:29:33.920 If you have a strong grip, you didn't just buy little grip squeezers on Amazon and filter away at them

01:29:41.180 while you were on calls on Zoom. You had to do the work. You had to be carrying heavy things,

01:29:48.660 whatever it be, chopping wood, carrying cinder blocks, doing farmer carries. And of course,

01:29:53.720 that also speaks to stability. That speaks to the stability that you have to be able to transmit

01:29:59.720 force from the torso right to the hand. So agree completely. Let's pivot for a moment to talk a

01:30:05.000 little bit about the amount of psychological trauma that exists in the patient with lower back pain.

01:30:13.200 And I'm thinking very specifically, even about some of my own patients or friends who have been in

01:30:20.620 the throes of lower back pain. And if nothing else, Stuart, I take a great degree of comfort from

01:30:28.720 the injury, the third injury that I had, the one in 2000, because it lasted so long and because it was

01:30:36.020 so debilitating and because I'm here today without pain, my confidence around small recurrences is so

01:30:46.140 high that I don't tend to awfulize about it and work myself up. But I have great empathy for a person

01:30:54.860 who doesn't have that knowledge. And instead, I don't know how to help someone sometimes because

01:31:01.400 I can't tell what is mind and what is body at this point. And I suspect that there's a significant

01:31:07.080 interplay. So can you speak more about this phenomenon and what those of us who want to help

01:31:13.380 these patients can do? I am certainly much more conscious of the point you're making now than I was

01:31:23.020 30 years ago. Absolutely. I'm going to start with a little story. This happens very often.

01:31:31.840 You mentioned earlier how MRIs don't show you the mechanism of pain. And I can give all kinds of

01:31:39.700 reasons why. But let's take this patient. This is true. He came to see me. He said, hi, doc, I hear

01:31:48.400 you're different. I've got this pain. I've been everywhere. I went to the pain clinic. They gave

01:31:55.320 me narcotics. And now they say the pain is in my head. I can live with the physical pain. I cannot live

01:32:02.860 with someone telling me the pain is in my head because that means I'm crazy. And if I'm crazy,

01:32:07.820 I don't deserve to live. You've got two weeks. And in two weeks, I'm blowing my brains out.

01:32:14.800 Now there's a heavy psychosocial challenge and a little bit of a story of what the system does to

01:32:25.120 people. And it's not unusual for someone to come here suicidal. So I said, all right, you don't appear

01:32:33.140 to have pain right now. And he says, no, I don't. And I said, okay, what causes your pain? And he said,

01:32:39.640 well, it's when I do a certain movement that I get a flash of pain, and it feels like someone has

01:32:46.820 broken a beer bottle and have ripped open my hamstring muscles. It's awful. And I said, oh,

01:32:53.640 can you show me the pain? And he said, what? You want me to show you how I create the pain? And I said,

01:33:00.280 it's the only chance I have to understand it. I said, you've been to 15 different clinicians.

01:33:06.400 Has no one ever asked you to show them the mechanism of your pain? Has anyone ever touched

01:33:11.520 you? He says, no. I said, well, it's the only way I know. Peter, I put on my instrumentation,

01:33:18.120 which was muscle EMG over the torso, the glutes, et cetera. We put on the spine motion monitor,

01:33:24.560 3D motion spine monitor. And then I said, all right, let's see what causes this. So he stood there

01:33:30.280 and he did a very weird thing. And he said, all right, well, here you go. And he wound himself

01:33:35.440 around in a circle like this. And when he got to Ted tucked at center, now at that time, I heard

01:33:43.360 like a little cavitation, little pop come out of his back. And that was the trap of the sciatic nerve.

01:33:50.360 And he was in a bad way. I laid him prone on a table, tried to give him a bit of decompression.

01:33:56.420 And he went home and I said, I know exactly what the mechanism of your pain is. Here's what you

01:34:03.180 should do over the next three days. But I want you to come back. But promise me you aren't going to do

01:34:07.400 anything silly. Remember what the threat was hanging over us. He said, I promise. I called him that night.

01:34:14.260 I called him the next day just to make sure. Then he came back. And I said, I know exactly what your

01:34:20.100 mechanism is. Here's what the data showed. As he was winding himself around, he was using muscle.

01:34:27.660 Muscle is stiffening and stabilizing. It's centrating of the joints. And as he got to top

01:34:33.580 dead center, he shut all his muscles off. He completely relaxed. And then there was a little

01:34:37.840 sheer translation or a clunk. And that's what we heard. And that's what scrapped the sciatic root.

01:34:44.260 I said, okay, you have no pain. Push my fingers out. Harder. Good. Hold that. Now talk to me

01:34:51.660 and keep talking to me with that controlling. We coached him through this in a minute. Very simple.

01:34:58.160 Keep the tone now. And we're going through. And as he came to top dead center, you could see him.

01:35:04.000 Ah, ah, ah, ah, ah, ah. I said, we're there. Do it again. Hold on. Keep control. He didn't clunk.

01:35:13.320 Now, it took him about four months to wind down the ache. But he never had another clunk or a trap.

01:35:22.820 Ten years later, he brought his daughter to me. I saw her for back pain and he brought me a case of

01:35:28.900 beer. I said, I did my one-year follow-up with you. But how have you been? He says, fabulous.

01:35:34.820 I said, did you ever get another episode? Never had one. Now, some people will think that that's a

01:35:43.380 fantastic, impossible story. Pete, after that one coaching class and he gave him, he was so coachable

01:35:52.180 and he got it. He understood. He was a mechanical mind. He never had another acute episode ever.

01:35:58.580 So, a suicide case from the medical system not having a sufficient evaluation procedure to really

01:36:07.380 get at what the mechanism of his pain was to a point where they defaulted and said, we've tried

01:36:14.960 everything with you. It's not working. Therefore, the pain is in your head. The key was to prove to him

01:36:20.980 immediately that he had the ability. It's just he had to be shown how. So, it was a process of

01:36:26.900 understanding the mechanism, giving him a strategy to address the mechanism and the psyche just

01:36:34.820 changes. It empowered him. May I give you one more story? Absolutely. Okay. I was giving a lecture

01:36:40.560 in England and there was a fella off to the side and he was slumped down. Now, if you get a clinical

01:36:49.000 psychology textbook, the picture of depression is this. Knees together, slumped down in that demeanor.

01:36:55.800 Now, if you have a posterior disc bulge, that is not a good position to be. So, there we're starting

01:37:02.200 with clinical depression, feeding a disc bulge. Two don't go together. And he just sat there. And

01:37:08.420 then in the break, he came over to me, a very quiet, spoken fella. And he said, I hear what you're

01:37:14.260 saying. Do you have 30 seconds for me to tell you my story? And I said, sure. He said, I used to be a

01:37:19.940 police officer. Hurt my back. I went through the NHS system. They only gave me exercises that hurt

01:37:27.780 me more. Finally, they gave me a pamphlet, how to live with your back pain. And he said, that book

01:37:36.140 destroyed me. What? You mean I have to live the rest of my life with my back pain and no one's ever

01:37:41.880 touched me or shown me any of this? And I said, oh. And then you'll remember that squat procedure that

01:37:48.180 we went with the older woman that I described earlier. I simply showed him that. And he went

01:37:52.740 back and he sat down on the chair, nice and tall. And then at the end of the lecture, I went over to

01:37:58.360 him and I said, how's your pain? And he stood up and he said, it's gone. And he started to cry

01:38:02.540 because he realized now what the system had done to him. In the meantime, he lost his job

01:38:10.000 and he realized that he'd been stolen from. And those are his words. He said, they stole my career

01:38:16.020 from me, giving me that book, how to live with my back pain. Why didn't anyone show me what my pain

01:38:22.160 was like you just did in 30 seconds? I've been watching this pattern for so many years, you could

01:38:28.100 see it a mile away. Anyway, those are two stories to link the mechanics. And ultimately, what we're

01:38:38.140 trying to do is to empower people in showing them they have the ability within themselves. They just need

01:38:45.620 to understand the mechanism. And most of the time, they are able to mitigate the cause and then build

01:38:55.420 a robust foundation. So I wrote back mechanic and I started the experimental research clinic at the

01:39:03.460 University of Waterloo. Maybe you've heard of this, but I've never heard of another clinic where they

01:39:09.360 follow up with every single patient that they ever saw. We did a two-year follow-up with every single

01:39:15.280 patient who came in and we subcategorized them because we assessed everyone into the mechanism of

01:39:22.640 their pain pathway. We gave them an appropriate exercise prescription. We followed up to see did

01:39:33.420 they even comply because some people didn't. And then how are you doing after two years? If you were in

01:39:39.880 the subcategory that everything has failed, you've been told you need surgery. So you're at the end of

01:39:47.140 the road now, you're a surgery case. In the two-year follow-up, following the plan that I just described

01:39:54.480 for you with this thing called virtual surgery, which is part of it, 95% reported that they avoided

01:40:01.920 surgery. And they were glad that they did. So that's my efficacy to the empowerment and psychology issue.

01:40:12.120 What stands out to me the most in those stories, Stuart, is your consistent, adamant drive towards

01:40:22.120 understanding the mechanism of the pain. So it's how do we break this down into a physics and biology

01:40:29.160 problem. And I guess my question is, which type of healthcare providers are most in line with that?

01:40:37.900 Is your PhD through the School of Kinesiology? Yes. I should back that up. Yeah, there's a lot

01:40:44.100 of mechanical engineering in there. But nonetheless, yeah, basically. But when we think of all the

01:40:49.360 different practitioners that interact with patients who have lower back pain, ranging from neurosurgeons,

01:40:58.380 orthopedic surgeons, chiropractors, physical therapists, kinesiologists, I mean, there are so

01:41:05.740 many people. And I never want to suggest that the profession determines the school of thought. Like,

01:41:12.740 I really think there are great people and there are lousy people within all of those categories.

01:41:17.920 But what are the characteristics that you see driving that type of search for a true mechanistic

01:41:25.140 understanding of the pain? Because I'll be honest with you, like, in all of my back bouts of misery,

01:41:31.620 nobody ever explained to me what was going on. I mean, nobody said to me, this is happening.

01:41:37.140 Even as a medical student, yes, I could look at the MRI, I could see the fragment.

01:41:42.960 It clearly had to come out, presumably, given that I was in such excruciating pain and the thing wasn't,

01:41:48.940 you know, it might have taken months for the thing to have been resorbed.

01:41:51.580 But there wasn't a sort of, we need to understand the why this is happening,

01:41:55.900 so that we're going to fix the underlying behavior that's causing it. That's the thing

01:42:01.360 that strikes me as the most interesting of those stories. And I guess what my long-winded

01:42:08.060 apologies question is, is that a function of the individual or of the school of training?

01:42:12.800 Both. So the elephant in the room here is there is no billing code that exists for an assessment

01:42:23.860 of back injury mechanism. It doesn't exist. You can't bill an insurance company and say,

01:42:29.860 well, I assess the person's back pain. When I started the experimental research clinic,

01:42:34.600 I set aside two hours to see a back pained person. And I'm a black guy, that's all I ever saw,

01:42:40.900 two hours. My medical colleagues who'd been through medical school training, which I had not,

01:42:46.060 I'd only have ever been a guest professor at a medical school, but I sure didn't even graduate

01:42:50.740 from one. My medical colleagues said, two hours, what are you going to do for two hours? Well,

01:42:56.840 I've been spending 30 years figuring out how I'm going to test shear tolerance to compression,

01:43:03.860 pulling a nerve root one way, pulling it the other way. Is it flossing? Is it friction? Is it stuck?

01:43:08.980 Et cetera. Again, I said a handful of people in the world that would take cadaveric spines and create

01:43:16.380 the injuries. So I knew how to measure them and what to look for in terms of the full pattern.

01:43:23.240 But that's the first political impediment to all of this. There's no billing code. Therefore,

01:43:30.920 you're left with clinicians who are billing for a procedure that they've been trained to perform.

01:43:40.540 Well, if you have nonspecific back pain, it's an absolute crapshoot, whether a manipulation for

01:43:48.080 mobility, an exercise prescription for stability, just a movement tool not to create a stress riser

01:43:55.820 or a stress concentration on the tissue that is sensitized. Simple as that. So where I've arrived

01:44:04.160 at with all of this, we have to train our own clinicians. And that's what I've been doing through

01:44:10.220 BackFit Pro. And I do not care if you come from a chiropractic, physical therapy, coaching, training,

01:44:18.840 physiatry, neurology, radiology, even background. All I care is that you have passion. It's a 50-hour

01:44:28.380 online course of me going through anatomy, physiology, neurology, psychology, biomechanics,

01:44:37.340 et cetera. And then the probably 100 subcategories of pain mechanisms. And then how do you test for all

01:44:48.580 of these? And then how do you coach them? And then after all of that, we have three days together

01:44:54.520 where we do hands-on skills training at a table. So again, there's no subcategory in the medical

01:45:01.780 rubric that trains how to assess back pain from the perspective of biomechanics, psychology, neurology,

01:45:12.040 physiology, et cetera. They don't exist. So that was my challenge.

01:45:16.120 Stuart, what's the name of that course?

01:45:18.580 It's called the Summit course, and you can read about it on backfitpro.com.

01:45:23.340 And is it only for practitioners? Or is there a variant of that course that an individual can

01:45:29.280 take to become sort of a master of their own domain?

01:45:33.600 Okay, good question. It's mostly for clinicians. It's only been clinicians that I know of that have

01:45:40.240 ever registered for it. I don't think we would stop a member of the lay public because some of them

01:45:45.660 are very savvy from taking it. However, the gatekeeper of all of this is there's a fairly

01:45:52.360 extensive exam at the end. It is a written exam. There's a practical exam where the person must assess

01:45:59.320 a real patient, usually online, with one of our examiners. They have to come up with a written

01:46:07.000 explanation of the pain pathway, and then a program of what they're going to do with the person. And

01:46:14.160 then they have to coach elements of it. So they have to see the coaching scale as well.

01:46:18.400 So that's sort of a gatekeeper at the end that I think would only be for clinicians. But that's

01:46:24.700 the only way that I've found possible. I'm like you. I'm very agnostic in terms of preparation.

01:46:32.760 There are fabulous chiropractors, and it's the absolute opposite. There's fabulous therapists.

01:46:38.240 There were fabulous professors and terrible professors. It's just the way it is.

01:46:43.400 It's a very interesting course. It's almost something I wonder. I'd love to figure out a way

01:46:47.480 to make the time. So it's 50 hours online plus three days in person is what it sounds like.

01:46:51.900 Correct. Yeah. Let's talk about the cases where you think surgery is really the best course of

01:47:00.400 action. And again, I think it should always be stated that surgery without understanding how

01:47:06.420 you got there and then making sure you correct it post-surgically is not what we're talking about.

01:47:12.300 So it should always be assumed that you want to understand what got you there. But what are the

01:47:18.100 indications in your mind for where a patient is better off getting a surgical procedure? And we

01:47:25.060 could talk about what do you think are the best indications for discectomy, fusion, etc. Versus

01:47:30.740 where would you take a contrarian approach where many people would say yes, surgery, and you would say

01:47:35.900 let's push a little bit harder before? Wow. A lot of elements there. So I'll just

01:47:41.560 start at the beginning and hope I can create a logic story. I did mention the follow-up that we did

01:47:50.240 where 95% of people who were told they needed surgery, in fact, avoided it. And what we did there

01:47:58.180 was I anointed them and said, there is your virtual surgery. This worked really well on people who I'll

01:48:06.860 paint the picture of let's take a stay-at-home mom with two young kids. Every day has to go to the gym

01:48:13.260 and ride the elliptical for 20 minutes, do something else as a stress reliever. Otherwise,

01:48:17.600 she's going to murder her husband. You've heard that story before. I'll say, good, go get your surgery.

01:48:24.660 Are you going to do that tomorrow? No, you are going to lay in bed. You're going to behave like a

01:48:30.000 post-surgical person. You're going to get out of bed and go for a pee three times. That is your total

01:48:34.520 workload tomorrow. And slowly, you're going to build yourself back. In other words, surgery

01:48:38.880 may work for you because it's forced rest. Now I'm going to give you a tool that will mimic the

01:48:45.020 forced rest. It's called virtual surgery. Tomorrow, here's the plan. Here's how you're going to behave.

01:48:49.920 We are going to desensitize strategically the pain mechanism as we've measured it. And we're going to

01:48:56.600 retune your body with strategic mobility and stability plus movement skill so we don't replicate

01:49:03.600 the stress concentrations that caused your problem in the first place. Let's see how you are. Now,

01:49:09.360 if they can do that, 95% will avoid surgery. So there's my first little story for people in that

01:49:17.140 category. Stuart, just to be clear, what are the patients who you would not offer that virtual

01:49:23.540 surgery to? Give me an indication where you would say, you know what, this is too pressing.

01:49:28.980 Right. Obvious red flags, which before we see a patient, we don't take patients off the street.

01:49:37.540 Never. They always come through physician referral. So I'm hoping they've been checked for red flags.

01:49:44.940 Do you know how many have not? Even though we state in the referral directions to the referring medic,

01:49:51.240 we've had cases of aortic aneurysm, lung embolism, cancerous tumors, metastasized,

01:50:00.120 all sorts of things that somehow these poor people got through the system and we were the ones that

01:50:06.120 found it and saved their lives. I wish that wasn't the case, but all of those obviously are surgery

01:50:13.960 cases and they should never have come to us in the first place. So obvious red flags is number one.

01:50:20.880 Number two is when the pattern doesn't fit. So I was smiling when you were telling your original

01:50:28.980 story only because it was such a familiar spot on pattern consistency. You fit the pattern. I knew

01:50:37.220 exactly what it was. When the pattern doesn't fit, I'll say, no, something's not right. I need you

01:50:44.460 to go back to your doc. And here's the reason why there is a turgidness under your liver. We're not

01:50:53.380 able to move that pain by moving stress concentrations around your spine. So it's not a nerve. It's nothing

01:51:01.020 vertebral or facet. The pattern doesn't fit. It's something else. So there is a person where we refer

01:51:08.340 back and say something needs further investigation. But now the last part of your question was about

01:51:17.180 the need or when we would say for a person, you're not our person. You need to see a surgeon. Surgeons,

01:51:25.980 and by the way, we see far too many post-surgical patients who they went through. Maybe the surgery

01:51:32.640 was botched. When I see a horrible scar on the outside of the skin, I think, man, if that's the

01:51:39.600 pride that the surgeon took on the outside, what carnage has gone on the inside. Or sometimes it's

01:51:44.920 a shit happens story. The nerve scarred in and adhered. Ah, that's rough. Or the post-rehab was

01:51:54.860 terrible. Here's a person that went to a fabulous surgeon, and the surgeon says, oh, go do PT. That's

01:52:00.880 your rehab. And the PT goes and gives them toe touches or something after they've just had a

01:52:06.420 microdisc surgery. And guess what? They're re-herniated again, and now we're seeing them.

01:52:11.600 But when would we say, no, you're not for us? The surgeons are at their best in cases of a real

01:52:21.380 heavy stenosis. So there's not much room in the neural canal. The facet joints are thick in behind,

01:52:29.200 so you've got encroachment from behind. You've got a calcified disc bulge coming from the front.

01:52:35.420 So a couple-level aminectomy to give the nerve some space. That really is when the surgeons are

01:52:43.720 at their best. Some of the spondylomalopathies that we'll see in the neck, I think of a lead

01:52:50.300 lawyer in the courtrooms. And the judges would ask him, sir, are you drunk? And he said to us,

01:52:57.320 well, when I stand, I start my presentation, I'm fine, he says. But after two or three minutes,

01:53:02.520 I'm losing my balance and falling over. And the judges think he's drunk. And then we found it.

01:53:07.840 It was a cervical spondylomyelopathy that was also co-presenting with back pain. But no one had

01:53:14.160 figured this out. So that was a surgery case, obviously. So it's either post-trauma,

01:53:21.220 and then that one's obvious. They need a little bit of hardware to stabilize their spine.

01:53:26.460 But it may also be spondylolisthesis. The listhesis or the sheer translation is just choking off

01:53:34.700 the tata equina or another nerve. We recommend surgeons who we have really good luck with.

01:53:43.180 And in that situation, if the spondylolisthesis is significant enough, is the only treatment a

01:53:48.820 fusion? I'm going to say yes. There's no amount of stability you can generate

01:53:55.300 in the paraspinous muscles, in the QL, in the psoas to compensate for that. I mean,

01:54:02.400 I realize that you have to forgive me because I'm not an orthopedic surgeon, but I would assume that

01:54:06.860 there's some threshold. One millimeter of spondylolisthesis might be tolerated. And

01:54:11.680 at some level, they would say, no, it's too unstable.

01:54:15.260 I wouldn't agree with that, Peter. It's not the distance at all. You go with the assessment.

01:54:19.920 Again, the evidence I offer there is we're coming down to the next Olympics now. So I don't know how

01:54:26.660 many Olympians and people who are tapering now for the Olympic trials we've had here over the past year.

01:54:34.720 But this is every four years we're inundated with these types of athletes. And they come in pairs

01:54:40.100 where we might have two young women who are competing for a place on the U.S. Olympic team

01:54:46.380 in gymnastics. Both have the same spondy. One will say, we need six months off here

01:54:54.360 of gymnastics. And here's what we're going to do. We're going to do a heavy stabilization program.

01:55:00.380 The next one says, oh, no, we really got to make the trials. We're just going to keep going with

01:55:05.800 going to gym. And I can almost predict with 100% accuracy who's going to make it.

01:55:12.040 So I wouldn't say at all that we don't try a heavy exercise stability program,

01:55:20.520 regardless of the amount of slippage. And I've done that with people trying to make

01:55:26.240 the special forces in the U.S. You've got to do a speed sit-up test. You've got to do all of these

01:55:32.020 things. Oh, but you've got a heavy spondy. Okay. Here is the program to try and get there. You might

01:55:37.800 make it. What about nerve pain? What about patients who are either having weakness, such as a foot drop

01:55:44.580 or significant pain like the pain I had? We have them all the time. If I can get the nerve pain to

01:55:52.760 move on the assessment, please don't have surgery. Let us have a try at it. Most of the time,

01:55:57.840 they will be pleased. Wow. We have to play with certain rules.

01:56:03.460 Give me an example of some of those. So let's say your assessment comes out that

01:56:06.920 this person who's having intermittent sciatic pain and you do an assessment and you say, look,

01:56:12.700 there is no doubt that you have a ruptured annulus here. You've got a protruding segment of

01:56:20.340 disc and it is clearly at times, depending on your activity, getting nearer to the nerve root. It's

01:56:26.400 driving that sciatic pain. But during your assessment, I assume what you're getting at is

01:56:30.100 through some of those positional things, such as laying the person on their front,

01:56:34.000 manipulating the legs, getting the herniation to retreat into the annulus. So you're saying if you

01:56:39.420 can demonstrate resolution under a changing movement pattern, that gives you enough confidence

01:56:45.900 that this doesn't need to be removed surgically. Not resolution. Can I move the pain a little bit?

01:56:51.620 Can I make it worse? And can I make it better? Now I'm starting to understand the variables that

01:56:57.020 make it worse, make it better. And I play with those. I'm trying not to sound boastful. I'm trying

01:57:02.280 to be scientific here. There was a day not that long ago. I'm losing track of time. It was probably,

01:57:09.540 well, it was the NHL playoffs. So there's our time marker. I don't watch TV really, but for some dumb

01:57:15.520 reason, it was Saturday, I flipped on the TV, it was the NHL playoffs. And I listened to the announcer,

01:57:23.160 the name. Oh, that's my patient. Next player, my patient. Two of my patients are now in the NHL

01:57:30.440 playoffs series. A little bit later, I flip over to TSN, tennis tour. I look at that, my patient.

01:57:39.320 And then that night, the UFC comes on. There's my patient again. So in one day,

01:57:46.660 I see three different pro sports. Every single one of them had sciatica when they came to me.

01:57:52.620 That's some evidence that I can offer. Now, I remember one of those players in the NHL,

01:58:00.000 if he fully flexed, he would stir up sciatica and increase the risk of a full-blown acute attack,

01:58:07.520 as you and I know very well. So we got him to move well. He played hockey, mindful of a skating

01:58:16.460 style that he didn't get too flexed up. We didn't allow him to tie his own skates. He said,

01:58:22.200 tying my own skates really set my back up. I said, good. Now, NHL players are very particular how they

01:58:31.040 tie their skates, but they coached one of the training staff to tie his skates for him.

01:58:35.200 Now, I know some people will laugh at that, but that was all part of the plan to keep the capacity

01:58:43.520 as high as he could to utilize in the game. How he sat on the bench was also instructed.

01:58:51.280 The fellow in the UFC, this is no slouch, jiu-jitsu really put his spine in a place where it could

01:59:01.880 fire off an acute attack. You do not want to be in the cage fighting for your life and having an

01:59:07.740 acute attack. That's the last thing you want. We would limit the mat time on jiu-jitsu. He would do

01:59:15.120 stand-up, all kinds of things to minimize the accumulative stress on the disc bulge causing

01:59:23.220 sciatica. He competed. I wish I could tell you who he was and what he did that night.

01:59:28.240 So, I'm not afraid of nerve irritation, sciatica, etc. And it certainly doesn't fall into the category

01:59:37.920 of you need surgery. We've proven that far too many times. But as I said, heavy instability. And when we

01:59:46.680 fail to arrest the shearing movements, trapping nerves, it's gone on for quite a time. We can't

01:59:55.000 hack our way around it. It's best to see a surgeon, a stenosis.

02:00:00.200 Yeah. And stenosis as well.

02:00:01.860 Yeah. And it's many, many different forms. Central stenosis. It might be a foraminal stenosis and a bit

02:00:09.380 of arthritic activity where they can just basically take a Dremel tool to describe it for your audience

02:00:14.720 and burr out around the foramen or the hole that the lateral nerve comes out. Another one is,

02:00:21.680 I know a lot of our medical colleagues say, well, a Tarloff cyst, a neural cyst. Well,

02:00:26.840 they don't cause pain. Really? I will prove to you very quickly whether or not that's causing pain

02:00:32.900 by pulling the nerve root one way or the other. Typical pattern recognition might be a physio might

02:00:39.640 do a slump test, which is you straighten one leg and you flex the spine and neck. But the net

02:00:45.400 stress in the middle of the cord is zero. You're pulling it one way, you're pulling it the other

02:00:51.460 way. It just goes into a little bit of tension. If that's a Tarloff cyst, that won't be triggered.

02:00:57.120 A Tarloff cyst doesn't like being pulled one way. So that patient on exam might say, well,

02:01:02.140 I don't get pain with a slump test, but I can't stand driving my car. Oh, tell me about your car.

02:01:08.600 Well, I sit upright, put my head back and extend my leg to push on the accelerator.

02:01:13.800 You're pulling the nerve root one way. Where's the pain? It's in my big toe.

02:01:18.940 Aha. I am now going to inform my inspection of the MRI because the radiologists missed it.

02:01:27.100 They're not going to find a Tarloff cyst distal on the fifth root. But I know that the symptom and

02:01:31.960 the assessment took me there logically to say, I know there's something hanging up there that's

02:01:37.060 directionally specific. It's not a friction. It's a direction specific tension. There's the

02:01:44.120 Tarloff cyst. I found it. Now, boy, what's the surgical procedure there? Typically, they'll try

02:01:50.680 and drain the cyst and it comes right back again. Typically. But there's a doc in Dallas who we send

02:01:57.920 all our Tarloff cyst patients to. And he has a reasonable rate, at least better than anyone else

02:02:03.880 in dealing with those pesky cysts. Bit of an off the wall. I can't do a damn thing about that

02:02:10.100 assist. It's eroding the bone. They're pesky little things, but here's a surgical referral.

02:02:17.040 That's great. Stuart, how often, if you're doing a two-hour assessment on a patient,

02:02:20.840 I assume you're also looking at an MRI.

02:02:22.940 Let me stop that. After the first year of the experimental research clinic running two years,

02:02:29.960 I changed it to a three-hour consult. I needed even more time. Now, if they're an old athlete and

02:02:38.360 they still have films on the film, remember how we used to get MRIs? I read them on the reader. I put

02:02:44.780 them up on the screen there. Full medical images we go through. What are the things you're looking for

02:02:51.600 in the MRI that maybe aren't as readily apparent? In other words, what are you looking at in an MRI that

02:02:58.400 isn't obvious to the radiologist? Because presumably, yeah, you can maybe explain to

02:03:02.800 somebody what the MRIs are showing, but you're getting axial cuts. You're getting coronal and

02:03:07.540 sagittal cuts. They're T1-weighted. They're T2-weighted. They highlight the disc. A nice

02:03:13.680 healthy disc looks white on the MRI. Of course, mine are jet black. What are things you're picking up on

02:03:20.240 that MRI read? Well, all of the things that you've mentioned. I don't know if you looked at my CV

02:03:27.000 and the number of papers and the topics that we covered over the years, but the very last study

02:03:31.580 that I ever published as a professor was exactly that. We took a cohort of whiplash patients. I

02:03:39.840 didn't do very much cervical spine-specific work. Most of mine was lumbar. But just to answer your

02:03:46.600 question, we took whiplash patients. Every single one of them had been denied compensation because they're

02:03:54.220 now more than two years post-whiplash. They still continue to have symptoms. The medical profession

02:04:00.620 and the legal system was declaring them pain magnifiers. They were exacerbating their pain for

02:04:08.340 financial gain. Terrible. The MRs said, there's no reason for your pain. Really? The MR is a static

02:04:18.860 picture. What do you expect? So we took video fluoroscopy, which you know is a real-time

02:04:24.020 moving x-ray. So we're watching the bones move now. And we would have them move through their pain.

02:04:30.660 And their pain wasn't very rarely at the end range of motion. It was actually somewhere in the middle

02:04:36.080 of the range. And they would move their head like this. And then the spine would clunk. And then they'd go,

02:04:41.980 and then they'd continue to move through. On the video fluoroscopy, we'd watch the rotations occurring

02:04:49.020 between every vertebra, but we know what instability is. It's when the rotation stops and the shear begins.

02:04:57.000 So the ratio of rotation and shear is the marker of that cervical instability. So if I can just show

02:05:05.580 with my hands, here would be the neck moving, rotating well, and then it would clunk. It was

02:05:11.820 the clunk that corresponded 100% with the shot of pain. Now, you and I both know that when a muscle

02:05:19.560 contracts, it does two things. It creates force, but it also creates stiffness. The body uses stiffness

02:05:27.020 to control motion. Okay. So if you just want to observe me now, and you can play along and do this

02:05:33.540 if you like, I want you to lightly stack your ears over your shoulders and have a pitch to your head

02:05:42.040 that's neutral. Stare straight ahead. Now, lightly touch yourself under your jaw, just above your

02:05:48.760 Adam's apple. Don't retract. You're too stiff feet. Relax. Now, push your tongue hard to the roof of the

02:05:56.600 mouth behind your front teeth. You felt the deep flexors activate. Now, corners of your mouth

02:06:03.080 grimace down. Do this to your neck. Now, keep that. Imagine the person who's rotating and then has the

02:06:10.540 clunk. Keep that controlling stiffness and repeat the offensive movement. Would you believe in most people

02:06:17.800 the clunk was arrested? It was gone. Proving that the MR had no ability to pick up that dynamic pain

02:06:27.000 trigger. We just proved what their pain trigger was. You can imagine the psychological relief that they had to

02:06:34.500 know that it isn't in their head. The medical profession was wrong. And finally, they're empowered now because

02:06:41.680 they have a strategy to start learning just a little bit of a strategy to take the clunk out. If you arrest the

02:06:50.200 clunk over time, the joint will stiffen. The bad news is you don't move so well through that joint.

02:06:56.780 The good news is the pain clunk is gone. So, we all experience this and you're going to be experiencing

02:07:02.900 this now over the next 15 years, particularly. If you're in your early 50s, things are going to be

02:07:09.480 stiffening in your body. The good news is your pain will go. You know who really gets this? I've worked

02:07:17.420 with a couple of former Mr. Olympians. That's the top professional level of bodybuilding.

02:07:24.240 They put a lot of mileage on their joints. They don't really get joint pain when they're competing

02:07:29.800 because the muscles are so big, so bulky. They have enormous wrench handle moment arms and the

02:07:38.440 stiffness holds the joints together. When we work with them, tapering down back to civilian life,

02:07:45.820 some of them don't look that different than you and me. Believe it or not, what they looked like

02:07:51.340 in their former glory, they ache like hell. All their joints have these shearing translations to them

02:07:57.360 now. So, the cure is getting a little bit of the muscle bulk back to add some controlling stiffness

02:08:06.600 and all their aches go away. Anyway, these are all sort of fun stories. I don't know if that's

02:08:13.380 really answered your question on instability, sciatica, brachial plexus nerve traps, numb thumb and first

02:08:23.880 finger, whatever. They're not indicators for surgery at all. Try some of these voluntary skills and let

02:08:34.420 nature take its course. Most of the time, and I can with confidence prove it and say most of the time,

02:08:41.860 it will work out well with some patience and skill.

02:08:46.360 One of the really good spine surgeons I know, and you can always tell a great surgeon by talking to

02:08:51.900 them. Maybe I'm fortunate because having trained as a surgeon, you sort of learn what the signs are

02:08:57.960 of the hacks and the good ones. As we can all attest to in our own respective profession, we're pretty

02:09:04.180 good at picking up who the good ones are and the bad ones are. Speaking to this spine surgeon,

02:09:08.940 it's just really clear. She's a really good surgeon. And one of the signs of a really good surgeon

02:09:14.520 is a surgeon who's really happy to not operate. The really good surgeons are really happy to not

02:09:21.480 operate on somebody. Partly what makes them so good is their judgment. It's their knowing who to operate

02:09:27.460 on and who not to. We did a really fun exercise one day where we went through my MRI. Every time I get

02:09:33.580 an MRI for another reason, if it's going to get any sort of back cut, I just send it to her,

02:09:38.360 even if it's not a dedicated spine MRI. And I say, what do you think of this? Does it look any worse?

02:09:43.060 And again, we're always collectively amazed at how bad my spine looks on MRI relative to the fact that

02:09:48.980 I don't have any symptoms. One of the discussions we had prompted her to contrast my back with that of

02:09:56.700 another patient she had who has no obvious disc pathology and yet is in debilitating pain.

02:10:05.400 And she said, look at the difference. And again, I'm not saying this to be boastful,

02:10:10.120 but I'm just trying to make the contrast. She goes, look at the difference in the musculature

02:10:13.780 of your psoas, your QL, your erector spinae. These are big, beefy muscles here. And now compare it to

02:10:21.360 this other patient. First of all, the muscles are about half the size and they look like wagyu.

02:10:26.160 They're very fatty. And the way she was explaining it to me, she goes, this is a person who's never

02:10:31.720 lifted anything in their life and they don't have any of the disc pain. Their discs haven't been

02:10:37.480 decimated like yours have, but they're more debilitated. Their inactivity has led to instability

02:10:45.000 and tremendous pain. You've already sort of alluded to this where we've agreed that the

02:10:49.860 deadlift till you drop strategy and the do nothing strategy are both bad. But can you speak a little

02:10:55.540 bit to why that person might be in pain? Because what I don't want anybody to come away from this

02:11:00.140 podcast feeling is, oh, I better not lift weights because that's clearly the wrong message.

02:11:06.040 A hundred percent. Okay. I'm so glad you brought this up. I would love to talk to her and I'd say,

02:11:12.140 tell me about your training program or your daily routine or your life in physical terms.

02:11:17.240 Yes. I will bet she's a mobility monster. She keeps pushing the end range, softening the joints

02:11:24.420 even more. So on MRI, they look plump and pristine. I bet if we put her under load or we put her in bed

02:11:31.960 and she had this instability that I've showed earlier and she lays in bed and the joints just

02:11:39.240 fall like that a little bit, she'll get a hell of an ache to her back. My first question would be,

02:11:44.080 when you roll over in bed, do you ever have a sharp pain? That's a beautiful follow-up question.

02:11:51.080 It is so indicative of if she has nice plump discs, but micro movements. How many pillows do you go to

02:11:59.160 bed with at night? That is a wonderfully telling question. The more the pillows, the more the

02:12:05.180 joint instability. It's quite a high correlate. Anyway, I'd love to have that conversation with her.

02:12:12.680 And I will bet we will get some real insight from that versus the person who has a mature strength

02:12:23.180 history and the joints are held together. A little bit of arthritis and people are going to nail me for

02:12:30.440 this one, but a little bit of arthritis is good for adding certain amount of joint stability and

02:12:37.540 holding it all together. I had a fracture of C4 as a young fellow. Oh, I would have some terrible

02:12:45.680 episodes checking my blind spot or craning my neck to back a trailer up or something. I have zero pain

02:12:52.880 now. My neck is bulletproof again. It looks horrible on a CT or an MR. But my point is the arthritis has now

02:13:01.100 stabilized the joint. All the pain's gone. I don't move it very well, but I don't worry about it.

02:13:08.700 My sister's a vet. She sends me x-rays of a dog. Terrible. And as you know, spine arthritis and

02:13:16.940 nerve compromise in dogs, which is very breed specific as well. They lose their hind end. It just

02:13:24.640 atrophies just like in a person. But anyway, she'll send me this x-ray of a dog. She says,

02:13:29.260 what do you think this dog's doing right now? And I said, well, it's just laying in its bed.

02:13:33.640 She goes, no, that just won the Frisbee championship, the Frisbee catching championships.

02:13:39.280 So again, I just keep coming back to the assessment. And between you and I, I don't ever want to see

02:13:46.180 another MRI of my spine until the pattern doesn't fit and I can't move the pain anymore.

02:13:52.920 The only time I ever want to see an MR of my own back. I'm like you. Doesn't look so good. However,

02:14:00.460 I've got a few miles on my back and I'm the person I am today because of that. I do everything I want to

02:14:07.920 do with certain guidelines. I'm not 16 and I don't have infinite capacity. So I play with that tipping

02:14:16.100 point all the time.

02:14:17.220 What would you say to the person who's watching or listening to us right now? And I realize

02:14:22.880 that there's a pretty good chance that by now, because we're a couple hours into this podcast,

02:14:28.000 if you have never experienced back pain, you might not be listening anymore. Because the truth of it is

02:14:33.760 there's going to be a lot of people listening because if you've experienced back pain, especially

02:14:38.200 if it's happened more than once or if it lasted more than a week or so, this is a riveting discussion.

02:14:43.820 But if you were talking to a person of any age who had yet to experience it, but in particular,

02:14:51.280 maybe a young person, someone in their twenties or thirties, what would you say to them? And how

02:14:57.060 would you counsel them with respect to what they could do to maximize the longevity of their spine?

02:15:04.040 What a fabulous question. If I was to say to you, a young fella comes into your office with a cigarette

02:15:11.880 hanging out of his mouth, what would you say to him that he hasn't already heard? I would love to

02:15:20.360 take you over to the cancer ward at the hospital. And I want to show you how your last days are going to

02:15:27.420 look. That might convince a few of them on the lunacy of what they're doing to themselves.

02:15:35.860 It won't be a hundred percent effective. And I would hazard a guess it wouldn't be close to a hundred

02:15:40.660 percent. Their friends and peer pressure is far more important for them now. That's how I'm going

02:15:45.960 to answer the question you just asked of me. I don't have very good luck when I see someone who's just

02:15:52.960 all balled up. Kid called me, not a kid, a 30 year old called me last week. This guy was all balled up

02:15:59.880 like this. And he said, Oh, he says, whenever I do exercise, I'm just exhausted. I said, Oh yeah.

02:16:06.980 I said, would you move away from your desk a little bit? And would you ask someone to come in and hold

02:16:12.620 your cell phone up so I can see all of you? And there he was. And I said, all right, would you now sit

02:16:18.900 at your stool, your chair, sit upright for me? Do you have pain? And he goes, no. And I said, good.

02:16:25.900 Drop your chest down and slouch and lower your head. Do you have pain? He says, yeah, I do.

02:16:31.400 Now, don't you think I just proved to him what caused his pain? He said, well, I've heard that

02:16:36.840 before. I've sat like a cashew. And that was his exact words since I was 14. I coached him. Okay,

02:16:43.640 sit up, lay on your tummy for a little bit. Let this thing calm down. By the way, what do you do when

02:16:48.720 you get up in the morning? Well, I go down and I get a coffee. And I said, how do you get to work?

02:16:53.120 He says, I drive. And I said, tomorrow, I want you to get up half an hour early and go for a walk.

02:16:58.980 And it was snowing here. So I said, it's snowing outside. You live in LA, get your, you know what,

02:17:04.280 out of bed and go for a walk for half an hour tomorrow morning before you get in your car.

02:17:08.500 Do you know he was bucking me on that? So to your point, I don't think I changed his behavior one

02:17:16.140 little bit. And he's going to have to suffer a little bit more before he comes to a realization

02:17:23.140 that he does have the power to do something. And I know your thesis loud and clear in Outlive.

02:17:34.080 We're identical. We're trying to get people on a program now when he's 30 and not wait to have

02:17:42.980 more misery and more misery. It's so hard to motivate someone. Maybe you have a hint for me.

02:17:50.980 I share your sentiment exactly. And that's why I've often referred to that third bout of back pain

02:18:00.000 that I had, the one that lasted for a year as the best worst experience of my life. It was the worst

02:18:06.180 experience in that I wouldn't wish that duration or depth of pain on anyone. But what was so good

02:18:14.760 about it is that it lasted for so long that it created a lifelong change in behavior and an

02:18:22.880 appreciation for something, which is without that experience, this idea of a centenarian decathlon

02:18:28.980 wouldn't exist. Because you have to sort of see what a life looks like with immobility and pain.

02:18:36.860 Because even though I was only 27, I lived that year as though I was 87. And a year is long enough

02:18:43.980 that it imprints. If it was only a week, no matter how bad it is, I don't think it would have imprinted.

02:18:49.500 But a year of that really imprinted in me. I've said this before many times, but to this day, I still

02:18:56.740 enjoy parking as far away as possible in the parking lot, even if there are plenty of spots

02:19:02.640 close to the grocery store or wherever, because I remember what it was like to not be able to walk

02:19:08.700 from the car to the grocery store. So unfortunately, that's probably the nature of our species in that

02:19:15.880 it's very difficult to make a short term sacrifice for a long term objective without a more pressing

02:19:26.400 reason. So instead, I'll turn my attention to who I think is the larger population listening to us,

02:19:33.500 which are the people who have experienced either personally or through watching someone they care

02:19:39.380 about perhaps. Let's start with this. What are the best online resources we can point people to

02:19:46.880 that can help with the types of exercises, maybe some do's and don'ts around lower back pain?

02:19:56.720 I love that you even clarified around the big three, which is, hey, the big three are great if you need

02:20:01.980 stability, but if you need mobility, we might need some different exercise. So how can people sort of

02:20:06.700 navigate their way through that? I challenged myself with exactly the same issue 15 years ago,

02:20:15.640 just as the internet was getting going. But here's the thing. There is no such thing as nonspecific back

02:20:23.820 pain. And if that's what the person operates on in their strategy, this nonspecific thing, it will only be

02:20:32.060 dumb luck if they're able to come up with a strategy to mitigate it. They have to have an

02:20:38.220 assessment. Well, they can go and see someone who is very knowledgeable in converging on an understanding

02:20:46.680 of their pain most of the time. Well, short of that, I wrote back mechanic. Now, it's not on the

02:20:52.200 internet. And the reason is, they have to have some background understanding of how their back works,

02:20:58.680 and then go through a series of self-tests. That's what the book does. The first thing is,

02:21:04.840 it just says, draw a table. What are activities that cause you pain? What are activities that

02:21:10.340 either take your pain away or are neutral? Write them all out. Now, here is how you pattern recognize

02:21:17.520 those. All of those activities involve you bending backwards. Guess what? Change a light bulb overhead,

02:21:24.600 that triggers your pain. We're starting to learn a little bit about what could the candidates be.

02:21:29.960 Then we take them through some physical tests. Sit on a chair, slouch, extend, drop one shoulder back,

02:21:36.200 hold five pounds out at front with arms straight. So that's a compression test. Then we do a few self-sheer

02:21:42.580 tests. Then we do some nerve tensioning postures to start converging on subcategories of their pain.

02:21:51.240 Then we say, if you have this subcategory, let's do a real simple one. You get pain when you sit in

02:21:58.140 front of your computer going for a walk is relieving. The next person sitting in the computer

02:22:02.920 is their relief, and they go for a walk, and that causes their pain. Probably more in the stenosis

02:22:07.960 older person kind of category. The other one is a younger dynamic disc bulge. Okay, sit with a lumbar

02:22:14.020 support. Number one. Number two, we are now going to have a strategic exercise session. You're going

02:22:22.720 to do it every day. You're going to do the big three. We'll mobilize the hips. You're not going

02:22:27.780 to sit longer than an hour at your computer. You just cannot reach a stage of sufficient health if you

02:22:33.740 continue with that behavior, etc. So that's why you won't find it on the internet. You're going to find a

02:22:41.160 lot of people who do not have the expertise. Oh, here's the quick fix for your back pain. Well,

02:22:46.980 good luck with that. So that's my answer to your question and the solution. And just going back to

02:22:54.980 listening to you as you started to answer that question, I've got a little bit of good news for

02:23:01.320 you in terms of your own back. And by the way, I know who I'm talking to, so I know you get this,

02:23:06.660 but this is for the listenership. I retired early. I retired when I was 60. I reached a stage

02:23:14.900 where I realized what my job was. I started as a professor in 1986. Student meetings meant students

02:23:24.860 came to see you and we would get up and we'd work through things and we'd do things in the laboratory

02:23:29.680 and whatnot. And then the students started to migrate to this idea, oh, sir, could we have an online call for

02:23:35.540 student hours? No, you can't. You get down here and we're going to work through this problem. In other

02:23:39.800 words, my job got turned into a sitting job and it was killing me. And I realized that my health was

02:23:48.320 declining. My fitness was declining. I still walked to the university. I strategically bought a home right

02:23:54.140 on the edge of campus. So I would have a 20-minute walk to and from my office and laboratory. Still,

02:24:00.780 I was declining. So I walked away. I shut the door in my office. I said to the graduate students,

02:24:08.840 there's all my books, go take them. To all the other professors, there's my lab, go take it. And

02:24:15.200 I just walked away, never thinking that anyone would ever ask me again because I'm not producing new

02:24:19.780 data anymore. I was sort of wrong on that estimate. But anyway, my point is, Peter,

02:24:24.440 I'm healthier now than I ever was in the latter 15 years of my computerized work life. I hardly go on

02:24:34.320 the computer. It's fabulous. I can talk about my life now if you want and what I do. But my point in

02:24:42.160 this story is, I think you're going to look forward to a resurgence of your health. Maybe you've got it

02:24:49.080 dialed in with your seeing patients and traveling and everything else. Maybe you don't. But trust me,

02:24:54.640 when you retire, and that doesn't mean leaving your whole medical family and expertise. I mean,

02:25:02.800 I'm sort of working right now. I still see patients two days a week. It's a wonderful marker for my

02:25:09.140 week. I love it. But the other five days, I live a healthy life. Anyway, my point in all of that is

02:25:15.340 things are going to get really better for you. They're not going to decline more. I've heard you

02:25:20.640 say that. And I think, come over with me, man. Spend a couple of days and you'll see how you're

02:25:27.440 not on this decline as you think is a fait accompli. You just said something a moment ago that I was going

02:25:33.040 to ask you about. So at the risk of overwhelming you, because I know that there are going to be so

02:25:38.860 many people listening to us who are going to say, you know what, I am not happy with the assessment

02:25:44.960 or lack thereof that I've received. I'm not happy with the care that I'm receiving with respect to

02:25:51.500 my lower back injury. I need to go and see Dr. McGill. What is involved in arranging that type

02:25:58.920 of a consultation with you? I feel awkward saying this, but that's why I wrote back mechanic.

02:26:05.700 So I don't see anybody until they've read the book. Most of them say, I don't need to see you now.

02:26:11.980 So they've been through the self-assessment. They've got enough out of it. Now, if they're

02:26:15.920 not getting enough out of it, on our website, backfitpro.com, we have two layers of clinicians.

02:26:23.120 We have the certified clinicians who've taken that 50-hour course. They've gone through the

02:26:30.240 hands-on skills training. They've written the exam, but I've never worked with them personally,

02:26:35.060 but they are all there on a page. Then we have a different level called master clinicians.

02:26:41.020 I have worked with every single one of those people and trained them. I've seen patients with

02:26:45.740 them. They have my confidence now that I can send them any patient and they will subcategorize them

02:26:53.020 and know pretty well what to do with them. I continue to train those individuals. I seek out

02:27:01.420 stars or people who have the passion and the skill. And I go to them and say, would you now study with

02:27:10.020 me? And I'd like you to become one of our master clinicians.

02:27:13.440 How many master clinicians are there in North America, Stuart?

02:27:16.020 Not many. I don't know. A dozen, 15, maybe something like that.

02:27:20.000 But they're all identifiable on the website, which was backfitpro.com?

02:27:24.980 Correct. And the certified, that's growing all the time. There's maybe 30 or 40 of them.

02:27:30.960 We add to that every couple of months.

02:27:34.740 Okay.

02:27:35.240 I think people in reading that book, it's quite a quick read. It was a very difficult book to write.

02:27:41.940 As you can imagine, I've written my medical textbooks for my medical colleagues. Those are

02:27:47.380 easy to write. You put in the references, you make your points, you show the strength of evidence,

02:27:51.460 et cetera. But you can't do that with the public. You have to give them enough of the truth

02:27:58.500 to guide a effective strategy, but you can't overwhelm them with jargon and all of that.

02:28:06.740 So that's why those things are so difficult to write. But people tell me that back mechanic in

02:28:11.760 any case, I sent you a copy. I hope you got it.

02:28:15.140 And not only got it, I greatly appreciated the inscription in it. Thank you.

02:28:18.320 Oh, yeah. Okay. That was special. Heartfelt. In any case, that is my solution to that conundrum.

02:28:29.380 And that's why going to the internet, as you know, it's the wild west. You can get screwed up as much

02:28:34.660 as you can be helped.

02:28:36.560 Well, Stuart, this has been a really enlightening discussion for me. And given how much I've thought

02:28:43.640 about this topic, I think that says something, but it tells me that more than anything else,

02:28:48.620 a lot of people listening to this, which again, I think is a lot of people who can relate to what

02:28:53.040 we're talking about personally. I think this, I hope offers more than just a glimmer of hope

02:28:58.180 and also a set of resources that people can look to. And I will take you up on this offer.

02:29:03.140 The next time I'm in Toronto, we'll make that trip up to Gravenhurst.

02:29:07.340 And apologies for my poor Canadian geography. I always thought Gravenhurst was just outside

02:29:13.220 of Toronto. I didn't realize it was that far north.

02:29:15.980 Yeah. Huntsville, Bracebridge, Gravenhurst, if you know that area, right in the heart of Muskoka.

02:29:20.940 Yeah. So just from like Aurora, we're talking like what, 90 minutes, two hours?

02:29:27.040 No, about an hour and an hour and a half north of Aurora.

02:29:30.540 Okay. Yeah. All right. Well, we'll make that happen.

02:29:34.220 Okay. Well, I hope so. Peter, I've looked forward to this day ever since we scheduled

02:29:40.600 it a couple of months ago. The leadership that you've provided is fabulous. I've spent many

02:29:48.320 hours listening to your podcasts and getting wisdom from your guests and the level that you

02:29:54.060 take all these issues to is just the foundation I need for a lot of the things that I think about

02:30:04.220 for all you do. Thank you so much. The way you posed your questions today were not really typical,

02:30:10.560 so I appreciate that very much. But again, thanks for all you do.

02:30:14.100 Well, thank you for what you do because that's where I'm learning today. So thank you, Stuart.

02:30:18.860 Okay. My pleasure.

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02:33:21.420 I'll see you next time.

02:33:51.420 Bye.

02:34:21.420 Bye.

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02:35:23.600 You

The Peter Attia Drive - January 29, 2024

#287 ‒ Lower back pain： causes, treatment, and prevention of lower back injuries and pain ｜ Stuart McGill, Ph.D.

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