The Peter Attia Drive - 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,

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00:00:53.200 of a 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. Welcome to a special episode of

00:01:05.960 The Drive. For this week's episode, we would like to rebroadcast one of our most popular episodes,

00:01:11.280 a conversation with Stuart McGill that first aired in January of 2024. Stuart is a world-renowned spine

00:01:18.200 biomechanist who spent more than three decades as a professor at the University of Waterloo,

00:01:24.020 where he founded an experimental research clinic devoted exclusively to solving back pain puzzles.

00:01:30.480 He's also the author of The Self-Assessment Guide, Back Mechanic, and other seminal texts on spine health.

00:01:37.200 I wanted to rebroadcast this episode as low back pain touches almost everyone at some point in life,

00:01:43.360 and Stuart's frameworks provide a clear roadmap for assessment, re-eb, and long-term spine resilience.

00:01:51.200 Since this episode originally aired, I have referred many of my patients to it, and without exception,

00:01:57.980 those who have stuck with the protocols that Stu put in place have experienced a significant relief

00:02:03.620 from their lower back pain. In this conversation, we discuss why Stuart rejects the idea of non-specific

00:02:09.260 low back pain and insists on a truly individualized assessment before any therapy begins. The most

00:02:15.060 common movement triggers? Prolonged sitting, flexion, shear, heavy lifting, and how mapping

00:02:20.500 your triggers guides effective rehab. Stuart's big three core stability exercises, the modified curl-up,

00:02:27.820 the side plank, and the bird dog, and the right way to scale them for both pain relief and performance.

00:02:33.740 How proximal stiffness lets you transmit force efficiently, boost athletic power,

00:02:38.680 and plug the energy leaks that invite injury. When heavy lifting is helpful, when it's harmful,

00:02:45.300 and why chasing enough strength often beats chasing lifetime PRs for long-term spine health.

00:02:52.460 Simple daily habits, walking, posture tweaks, hip hinge practice that calm flares quickly and keep

00:02:59.080 the spine resilient for decades. So without further delay, please enjoy or re-enjoy my conversation with

00:03:06.360 Stuart McGill.

00:03:08.680 Hey Stuart, thank you so much for joining me today. Wish we were doing this in person because there's

00:03:17.320 so much I'd love to get into, but I have a feeling we're going to be able to do a pretty good job

00:03:22.340 remotely, and I get the sense that you're very well-versed at communicating your ideas

00:03:28.100 in two dimensions rather than three. So great to make your acquaintance today.

00:03:33.140 Same here, Peter. I've been looking forward to this day for quite a long time. At some point,

00:03:39.680 I'm going to thank you for writing your book. You are one of the few people on this planet who,

00:03:49.400 A, I allowed, and B, I did change my behavior. So thank you very much for that. Let's see where we go today.

00:03:57.840 You're going to leave me hanging with that. I'm curious to know what it was. Were you a smoker

00:04:02.360 who somehow stopped? No, I'm kidding. What was it?

00:04:06.380 Well, a couple of years ago, my family doc right now is one of my former students. This may bring

00:04:12.940 a smile to your face. I don't remember this, but apparently when he was an undergrad and he asked

00:04:18.200 me to write the letter of recommendation for medical school, I told him, of course, I'm going to

00:04:23.000 write this because one day I'm going to need a good doc when I'm an old man. Well, wouldn't you know?

00:04:28.500 Anyway, so we did my blood and I was just on the edge of what the cardiology association is saying,

00:04:38.480 needing Crestor or Lipitor or something like that. And this doc knows me well enough. He said,

00:04:45.840 let's run the experiment. We're doing it for three months. I'm living Peter Atiyah's life.

00:04:53.140 And then I love to work hard physically and finish it off with a beer, which of course,

00:04:58.080 six days out of seven, I'm denying myself of that. But long story short, I have my blood done again

00:05:04.160 in two weeks and we'll see if this three-month experiment has paid off. He says, no, it's in

00:05:09.880 your genetics. You're not going to move the marker. But my sister says, oh no, you will. She did.

00:05:15.880 Anyway, thanks and no thanks, but I think I'm sleeping a little bit better. I think I'm a

00:05:23.400 little more mentally sharp, but we'll see over the next hour if that's true.

00:05:29.040 We can revisit this. I'll reserve the right to come back and say,

00:05:32.740 maybe you don't have to be quite as restrictive. I don't necessarily believe in denying all the

00:05:38.820 pleasures of life and I don't deny them myself.

00:05:41.280 There were some paragraphs in your book that just burned into my memory. You allowed yourself some

00:05:46.800 french fries and I thought, oh, okay, I'm going to stay with the plan come hell or high water. But

00:05:51.560 anyway, there you go.

00:05:52.780 I'm going to start with a story, Stuart. It's a story that some of the listeners might know, but

00:05:58.060 you probably don't know in this level of detail. And it sets the stage for why this is a topic that

00:06:03.560 is of great interest to me personally. And of course, by extension, I suspect that there are

00:06:08.720 very few people who are going to listen to us today who can't relate to the subject at hand.

00:06:14.840 The very abridged version of the story is I grew up doing all sorts of really aggressive things and

00:06:21.320 really took to powerlifting when I was probably 14 and found myself reasonably strong for a little

00:06:28.680 scrawny kid. And between about the ages of 14 and 19, I really, really pushed, couldn't bench press to

00:06:35.140 save my life, but seemed pretty strong in a squat and deadlift and kind of ignored any claims my parents

00:06:42.020 made that maybe I was doing a little too much. Truthfully and sadly had no formal instruction.

00:06:48.900 I was just watching the other grown men in the gym who were insanely powerful and sort of just trying

00:06:55.360 to replicate what they were doing, but truthfully had no sense of what I was doing. Anyway, fast forward,

00:07:00.700 I am 21 years old. I'm rowing at the time. So rowing crew. And for the first time in my life,

00:07:09.440 I experienced lower back pain. This really rocked my world because I always thought that people who

00:07:14.660 got lower back pain were people who did nothing. I never really thought someone who was as active

00:07:19.220 as I was could get it. And for about two weeks, Stuart, it completely disabled me. I could sort of

00:07:27.320 get around, but barely. And being a college student, I didn't really have any resources. I didn't know

00:07:32.300 what to do. This was actually, I think it occurred during the summer. So I didn't have classes,

00:07:36.540 but I had to stop rowing. I remember that. And otherwise I was able to work. It went away and

00:07:42.980 I thought everything was fine. And I never thought about it again until the summer three years later,

00:07:47.760 when I was 24 years old. And I remember exactly where I was. I was in San Diego riding my bike

00:07:53.920 up the steepest hill in San Diego, which is a certain patch of a mountain called Mount Soledad.

00:08:00.220 There's a section of this thing where you make a sharp right turn. And at that moment,

00:08:04.480 it's about a 25 degree pitch. I experienced this very sudden pain in my lower back and like a

00:08:11.720 typical idiot, just kept on pushing and climbing to the top and finished my ride, but then went on

00:08:18.260 to experience the exact same thing, Stuart. For two weeks, I was debilitated. Couldn't do a thing

00:08:26.360 other than sort of lay around and walk. But then it got better and I kind of just forgot all about it.

00:08:32.400 And then fast forward to the big one. I'm doing pattern recognition here, Peter.

00:08:38.260 So the big one occurred in my third year of medical school. I'm now 27 years old and the

00:08:44.460 remarkable consistency of this is not lost on me. It is every three years by the summer,

00:08:49.640 the summer of 94, 97 and 2000. And I'm riding my bike from class to the gym. I get to the gym,

00:08:58.000 hop off my bike to lock it up. And all of a sudden I feel that same familiar, horrible pain in my back.

00:09:07.200 But this time it's a little worse than the previous two bouts. And it was so bad that I did something

00:09:12.700 I'd never done before, Stuart. I decided not to go into the gym. And so I just slowly got back on the

00:09:20.760 bike and limped my way back to my apartment and wasn't able to do anything other than just sort

00:09:27.240 of lay in bed. I assumed I'd be fine the next morning. And I woke up the next morning and actually

00:09:33.360 couldn't get out of bed. Luckily, my roommate and I each had separate phone lines. So I was able to

00:09:38.200 call him from my room. So began a really painful journey over the next couple of weeks where the

00:09:45.580 only place I could find relief was bent at 90 degrees forward, where I would basically stand

00:09:53.040 and bend over the nurse's station. By this point, I was doing my clinical rotations. And as every good

00:09:59.620 gunning medical student knows, there was no way I was going to miss a day of this. So I would drag

00:10:04.900 myself into the hospital each day and somehow managed to get through this. The nurses took pity on me and

00:10:11.580 so did the residents and they were injecting me full of Tordal. And this went on for a month.

00:10:18.020 And it got so bad that eventually the pain progressed from just being debilitating in my lower back

00:10:24.280 to a nerve pain that felt like my foot was being skinned. And it was interesting in that the pain

00:10:30.900 in my lower back started to subside as it was replaced by the feeling of my left foot being skinned

00:10:37.820 from the bottom. I'm not going to go into the more details of the story because it gets worse and worse

00:10:42.640 before getting better. But needless to say, I have a graduate degree in back pain. There's a happy ending

00:10:48.580 to this story, Stuart, which is after this bout, which occurred when I was 27, which took a year to

00:10:54.980 resolve, I made it a mission to figure out what was going on. And I'm not suggesting that I have,

00:11:01.920 but I know so much more now than I did then. And fortunately, anytime I've had back pain since then,

00:11:08.760 it has been a very, very short-lived experience. I'll plant one last seed before we jump into this

00:11:14.440 just for both you and the listener so that we can come back to it. If you are to look at an MRI of my

00:11:20.640 spine today, you would ask yourself, maybe not you because you're so well-versed, but a reasonable person

00:11:27.320 would look at an MRI of my spine today at the age of 50 and say, how does he walk? This person must be

00:11:34.140 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.

00:11:40.860 Occasionally I get a little tight in my, my lower back musculature, but you know, I don't have

00:11:46.140 ridiculous pain. I'm not limited in anything I do. Again, suggesting that the correlation between

00:11:52.260 the image of my back on an MRI and my symptoms is pretty light. So with all that as a backdrop,

00:11:58.800 the fact that you're smiling so much as I tell you this story tells me not that you're taking

00:12:04.540 pleasure in my pain, but rather the familiarity of my story. Exactly. I've been doing pattern

00:12:10.480 recognition. There's only one thing that would account for the repeated acute episodes.

00:12:18.280 In the interim between each one, you were quite fine. Then it shifted to a radicular pain. And now

00:12:25.900 you're at the stage of your life where it's more an occasional grumpiness when you cross what we

00:12:31.100 call the tipping point. Did the pain go to your foot, Peter? Yes. Big toes or little toes? No, it was

00:12:37.740 actually really interesting. It was burning pain that was like the bottom of the foot was being skinned.

00:12:43.240 I should have, there's one detail I should have shared with you that might explain this.

00:12:46.560 When I finally did have surgery, it turned out I had a free fragment that was about five centimeters

00:12:53.080 long from the L5 S1 disc. So that free fragment had broken off. Well, I was going to guess this for

00:13:01.060 you, actually. I was going to ask you which foot, so the fifth root goes to your big toe. But anyway,

00:13:06.540 you carry on. Yep. So basically the really, really unbearable pain I was having presumably was because

00:13:12.380 that free fragment was parked on the S1 nerve root. And even though it ended up taking two surgeries to

00:13:18.640 get that out, and those surgeries ended up causing more damage that needed more repair that turned into

00:13:24.460 a journey of a thousand cuts, I was on the road to recovery. But the radicular pain seemed to be

00:13:30.180 directly a result of the S1 nerve root. Well, if you want me to react to that story a little bit,

00:13:36.840 I'm smiling because you told me exactly what the pain mechanism was. I knew it was a disc with an

00:13:47.620 open fissured disc bulge. It would be on the side of your foot, right or left. What foot was it?

00:13:54.040 It was left.

00:13:54.980 Okay. So you had a posterior left-sided biased open fissured disc bulge that would open and close

00:14:02.480 as a function of the flexion postures, bending down to lock your bicycle. You just gave it to me

00:14:09.220 every single time. And then you were able to vacuum that in. It lasted for a couple of weeks.

00:14:16.020 Now you're in the unstable. Do you want me to show you a couple of mechanisms?

00:14:21.020 What I was going to suggest, even before we get into that, this is exactly where I want to go,

00:14:25.400 Stuart, is let's walk people through the anatomy of the back. Now, I understand that there are some

00:14:30.840 people who are going to be listening to us. So whenever possible, do your best imagining somebody

00:14:35.660 can't see us. But I think there's also going to be enough people watching on video. And we'll

00:14:39.860 certainly refer people to the video, at least for this section, in addition to some diagrams.

00:14:44.700 But let's really explain to people what this remarkable structure of the human back is.

00:14:51.020 The stability, the flexibility, the mobility, the amount of nerves, muscles, and ligaments that are

00:14:56.520 involved. You could almost argue it's a miracle we don't get more injured, even though the frequency

00:15:01.620 with which we do is intense. Take us through the anatomy.

00:15:06.120 I would almost argue the opposite, Peter. There was a television show that they were producing and

00:15:11.980 asking various experts around the world, if you got to re-engineer your particular area,

00:15:17.600 me being the spine guy, and they had a cardiac person, endocrine system person,

00:15:23.160 how would you re-engineer it and make it better? And every expert said they couldn't. It was

00:15:29.020 perfect. So everything in terms of systems in your body comes with a trade-off, and there are rules

00:15:38.380 that manage the trade-off. So with that, I can start the anatomy. The spine is a series of vertebra,

00:15:47.360 as you know, forming a flexible rod. This allows us to dance and move and procreate, tie our shoes,

00:15:54.280 and do all of these wonderful things. But at some point, you now, say, are picking your child out of

00:16:00.820 the crib. You reach across the crib, gather your child, pull them in. If you had a flexible rod,

00:16:07.140 consider a series of stacked oranges, it would fall apart. So you need a flexible rod that you can then

00:16:16.420 stiffen to bear a load. You cannot push rope, but you can push stone, or in this case, an IV to bear

00:16:23.560 load. So all of these things are necessary to have a functional spine. What else can I say? Let's look

00:16:32.000 at the structure of the discs, which are the fabric. The disc actually forms the subcategory of a biological

00:16:41.260 fabric. It's not a ball and socket joint. Could you imagine if we had vertebra with ball and socket

00:16:47.040 joints? You would need an enormous musculature around that flexible rod to control all the ball

00:16:54.400 and sockets. You would need an enormous motor cortex to coordinate all of these. You would be so wide,

00:17:00.460 you couldn't walk, you couldn't run, etc. But we have this very slender torso because we have discs.

00:17:07.820 Now, the stress strain curve of a disc starts out with a little bit of a neutral zone in the neutral

00:17:13.980 range. And as you approach the end range, the disc provides stiffness, a mechanical stop to motion.

00:17:20.620 Fabulous. I didn't need all this complex musculature to do so. So the disc creates tremendous

00:17:28.020 evolutionary efficiency in your spine. Either end of the torso strategically is a ball and socket joint.

00:17:37.000 The ball and socket joints of the hips and shoulders are designed to create power. Power is force times

00:17:45.280 velocity. So if you were to watch a sprinter sprint, the extensor muscles explode like a hammer hitting

00:17:53.240 a stone, a stiffened structure. If they hit rope, the hips would balsam. You couldn't run anywhere. You

00:17:59.200 can't even walk without sufficient stiffness in the core. So I can get into an interesting discussion of

00:18:08.660 how stability works proximally to unleash and enable this distal athleticism. So in terms of anatomy,

00:18:18.200 we have a flexible disc that is a fabric. That great advantage is the efficiency of your dimensions that

00:18:29.340 I'm talking about. We're light, narrow in the waist, we can run, etc. The price that you pay, though,

00:18:35.880 is being a structure of many collagen fibers. Let's take my shirt, which is a fabric. If I wanted

00:18:46.120 to delaminate the fibers, I would have to create stress strain reversals back and forth and slowly

00:18:52.440 we would de-bond the fibers. This is what happens to people's discs. They de-bond the fibers with too

00:19:00.580 much load and motion simultaneously. And this is what you must have done as a younger fellow.

00:19:06.520 But the concentric rings of collagen that are held together with collagen type X, the binding

00:19:14.720 substance, they hold a pressurized gel, which is this incompressible hydraulic fluid that creates

00:19:22.500 the ball. That gets pressurized, but it's always seeking the weakness in the wall. If you delaminate

00:19:30.420 the collagen fibers, then the nucleus seeps through. And in some situations, the fibers are pulled

00:19:40.780 together and they create a fragment, as you described earlier. Or if it's an open fissure and

00:19:47.280 contained underneath the posterior longitudinal ligament, there's a good chance it's going to

00:19:52.000 get vacuumed back in and off you go for another two or three years. I can talk about the nerves,

00:19:58.020 I suppose. If you have a disc bulge, there is the spinal cord centrally behind the vertebra and at

00:20:06.120 each lumbar or spinal joint is a pair of nerve roots. Maybe one thing we can talk about before

00:20:12.980 that, Stuart, is the other point of fixation, which are the facet joints. So if anteriorly this

00:20:19.520 structure is bounded and the vertebral bodies are stuck together through their sharing of the disc,

00:20:27.020 on the back, we have these other joints that come from each of them called these facet joints. So

00:20:33.420 yeah, why don't you talk a little bit about that? I don't know if you can see those, but the facet

00:20:38.380 joints are guiding of motion. So you can see as I'm flexing and extending and twisting this model spine,

00:20:48.980 these are articular joints in the back that are guiding motion. What you will find, I know what I'm

00:20:56.000 going to find if I look at your MRI, at the level of the disc bulge, the facet joints will now be

00:21:02.020 getting a little thicker, a bit more gnarly looking. Am I right? Because the facets almost always two or

00:21:08.960 three years after a major disc injury, they take much more load. Think of air in your car tire. If you

00:21:18.880 let a little air out of your car tire, it bulges on the road. It gets a bit sloppy to drive your car.

00:21:25.060 You have to tune the pressure. This is exactly what happens with your body. So when you lose the

00:21:30.840 controlling stiffness of the disc, you get more work performed on the facet joints and they wear

00:21:38.500 a little bit faster than the adjacent joints and they grow thicker. And facet pain is very different

00:21:45.540 from disc pain. It's more of an ache. It comes on a bit more slowly. If you have a wound up facet joint,

00:21:53.220 it can take two or three months to wind it down versus a disc that as you described, you can wind

00:21:58.600 down in a couple of weeks. But if I can show this as a model now, this disc is normal. This bottom disc,

00:22:06.480 L5 is normal. L4 has been damaged. I'm just going to apply a torque to this spine. Do you see how

00:22:13.320 the majority of the motion now is occurring at the joint that's lost stiffness? Think of it like a knee

00:22:19.040 that has a damaged ACL ligament. It no longer has the guidance and the rotation motion of the knee,

00:22:27.580 which is normal, is now substitute with shearing motion. So shearing motion indicates it's the metric

00:22:34.740 for instability. So now you can see the shearing instability and now look at the work being

00:22:41.680 performed by the facet joints at the level of the disc being damaged and losing stiffness.

00:22:49.200 Now those will get grumpy and they will wear a little bit faster if you continue with the behavior

00:22:55.760 that you did prior to. So injury and this cascade changes the rules a little bit. So initially,

00:23:05.460 the goal was to create power in the shoulders and the hips and transfer it through a controlled spine.

00:23:13.840 But now the game has changed a little bit. You're 50 years old. You will have a little bit of

00:23:19.520 joint instability. It's more important now to create a muscular girdle around the joint that has lost a

00:23:28.940 bit of stiffness. And for the next little while, do your core exercises, develop a bit more muscular

00:23:36.320 control, arrest the shearing motions. And by the time you and I are very similar, by the way,

00:23:43.760 so I'm in my late 60s now, my pain is gone. So the joint has become so stiff, I can still do everything

00:23:53.360 I want to do. But the joint itself has stiffened up. Professor Kirkcaldy Willis, the famous Canadian

00:24:00.940 spine surgeon, wrote a book called Managing Low Back Pain. And he described very well the process that

00:24:08.260 most of us go through, the instability and the very acute episodes that come every two or three years

00:24:15.640 that are very debilitating to a muscular ache. And you wake up in the morning on one side with this ache

00:24:21.500 in your back. But if you push one heel away or put a pillow under your waist or something like that,

00:24:28.060 you can get rid of the ache. And then if you live a little bit longer and behave by the new rules,

00:24:33.360 I don't have any back pain. And I can encourage that you will seek that relief as well.

00:24:41.940 Stuart, give us a sense of the prevalence of acute lower back pain episodes. Is an acute lower back

00:24:48.080 pain episode defined as one that lasts up to some period of time, two weeks or something like that?

00:24:52.980 No, I don't define it that way at all. You'll be surprised. I'm not the guy who can give you those

00:24:59.940 statistics. I don't worry about those sorts of things. All I worry about is the people who come

00:25:05.220 here and ask for help with their back pain. I'm not out there doing population studies to

00:25:11.560 crack incidents. And even having said that, when I used to study that as a younger scientist,

00:25:18.920 what is back pain? What's an acute episode? Is it sufficient to be debilitating so you don't have

00:25:25.400 to work? I was a professor. I could have an acute attack and go to work. If I was a construction

00:25:30.720 worker, I couldn't. So even the definition of whether it was disabling or not gets lost. So

00:25:36.680 I didn't really get into those statistics. But having said that, I don't categorize pain as being

00:25:45.380 acute lasting a certain period of time and chronic lasting a longer period of time. Because when we

00:25:52.000 measure people here with back pain, very rarely do we find chronic back pain. It's almost always due to

00:26:02.400 them repeatedly insulting their back with many acute attacks and offenses all day long. So they think

00:26:11.600 they have chronic pain because it lingers. When we show them a strategy or whatever the treatment happens

00:26:18.820 to be, to stop the insults that occur throughout the day, all of a sudden their pain goes. And then

00:26:25.240 they realized, you know, I never did have chronic back pain. So chronic back pain to us is pain that is

00:26:33.060 intransigent, unrelenting. Their brains have changed. They've been traumatized. That is chronic pain

00:26:42.780 and not always having a strong mechanical trigger. That's how we set the

00:26:48.820 great chronic and acute. But the pattern that you described of the two week disabling, terribly

00:26:56.100 disabling pain you had, there's only one thing that that could be. And that was an open fissure disc

00:27:00.720 bulge. So let's talk about the mechanism of the discomfort. For example, is that disc actually

00:27:08.700 innervated? Is the pain that's being perceived due to sensory fibers of the disc? Or is it the response

00:27:17.540 of the body sensing that damage going into some sort of protective mechanism that is seizing all the

00:27:25.280 muscles within the proximity of it? Stretch? Or it could be both. So here's how I would answer that.

00:27:33.220 A healthy disc, by the way, all these models that I'm using, highly biofidelic models are made by

00:27:40.740 dynamic disc designs. So when a disc is healthy, people say, well, what's the number one thing you

00:27:48.940 can do to keep a healthy spine? And I will say, keep your end plates healthy. And they wonder about

00:27:54.320 that. Don't damage your joints. As you wrote in your book, if you damage your knee ligaments,

00:28:01.020 you will now have, in your last decade, disabled mobility. That's a fact.

00:28:07.500 So it's the same with the spine. If you can look into the nucleus of this model,

00:28:14.940 you will see that there are red vessels and yellow nerves. Now, there are all kinds of papers,

00:28:22.400 oh, there's no nerves inside the disc. And then you'll read another paper, oh, there are nerves in

00:28:27.580 the outer third. And then there are nerves all the way through. And the reason is, a healthy virgin

00:28:33.420 disc doesn't have any vascular tissues going into it, nor does it have any nerves. And the reason is,

00:28:41.200 when you squeeze a disc, you build up tremendous intradiscal pressure that kills any kind of

00:28:48.000 vascular sprouts or neural sprouts. It's a healthy environment containing the pressure.

00:28:53.440 When you damage the disc and you lose the ability to contain the high pressure,

00:28:58.280 now all of a sudden, vascular sprouts grow in and so do nerves. So it's so unfair.

00:29:05.460 You damage the disc and now the body grows a hardware, more nerves to feel pain even more.

00:29:12.920 And then eventually, this just goes to a very fibrous, gnarly structure, highly innervated,

00:29:21.000 but now it just basically gristles to bone and all the pain goes away.

00:29:25.480 But you can see where the damage line, if I can contrast there, do you see those fibers

00:29:32.540 posterior laterally on the right have delaminated? And if I squeeze the disc, then you see this,

00:29:40.800 I'm going to squeeze and flex. Do you see the fibers delaminating and allowing the nucleus to

00:29:48.380 seep out? But here's the antidote, Peter. Stay stacked and tall, and I'm going to squeeze

00:29:53.220 the whole disc bulges in a diffuse bulging pattern, but nothing comes out of the delaminated

00:30:02.560 region. So there's a little bit of an explanation of why some studies will show an innervated disc and

00:30:12.480 other shows they're not innervated at all. Think of where you get cadavers from. It's not young,

00:30:18.120 healthy people dying and donating to their body. It's almost always older people. So those discs

00:30:24.480 are innervated unless they're horribly down the cascade and they've gristled and all the nerves

00:30:31.160 have now disappeared once again. That's very helpful. And I was totally unaware of that,

00:30:36.740 by the way. So that's very interesting. And as you pointed out, almost a very cruel adaptation

00:30:42.280 that is quite counterintuitive. Let's talk a little bit about the curvature of the spine.

00:30:47.600 What is it about the way we interact with the world and the curvature of our spine that tends

00:30:54.980 to produce the majority of injuries at either the interface between L4 and L5 or the interface between

00:31:02.660 L5 and S1? Oh, what an interesting question. I'm thinking of several things that are going through

00:31:11.160 my mind as you ask that. Well, first of all, it's the thickest part of the spine. So if I was to take

00:31:17.860 a thin willow branch and bend the willow branch back and forth, no stress. Tissues damage because of

00:31:26.340 one metric and it's strain. Not the force supplied, not the pressure, anything. It's just strain on the

00:31:33.160 tissue that is the metric of when it's going to disrupt. So it's thin, the radial distance to the

00:31:39.020 neutral axis, which is the axis down the middle of that thin rod that doesn't go into compression or

00:31:44.460 tension. It's all very low. Now let's take a thicker stick and we bend it and it shatters right away

00:31:51.660 because it's much thicker. I'm going to digress a moment, go back to the flexible willow branch.

00:31:57.480 It's wonderful at bending. That's what it's made for. But don't ask it to bear compression because it

00:32:02.680 buckles right away. The thicker stick can bear tremendous compression, but it doesn't tolerate bending.

00:32:08.440 So you look at the neck, very thin, small diameter vertebra. It's made for bending and mobility.

00:32:16.280 Fabulous. But as you move down the spine and get to the bottom too, where the thickest is,

00:32:21.020 they do not tolerate bending near as much as they tolerate compression. So there's the first

00:32:27.400 anatomic feature that describes why the bending stresses are greatest at the thicker two joints,

00:32:34.900 which are at the bottom. The other things that matter are the shape of the disc. So some discs

00:32:41.960 are ovoid and the bigger the skeleton, they tend to go to a limacon. So you have the spinal cord

00:32:48.960 there and then the two lobes of the limacon. The bigger the spine, the more limacon the disc becomes.

00:32:57.360 When you twist a limacon, you create a stress riser on the edge of each lobe. The bigger the person,

00:33:06.020 you will see they don't tolerate sit-ups. Look at YouTube. Who is the man who has the world record

00:33:11.940 for consecutive sit-ups? Do you think he has a thick spine or a thin spine? He won't be a powerlifter.

00:33:17.900 Having worked with some fabulous powerlifters and strongmen competitors, not one of them does a sit-up.

00:33:24.500 They train other things to tune their body and make it suitable to that particular training

00:33:31.460 stimulation. So now we see that shape thickness determines why L4 and L5 are the target.

00:33:42.500 We know that they don't twist as well as a slender spine. The facet joints are also very interesting as

00:33:50.680 well. So some facet joints, since you brought those up earlier, are orientated like that in the sagittal

00:34:00.400 plane. Others are orientated more open, as we say. So if you look at a gymnast who, by definition,

00:34:09.560 me, I would never choose to be a gymnast. But you can tell, look at my facets, they're closed.

00:34:14.460 I don't twist very well. However, when you flex forward and pull a load, those facet joints just

00:34:23.380 glide past one another. So a gymnast, by definition, is someone who has a lot of mobility in their spine.

00:34:30.180 You will see that their facet joints tend to be open. Now, if I said to you, who among your patients

00:34:38.740 gets spondylolisthesis, the broken pars bone that holds the facet joint on, basically, you are going

00:34:47.380 to say, oh, dancers, gymnasts, the very people that had the mechanical advantage to twist, now when they

00:34:57.080 go into extension, their facet joints are like shingles on a roof. They bend the pars bone, creating

00:35:03.260 stress strain reversals, and eventually, that bone will get a stress fracture or a stress reaction,

00:35:10.660 and if they keep going, full-blown spondylolisthesis. So there's all kinds of reasons.

00:35:17.580 I'm just giving you a few now as to why those two discs really are the, as an engineer now, stress

00:35:26.040 risers. When I developed in my PhD thesis, actually, a very detailed anatomical model of the spine

00:35:33.820 computer model, that hit home loud and clear. We did stress maps of real people moving. The pain

00:35:42.600 and the injury was almost always at the site of the highest stress. And remember, I said, the metric is

00:35:50.180 strain that actually leads to damage. Or it actually, if it's below the tipping point,

00:35:56.740 it actually strengthens you. So we can have that conversation as well. What does not kill you makes

00:36:01.520 you stronger? There's a risk that you and I talking about this, because we're both engineers,

00:36:05.880 will easily get into the weeds of compression strain, tension strain. But for people listening

00:36:12.200 to us who might not have that background, can you explain the difference between stress and strain

00:36:16.980 and what happens under tensile load, compressive loads and things like that?

00:36:21.560 Let's not talk about stress and strain. Let's talk about applied load and deformation. So stress and

00:36:29.100 strain are normalized to an area. We won't get into that. If I apply a force to a structure, it deforms.

00:36:37.100 I'm applying a force and I'm getting a deformation. Mature skeletal bone breaks

00:36:46.500 at a certain amount of deformation. A child's bone breaks at a different level of deformation.

00:36:57.060 When you take a long bone and you bend it, the upper surface goes into tension. It's trying to pull

00:37:05.000 apart. The lower surface goes into compression. Some biological structures are stronger in tension

00:37:11.920 than they are in compression. A child is actually weaker in compression in a bending bone. And then

00:37:18.100 the adult is weaker on the tensile side. So a green stick fracture or a buckled bone in a young child

00:37:25.160 would be very rare to see in an adult as an example. So the behavior of biomaterials when you load them

00:37:32.960 and how they deform explains a lot of injuries. So if you were to put me on the witness stand,

00:37:40.100 as people do occasionally to explain, is the damage that we see, professor, in this MRI or in the

00:37:51.060 cadaver or whatever consistent with this particular mechanical alleged scenario? Yes or no? And that's

00:37:59.820 how we reconstruct that. Tissue stress and strain, shear, bend, tensile, pull apart, etc. And the

00:38:09.380 deformation causes very specific types of damage. I'd like to use this example for people. I'd like to

00:38:17.600 use the example of concrete, which is every engineering student's favorite example, right? So concrete

00:38:22.200 is so strong in compression. And yet, in tension, it is so weak that we need to come up with a hack.

00:38:32.000 How can we use this material to allow it to be both strong in compression and tension? Because the

00:38:37.620 example you use is really a good one. If you have a bridge made out of concrete and you're driving on

00:38:42.120 top of it, the bridge wants to deform, which means you're putting the top in compression, which it can

00:38:47.480 handle, the bottom in tension, which it can't. So we put rebar in because the steel rebar is, of course,

00:38:53.900 strong in tension. The saying is, the whole purpose of concrete is to hold the rebar in place.

00:39:00.080 When you think about the spine, I want to dig into this a little bit more if you think it's helpful.

00:39:05.240 So we take an axial load on the spine. And as you pointed out, the cervical spine is not built for

00:39:12.180 tolerating a big axial load. It's designed more to provide movement. It's a joint for great

00:39:19.340 flexibility. The lumbar spine, for all the reasons you just explained, is really designed around taking

00:39:26.460 a large compressive load. And it's, in the process, sacrificed the mobility we have in the neck.

00:39:33.500 But now let's talk about load in the context of flexion and extension, where you now do have,

00:39:40.420 within the disc, it's not just pure compression. Maybe just even explain to people, flexion is

00:39:47.020 bending forward, extension is going back. Now, if you have an axial load in that position,

00:39:53.380 which you could easily have if you're deadlifting something or squatting something,

00:39:58.020 any given disc, especially in that lower spine region, can be under compression and tension at the

00:40:04.760 same time, correct? Absolutely. I have a little bit of a story on that, Peter. It's so interesting

00:40:12.360 when, say, I'm asked to give a lecture to a group of radiologists, and they describe very well all the

00:40:20.120 subcategories of disc bulges and disc deformations and that kind of thing. But they've never been taught

00:40:25.760 what the applied load nor the adaptation was. So let me paint a little picture here of the deadlifter.

00:40:33.800 A deadlifter almost always gets a posterior disc bulge, as you may know. So a deadlifter is under

00:40:42.520 tremendous compressive load. And if they, say, get to the bottom of where the hips run out of room,

00:40:49.980 now the femur collides with the pelvis, and thereafter, the rotation takes place in their low

00:40:55.840 back. Because the nucleus is under such enormous compressive pressure, remember this model,

00:41:03.620 I had to bend it forward to get the nucleus to squirt back. So you're creating a center of hydraulic

00:41:10.540 effort posterior. Now let's consider a person who's adapted their spine to do yoga. This is why I say

00:41:20.380 please never mix up deadlifts and yoga. If you adapt your spine to be very flexible, you adapt the type X collagen

00:41:33.340 holding the type 1 and type 2, the heavy gristly collagen, and then the elastic collagen, all those fibers

00:41:40.400 together. A power lifter wants them to be stiff and tough. They even wear an exoskeleton of a lifting suit to

00:41:47.360 have even more stiffness and toughness. But the yoga master, that would be the kiss of death. They want

00:41:53.800 nice, viable, flexible spines. They soften the ground substance holding the collagen together.

00:42:00.920 So when they bend forward, in contrast to the disc bulge going backwards, the front of the disc now

00:42:07.020 buckles under compression. So when a power lifter typically now, of course, there are very odd cases

00:42:15.560 that are the exceptions. The power lifter bends forward and crushes the disc bulge posteriorly.

00:42:23.560 But when the yoga person, or very flexible spine, when they bend backwards, the collagen under

00:42:31.140 compression buckles. So one gets a disc bulge from extension, and the other gets a disc bulge from

00:42:37.920 flexion. Isn't that interesting? And it all depends on how they'd adapted their spine.

00:42:42.560 But my final point in all of that is don't mix up the adaptation schedules. So if you want to be a

00:42:50.300 power lifter, train your hip mobility, shoulder mobility, but torso stiffness. Try not to throughout

00:42:59.440 the day do a lot of bending versus the yoga master. Please stay away from the very heavy loads.

00:43:06.460 What is the pathologic response to the anterior bulging of the disc? Because when you have that

00:43:13.720 posterior bulge, we should have mentioned this earlier, and I guess it's worth stating,

00:43:18.200 the spinal cord stops quite high up. The spinal cord does not run down the entire canal. It stops around

00:43:23.840 L2. So for most of the people experiencing lower back pain vis-a-vis a herniation, fortunately,

00:43:32.400 the herniated disc is not hitting your spinal cord. It is hitting the nerves that emanate from it. But

00:43:39.000 again, there's so much real estate in that area. It's insane because you don't just have the nerve

00:43:45.560 roots. You have the dorsal roots. You have all of these other tiny little nerves that are going to

00:43:51.840 the facets and to the disc and to the vertebral bodies that's running musculature.

00:43:56.140 And to your genitals and everything that's important, of course.

00:43:59.400 That's absolutely correct. And I learned that the very, very hard way.

00:44:04.560 Yeah.

00:44:05.820 Yeah. We could tell some stories if we weren't on the air. Tell me about the manifestation

00:44:10.220 clinically of the anterior herniation in that very flexible person who's presumably greatly lacking

00:44:17.760 in any spinal stability.

00:44:19.960 There probably won't be too much. They will go along with their merry life and be flexible.

00:44:26.620 The anterior bulge is not, as a rule, picking up any nasty nerve root compressions. And on the grand

00:44:35.240 scheme, Peter, it's probably a non-clinical issue for them. Until they wanted to lift, they were in an

00:44:41.260 emergency situation now. They've come across a car wreck. Someone is in the car and if they don't get

00:44:46.680 them out, the car is going to explode. So we will all be placed into these situations at some point in

00:44:52.680 our life. And whether or not we have the physicality to deal with them is another issue.

00:44:57.860 But anyway, that's the downside of that particular adaptation and lifestyle, perhaps.

00:45:07.100 Which of these types of injuries leaves a person more susceptible to the movement of the vertebral

00:45:14.340 bodies in a slipped fashion, where we now get that spondyloth. I never remember which spondyla

00:45:20.960 we're talking about. I think we're now talking about spondylothesis when the vertebral body on top

00:45:25.460 moves relative to the bottom, correct?

00:45:27.240 Yeah, that's the anterior one. The answer is both. So a very flexible spine can get sheer

00:45:35.500 translations just the way as a stiffer spine can. So again, we wouldn't a priori judge and attribute

00:45:46.760 one of those to the symptoms. We always go by the assessment. It could be either spine, for sure.

00:45:53.780 I want to back up for just a second to the story I opened with and just kind of dig in a little bit

00:45:58.280 more to the pathophysiology. So that very, very first bout of back pain I had when I was 21 years old,

00:46:05.600 clearly the previous eight years or whatever, maybe seven years, eight years of really, really,

00:46:12.320 really heavy lifting. Certainly the technical knowledge I have today about how to do these

00:46:16.880 things correctly was completely absent. If you had to guess, and this is purely speculation,

00:46:22.600 what was the process that led to that injury on that day, that manifestation? You know, if I had had

00:46:28.520 MRIs examining my spine every year, starting at the age of 13 until that first real insult at age 21,

00:46:36.980 what would you have seen?

00:46:38.660 Well, I've done studies. Do you remember the NHL hockey strike a number of years ago?

00:46:44.120 Yeah. That was 94, wasn't it?

00:46:46.800 It was whatever year it was.

00:46:50.040 No, that was baseball. But anyway, okay. Yeah.

00:46:52.480 Well, whatever year it was, the younger players, they would go to Russia and whatnot and still

00:46:57.680 make a salary. But the older veterans hung around and I saw quite a few of them. You know,

00:47:02.500 my shoulder colleagues see some bridge shoulders. I ended up seeing them for low backs. But it was a

00:47:07.580 fabulous natural experiment, Peter, because they brought their MRIs every year. So say they were

00:47:14.080 11-year veteran. I would look at their MRs from the first year, the second year, and then I would

00:47:20.080 watch the cascade. And then I would say, what happened in the eighth year? Oh, that was the year

00:47:25.520 I started with a trainer and the trainer believed in doing astagrass squats with a heavy weight.

00:47:31.440 Aha! Look what happened to the spine. When was the last time you saw a hockey player do an astagrass

00:47:37.020 squat in the NHL? In any case, that was a wonderful experiment to give us insight into what you're

00:47:44.400 describing. And then the second layer of evidence that I would add there is I'm probably only of a

00:47:52.440 handful of people in the world. We had a radiology suite in our cadaver lab where we would take cadavers

00:48:00.880 and apply very specific loading scenarios to it. And we would watch the cascade of damage over time.

00:48:09.040 So both of those I'll put together and give an answer to what I expect I would have seen.

00:48:15.700 So we would have seen a lovely young spine in 14-year-old Peter, I think you said you started.

00:48:21.360 And then over time, we would have seen delamination from the inside out. So you were accumulating the

00:48:31.780 delamination, but on the outside, it was still Christine. Peter never knew. And the delamination

00:48:38.840 would continue to progress layer upon concentric layer until that day when you were 21 or whatever.

00:48:46.220 And the last layer was breached and the nuclear gel extruded just a little bit. Now, when you were

00:48:56.620 fertilized as an embryo or a blastocyst, I guess still at that case, around the end of the first month,

00:49:05.500 that little flat plate rolled, it's called neuralation, as you know, to create your primitive

00:49:12.940 spinal cord. On that day, your mother has not given you an immune system yet. Now it's fused up.

00:49:22.540 That nuclear gel has never seen the immune system yet. The end plates are pristine. It's never seen

00:49:30.960 your blood, which is where the immune system is active. So now you're 21. For the first time,

00:49:38.660 that nuclear gel comes out and sees the blood immune environment. It kicks off a hell of an

00:49:47.140 inflammatory response and you couldn't even move. It locked you up. And that's how strong and powerful

00:49:53.260 that was. Takes two weeks to subside. Now here's the rub. I don't know if you've been following some

00:49:59.880 of the recent literature on anti-inflammes.

00:50:02.260 I was going to ask you, would I have been better off if I had taken a prednisone taper

00:50:09.280 or had some local anti-inflammatory therapy? Of course, none of these were at my disposal as a

00:50:15.800 poor, dumb college kid. Of course not. But I can't tell you how much joy I'm having speaking with you

00:50:22.780 because your logic is fantastic. And the answer is, it could have gone either way. The anti-inflammatory

00:50:31.380 might have cleaned up the immune response and given you faster resolution. Or what the recent

00:50:38.280 literature is showing, there's a purpose for that inflammatory response. It brings in the immune

00:50:45.720 system and all the macrophages, etc. And it starts eating up the extruded material. Now that process can

00:50:53.160 go one of two ways as well. It can wall off what's extruded. And I think you've experienced that into a

00:50:58.560 free-floating body. Or it chews it up, digests it, for lack of a better word. And I wish I knew

00:51:06.940 you then because I bet I could have got you into, just lay on your tummy and breathe. And that vacuums

00:51:13.740 in. In fact, we did experiments. We would create partial disc herniations. And then if you traction

00:51:20.100 the spine and give a little bit of motion, all I do is wiggle your legs. You can vacuum in the disc

00:51:25.760 bulge in a matter of two or three minutes and people will say, you're dreaming. No, we've measured

00:51:30.620 it in some types of subcategories. That's actually possible. The answer to the inflams is, at least some

00:51:38.640 of the more recent data is showing dispense with the anti-inflammatories. Let the inflammatory response

00:51:45.360 give the patient health for two weeks. It's the best medicine for them in the long-term because it is

00:51:51.020 helping to reduce the long-term disc bulge. Whether there's any basis to what I'm about

00:51:57.380 to say, I don't know. But I will just say that anecdotally, these days when I have a flare-up,

00:52:04.920 and again, to be clear, these are really, really minor, Stuart. They don't interfere with anything I

00:52:10.180 do other than if that were a day when I was going to lift a little heavier, I would back off.

00:52:16.160 Given that I don't squat or deadlift or do any heavy stuff like that anymore, it's kind of a

00:52:21.460 non-issue. But what I find to be the most efficacious is not any sort of anti-inflammatory,

00:52:27.460 but a light muscle relaxant like a baclofen. So not a benzo or anything kind of sedating,

00:52:32.980 but just something that allows the paraspinous muscles to sort of relax a little bit. And frankly,

00:52:41.080 use that to allow me to do some deep breathing. And we're going to talk about the three most

00:52:48.020 important exercises that you prescribe at some point today, I'm sure. So it's mostly just a vehicle

00:52:53.680 to break the cycle of tension, but not the inflammation cycle. And truthfully, more of that

00:53:00.120 is not because I'm familiar with the literature that you've just spoken of, but frankly, because

00:53:04.860 there are downsides of taking prednisone as well. And we have to be mindful of those. And I don't want

00:53:09.480 to suggest people shouldn't take prednisone, but one needs to be circumspect about the frequency

00:53:13.680 with which they do it. Here's where I think you are now to answer the first question. I will bet

00:53:20.260 this is where you are now. You've got a little bit of micro movement in a sheer mode. So this joint

00:53:27.040 isn't translating as it should. It's lost a little bit of height. And those are the things that are

00:53:32.140 causing the low grade aches, not kicking off the heavy acute attacks that you used to have as a

00:53:37.620 younger man. Now, test number one, I understand your brother has a farm up around here somewhere

00:53:44.500 and you occasionally visit. If you want to spend an extra day, come on by the Gravenhurst and we'll

00:53:50.900 have some fun. But anyway, what I would do with you is I would get you to stand just as you are. And I

00:53:58.540 will bet you stand differently when you get out of that chair after doing this podcast for a bit

00:54:04.020 versus of you just walking around. So there would be a focal lean and intelligent. And if I palpated

00:54:10.820 your erector spinae, they would be active. And I would have to coach you to open up your hips a little

00:54:16.980 bit, ears over your shoulders, shoulders over your hips. And now all of a sudden, we've achieved that

00:54:23.440 muscular relaxation that you're after. So next time, before you think you need to take the relaxant,

00:54:33.560 humor me, lay on your tummy. Again, I don't know your spine well enough, but I would lay on your tummy,

00:54:40.200 maybe put your hands, palms up under your hips, maybe make a fist. Again, I don't know where you are,

00:54:45.280 but we would find a nice little relaxation place. And then I want you to melt into the table every time

00:54:52.240 you exhale. Keep doing that. And tell me, A, if that doesn't remove the ache, and we will play with

00:55:00.160 your hands to realign that little shearing micro movement. And then stand up. We might open up your

00:55:08.040 hips a little bit with a psoas-specific stretch. And then you will monitor your back muscles and see if

00:55:15.660 you've shut them down. But then if I said, poke your head forward, muscles on, pull your chin back,

00:55:23.040 muscles off. Soften your knees a little bit. Some people, they will stand with a strategy of

00:55:29.460 ramming their knees back into heart extension. Feel your erector spinae. Maybe it's just simply

00:55:35.700 jazz knees and soften your knees. In other words, those little postural cues, I have a sneaky suspicion,

00:55:43.240 and I've seen you enough moving on YouTube and whatnot, that I bet we could hack our way around

00:55:49.960 that. So there's our challenge. Let's see if we can do that without the med.

00:55:54.920 You got yourself a deal. I will happily add an extra day to my next Toronto trip when I'm up

00:56:01.100 at my brother's farm. And I'm sure my brother will want to join as well. We'll take you up on that.

00:56:06.600 Fabulous.

00:56:07.040 Let's talk about those three exercises, Stuart. There are three exercises. There's two of them

00:56:13.140 that I've done consistently for quite some time. I really fancy them a bit. The third one, the bird

00:56:19.560 dog, I only do occasionally. But let's go through the three of them. And just for the listener, we're

00:56:25.700 going to link to videos of these. So you're going to do your best to explain them and provide the

00:56:31.980 rationale for them. But ultimately, a demonstration will be forthcoming through videos we'll link to

00:56:37.820 in the show notes. But this is kind of like your core nutrition. This is sort of the, everybody should

00:56:45.540 be doing this. You don't wait till you have back pain to do this. Is that safe to say?

00:56:50.020 No, it isn't. This is a bit of a myth and something that I've been fighting basically my whole career.

00:56:56.280 The McGill Big Three. There are some people that are far too stiff. And this is not the mechanism of

00:57:03.760 their back pain. And we don't need to go there. Have you ever seen the type of body build where they

00:57:12.140 have a huge pneumatic cushion in front called a belly? It slaps on their thighs. It's that pendulous of

00:57:19.940 this. Do you ever see spine instability in that type of architecture? I don't. Those people have

00:57:26.060 difficulty getting on and off the floor. The big three is not for them. Again, the assessment

00:57:32.180 always leads us to the solution. I need to have a discussion of what stability is in terms of

00:57:41.060 creating resilience and performance. Then why are those particular exercises important? And then how

00:57:48.680 to do them? If I could follow that logic, Peter. Yeah, let's do it. And then the other thing,

00:57:53.940 Stuart, if you want to throw it in there, do you want to talk about some of the hallmarks of your

00:57:58.780 assessment, wherever it fits into those three things? Take it away. Yeah.

00:58:03.240 All right. So remind me, we're going to talk about non-specific low back pain and how I think it's a

00:58:08.960 myth and it doesn't exist. That will take us into the assessment. So let's go back to a basic discussion

00:58:16.720 of stability. If I was, I might use an example of a backhoe. So a backhoe is a machine with a tractor

00:58:25.540 and it has an arm on the back to dig earth. The first thing the operator does is put down the

00:58:30.460 stabilizer bars to lock the tractor into the ground. Because if you don't do that, you can't pull earth,

00:58:36.900 you just pull the machine around. So what's the human equivalent of that? We live in a linkage,

00:58:43.980 just like machinery. In other words, let's take the bench press muscle pec major. Pec major originates

00:58:52.260 on my rib cage, spans my ball and socket joint of the shoulder and inserts on the humerus. So when I

00:58:59.280 contract and shorten the pec major, it flexes my arm. So if I'm wanting to do a push or a punch,

00:59:07.060 there it is. That's on the distal side of the joint. Proximally, that same muscle shortening

00:59:14.620 collapses my rib cage towards my shoulder joint. So if all I used was the muscle that spans the joint,

00:59:23.400 that isn't a very effective push. All I'm doing is collapsing my own linkage. Or as an engineer,

00:59:30.140 we would say, well, you've just created an energy leak. I'm now going to build proximal stiffness.

00:59:36.480 I'm going to lock my core, create stiffness through my torso, which is proximal to the joint.

00:59:44.820 So now when I contract the muscle, 100% of the motion is directed distally. Now I've got my push.

00:59:52.200 So what is the best, most efficient way to create a proximal stiffness? We searched for years doing

01:00:01.660 all kinds of tests of every abdominal exercise you could think of, back exercises, twisting,

01:00:09.700 pal-off presses, throwing things, et cetera. The three exercises that kept bubbling up to the top

01:00:16.500 in the criteria of sparing the spine while you're doing them, because these people are hurting.

01:00:22.320 You don't have carte blanche to load up their spine. A guaranteed stability or proximal stiffness.

01:00:28.280 And it was later in my career that we found there is a residual stiffness that occurs. So if you do the

01:00:38.600 big three and you are an NFL football team, if you do the big three prior to practice, you will run and

01:00:46.400 cut just a little bit faster. So you're on the field, you run and you cut. The stiffer, the core,

01:00:54.160 when the hips explode into external rotation, you're now creating a faster directional change.

01:01:01.680 So what were the exercises? A modified curl up, which remember, I'm now I'm just going to start a

01:01:09.400 little bit of an assessment. I'm going to take a patient, I'm going to have them sit on a stool and

01:01:13.340 say, do you have symptoms right now? Humor me and let's say they don't. Now I'm going to say,

01:01:18.120 drop your chest down. Does that cause you're, oh yeah, my left toe is going numb and I've got back

01:01:24.860 pain. Good. Bring your chin down. And they might say that'll increase their pain or decrease it.

01:01:29.880 But the point is that posture created their pain. If that is true, when they lay on their back and they

01:01:39.460 imprinted their back into the floor, doing a Pilates roll up, for example, that would be their

01:01:46.040 specific pain trigger. So it's not much of a therapeutic exercise, but we can say, put your

01:01:51.300 hands under your low back as you're laying on the ground, lift your elbows, now hover up your head,

01:01:58.360 neck and shoulders. And we're going to propel the abdominal contraction, breathe through pursed lips

01:02:04.220 and allow the diaphragm to become the athlete inside this barrel. So that was the foundation of

01:02:13.200 the modified curl up. Now, if the person has a rotator cuff issue, or we will hack it and make

01:02:19.160 it tolerable, then I would see people, well, let's say a dumbbell or a kettlebell, and we're going to

01:02:24.700 raise it up laterally in the frontal plane like this for the side of the core. That would trigger pain

01:02:30.180 in a lot of people. I'll demonstrate all this if you want, but we could then do a side plank on the

01:02:36.940 floor. The beauty of the side plank is only half the musculature is heavily challenged. The downside

01:02:44.040 is heavily challenged. The upside is not. You've only got half the load on the spine. Very spine

01:02:49.740 sparing. We prescribe it on 10 second intervals. Why? We use the Russian training science to show

01:02:58.400 you build endurance through repeated 10 second exposures, not getting tired to the point where

01:03:06.060 you break form, nor do you develop a neural fatigue and you get a much higher tolerable training level

01:03:12.600 with this, what we call the Russian descending pyramid. And then for the back muscles, look at

01:03:18.240 the beauty of the bird dog, where you extend one leg, the opposite arm. One half of my low back is

01:03:25.160 active. One half of my upper back is active on the other side. We're developing a nice DNF pattern.

01:03:31.220 We're creating stiffness and stability in the core. We're teaching the brain to disassociate

01:03:38.380 ball and socket joint motion of the shoulders and hips with only half the spine load of say a Roman

01:03:45.800 chair extension or something like that. So that bubbled up to be a fabulous exercise. Then we did

01:03:55.040 experiments where we would train people. We would just have a single session exposure. We would measure

01:04:02.300 the core stiffness prior to doing the big three. They do the big three on the Russian descending

01:04:10.040 pyramid. And then we would remeasure their torso stiffness. Peter, they were stiffer. And some of my

01:04:16.520 muscle physiology colleagues said, well, you've added a turgidness to the muscle. I don't think so.

01:04:22.760 I think the brain created a lasting neural stiffness. And in some people, it lasts about

01:04:30.580 20 minutes. Some people, it lasts longer. So you will see some patients who say, you know,

01:04:35.100 when I do the big three, I don't have pain for the next hour. Fabulous. What you're going to do is

01:04:41.600 mid-morning, do a 12-minute big three session. Mid-afternoon, do a 12. So these are the little

01:04:47.600 tricks and hacks to slowly wind a person down out of pain. That was the pain side of the big three.

01:04:58.360 Then we started to look at the performance side. If you train a group of athletes versus graduate

01:05:05.400 students, the typical university experiment, not much difference was found in the athletes. But in

01:05:14.020 the graduate students, we would see an increase in stiffness over a six-week training trial. Now,

01:05:21.720 really interesting things started to happen. If you do isometric holds in the manner I've described,

01:05:28.740 you punch harder. We took a group of Muay Thai athletes. And when they dig the big three,

01:05:36.840 we measured the punching impulse, it was greater after they trained for six weeks.

01:05:45.660 When we did dynamic core exercises, it increased the closing velocity. So the closing velocity is

01:05:54.080 when you first get the first muscle pulse, boom, and then you relax closing velocity,

01:05:58.660 and then you strike with the second pulse, boom, boom. The closing velocity was faster with dynamic

01:06:05.140 core exercises. But the strike force, boom, in the end, was greater than the isometric big three.

01:06:13.080 Again, talk about performance. I know you're a bit of a pugilist. I certainly study combat techniques.

01:06:21.700 You know, if we were to take three styles, let's take Joe Frazier. And you would see him just always

01:06:31.340 on forward progression. But the punches came from his body weight behind them. He would create a

01:06:38.080 beautiful thrust line straight, but his body rotated and he lent his weight into them. And that was his

01:06:45.100 footwork. Wasn't the greatest for getting hit because that means you get hit a lot. Mike Tyson,

01:06:51.200 different body type, very compact type of a body, but contrast his footwork. Oh, it was just

01:06:58.160 beautiful. He would drop step, drop step, drop step, hook the liver, come back very quickly,

01:07:06.160 hook, boom, and cross. And there was the knockout. Again, all coming from the hips, drop step, boom.

01:07:14.780 You see, it's all hips. You know this. And then Ali breaks all the rules with Ali shuffle. And then he

01:07:22.520 would turn, rotate, hang on to it. And then at the end, look at a beautiful thrust line all through

01:07:29.720 the stick and core. I can go through athlete after athlete. I saw the other day, I've never worked with

01:07:36.640 Mick Jagger, but there's Mick Jagger doing the bird dog in his training. Usain Bolt, the fastest man on the

01:07:45.000 planet does the bird dog breeding extensor pulsing power into a stone. Or just to finish that off,

01:07:57.340 Usain Bolt does bird dogs. Bird dogs are beneath people. Really? They should see what I see.

01:08:03.680 Anyway, that was the end of that story. I was just going to add to it by saying,

01:08:07.420 I think that what I've become interested in as I've aged is looking at the greatest performers.

01:08:16.520 There's no doubt that the best athletes have a remarkable natural talent that the rest of us

01:08:21.260 don't have. I've measured it without question. Where I think people miss the talent, what they're

01:08:28.000 missing is a big part of the talent is the natural stability. In other words, it's the force transmission

01:08:36.300 without the energy leakage. And when I contrast really good athletes with myself and I examine

01:08:44.580 my athletic past, what is clear to me is that in everything I have ever done, despite all of my

01:08:51.980 hard efforts, my lack of natural ability and at the time coaching has meant that I have always suffered

01:09:00.340 from an unbelievable amount of energy leakage. Whatever I have done, whether it's been

01:09:06.280 boxing, swimming, powerlifting, all of those things, there's such a chasm between me and the really

01:09:14.480 good ones. And it's not due to hard work. I can promise you it is not due to effort. It is due to

01:09:20.720 probably some combination of natural ability and coaching that has allowed the really good ones to do

01:09:26.560 what you've demonstrated, which is a great punch begins in the back foot and it's transmitted through

01:09:34.380 the hip and it goes into the opposite fist. It's just hard for people to understand how that through

01:09:41.880 line of force can't lose anything along the way. The stories I could tell you about the number of

01:09:50.440 athletes being detuned by their trainers and coaches, violating this principle that you're describing.

01:09:58.580 It's astounding to me. Why are you getting them to do that? You've just detuned their athleticism.

01:10:05.120 I think where I want to go with this is most people listening to this are not going to lament the fact

01:10:12.280 that they didn't run as fast as they could have when they were younger or that they didn't punch or swim

01:10:18.780 with as much prowess as they could have. Where I think we should all care about this is that it's not

01:10:27.040 just that the energy leakage costs you performance. It clearly does. It's that it predisposes you to

01:10:33.540 injury and that's where I think we have to bring this back. When I exercise today, I don't care about

01:10:41.760 the performance. I care about the preservation and longevity of my body for whatever number of years

01:10:50.100 I have left. So this is really where I think stability matters. It's what are the exercises

01:10:56.680 I need to be doing? What are the exercises my patient need to be doing? So that as we age and we

01:11:04.240 walk up the flight of stairs or carry something heavy, we don't hurt ourselves because we don't have

01:11:12.660 that core stability that can resist the deformation that's going to allow energy to seep out of the

01:11:20.220 system. Well said. A story was coming to mind as you were saying that. I'll be giving a lecture

01:11:27.180 or teaching a class and I'll show some data from an elite athlete and there will be therapists and

01:11:34.820 clinicians in the room who say, we don't deal with elite athletes. We deal with the elderly or we deal

01:11:42.600 with sick people. And I think, what are you thinking? I'm showing you what the human body has the

01:11:51.920 potential to do. And your arrogance won't allow you to learn what is possible. And I'm going to give

01:12:00.340 you a very emotional, I hope I can get through this, a very emotional story to show the arrogance that

01:12:08.560 exists among some of our colleagues. Occasionally, medical groups, a hospital or whatever, will ask,

01:12:15.080 would you come out and assess three patients in our auditorium in front of all our medical staff?

01:12:21.680 I was at this facility. It was in Europe. The first person was a rugby player, fair enough. And I

01:12:27.240 had 20 minutes and declared what I thought was going on. The next one was a woman in her early 70s,

01:12:34.120 clearly distraught. You could look at her posture, her carriage. She was defeated by the world.

01:12:41.660 She came onto the stage and I said, can you tell me your story? She said a little few sentences.

01:12:49.380 And then she said, but the therapist says that I have to leave my home now. When I get off the toilet,

01:12:57.700 I'm a bit unsteady and she's afraid I'm going to fall on the floor. I can't get off the floor by

01:13:02.860 myself and I'm just going to lay there and no one will discover me. I have to leave my home.

01:13:07.880 She started to cry at this point, Peter. She said, what's going to happen to my cat and all this

01:13:13.160 sort of stuff? And I said, really, would someone please bring me out a stool and this will be our

01:13:18.640 simulated toilet. So an assistant brought her stool onto the stage. I said, okay, pretend that's the

01:13:24.220 toilet. Have a seat. She turned and had no idea how to move and just sort of plopped and collapsed on

01:13:31.660 the toilet. And then I'm just going to turn this down because I want you to see my lower body

01:13:36.700 kinematics as we're moving here. And then I said, would you get up off the chair? And I can't remember

01:13:44.220 whether she was wearing a skirt or pants. Pants, I think it was, but nonetheless, knees together and

01:13:49.360 she just sort of collapsed and I had to help her. She was going to collapse onto the floor.

01:13:54.580 And so I said, I want you to humor me now. You're my mirror. When I coach, I try and use minimum words.

01:14:04.060 I said, do this with your hands. Put your kneecap between your thumb and your hands as you slide

01:14:10.100 your hands down. Good. Now, I want you to be a leaning tower, leaning tower forward and backwards

01:14:18.720 and play with the curve of your back. Do you have any pain now? She said, no. And I said,

01:14:24.100 watch my shoulders. You're shrugged. I want you to anti-shrug. She did that. Perfect. And now I said,

01:14:32.480 pull your hands up your thighs by pulling your hips through. Don't lift with your back.

01:14:36.960 Pull your hips through. She had it done in three repetitions. That was now her pattern. And I said,

01:14:44.000 okay, think of what we've just done and sit on the toilet. And I said, whoops, spread your feet

01:14:51.520 apart. And there she went, slid her hands down. Then she put her knees together. And I said, now stand

01:14:59.080 up. She was going right back to the incompetent movement that caused her inability and disability

01:15:05.440 before. I said, spread your knees apart and pull your heels underneath you. Sniff some air. Now lean forward.

01:15:13.280 And do what you now know how to do. And she did a perfect squat. Do it again. And then by the third

01:15:22.240 repetition, big smile came on her face. It was the emotional part. I said, what's up with you?

01:15:30.480 She said, I don't have to leave my home, do I? I said, no. Do you know many of those hard-baked surgeons

01:15:37.360 and clinicians started to cry as well? For the first time, they realized all I did was teach her,

01:15:42.920 Weightlifting 101. And remember how this story started with the arrogance of some of our

01:15:51.580 colleagues who say, I don't want to hear stories about elite athletes. I deal with old people or

01:15:56.980 sick people. And that's why they continue to not have the skill set to help their people.

01:16:04.160 All I did was learn from the best weightlifters of the world, people who know how to move load,

01:16:12.500 learn what the efficiency was, and turn it into a hack to change a person's life. Anyway, that's a

01:16:19.140 pretty emotional story. And I hope we do that quite often. I know you like cars. Why does Honda race F1

01:16:28.240 race cars? Well, they don't anymore, but when they did, and the reason was they learned about

01:16:34.160 automotive technology and the gearshift change in your Honda Civic came from the F1 racetrack.

01:16:42.160 So that's why we work with elite athletes so I can bring it down. I love working with them,

01:16:48.580 of course, but they just give it away free to us. And yet some of our colleagues are just so

01:16:53.720 closed off. They don't want to hear about elite performance. That's an absolutely beautiful story,

01:16:58.360 Stuart. And thank you for sharing that. It's a sadly common story too. And to me, I think the

01:17:03.700 saddest part of that story is how many of those patients don't get the chance to sit on a stage

01:17:10.420 with you for 30 minutes and learn that movement. You've been around long enough that I'm sure you

01:17:15.600 have a better sense of this, but I feel maybe optimistically that we are in a place now where people

01:17:22.560 are starting to appreciate the importance of strength and stability and that we're less afraid

01:17:29.640 of this. There's more discussion of the importance of resistance training and that it's not a young

01:17:35.980 guy thing to do. It's an everybody thing to do. But given the arc of your career, am I being just

01:17:42.960 sort of delusional or do you really think that we're in a coming of age here?

01:17:46.380 The way you phrase questions are fabulous. What was going through my mind? I try and answer every

01:17:53.360 question. What's the evidence and what's the application? The evidence at the university

01:17:58.700 with all our first year students, one of their first courses they took was on just basic fitness

01:18:05.600 evaluation. Range of motion, strength, hand grip, VO2 max, some of these markers. And they would measure

01:18:14.760 each other and we kept the scores year after year of the incoming class. The students got terribly soft

01:18:23.720 and I can prove it based on that data and we would graph it. Now, whatever year was the year where the

01:18:30.200 students had grown up with the personal computer? It was right at the very late 90s, I think. All of a

01:18:36.120 sudden we saw the incoming class fitness plummet. Then something happened. They were a soft bunch for about

01:18:43.740 five years. And then slowly, to your point, they started to come back. And so I think your perception

01:18:51.400 is right on. It did go to a terrible state, however many years ago that was, 15 or 20 years ago. But it

01:19:00.220 is coming back. Now, among our colleagues, and having said that, I think some of them are terribly

01:19:06.200 misguided as well. You know, they think, oh, you're not a real woman because I heard this on social media

01:19:11.920 until you can deadlift twice your body weight. Well, wait a second. If they could come here and

01:19:18.520 see the number of people who've been caused by overzealous trainers and going bonkers on

01:19:23.680 deadlift magnitude. Let's talk a little bit about that because I have to tell you, Stuart,

01:19:28.780 I'm a bit conflicted personally, and I'll explain why. I obviously have no desire to do anything

01:19:34.080 that I deem stupid anymore. My days of gritting through painful anything are long over. I know the

01:19:43.240 difference between discomfort that is worth pushing through and pain that is not. But when I think about

01:19:49.820 in particular squats and deadlifts, especially around the deadlift, an exercise I really, really enjoy

01:19:57.320 where I feel conflicted. On the one hand, I feel like now that I'm so tuned in to how to do this

01:20:05.300 movement correctly, it's a really wonderful audit for my stability system. I'm embarrassed to tell you

01:20:14.200 how much I didn't know when I was deadlifting. At no point did I understand the importance of tension

01:20:20.260 in the arms, intra-abdominal pressure, the variability in foot pressure on the ground, like none of that

01:20:26.240 stuff, right? It was just pure brute force stupidity. Today, as I know those things, it allows me to

01:20:33.840 modulate force and to, on a good day, push the envelope a little bit in what I perceive as safe.

01:20:40.500 So on the one hand, I think, yeah, I should be deadlifting my whole life. I don't need to deadlift

01:20:45.320 400 pounds anymore, but I should be deadlifting because it's this great audit. And on the days that

01:20:50.580 I don't feel that I back off. And then on the other days, I say, Peter, you don't need to do this

01:20:55.540 anymore because honestly, you can still get the same or nearly the same activation for all of the

01:21:03.540 muscles involved using other movements, single leg movements in particular, where you don't have a

01:21:10.100 fraction of the axial loading. And yeah, you might need to do two exercises instead of one, but at the

01:21:15.580 end of the day, there's a lower risk approach to get it. In other words, deadlifting is valuable,

01:21:22.620 but you have a narrow operating window in which you can potentially hurt yourself. So I continue to

01:21:28.580 go back and forth on this, Stuart. As such, here I am telling you, I still will go periods of my life

01:21:35.720 where I'll deadlift every week and then I'll take three months off feeling like I don't want to push

01:21:41.040 it. How would you advise a middle-aged person or even a non-middle-aged person who's thinking through

01:21:47.740 this particular issue? Again, I have so many thoughts going through my mind. It's interesting

01:21:54.220 when we have a back-pained 50-year-old coming here and I'll say, what are your goals? Oh, I want to

01:22:00.820 set a personal best in deadlift. And I said, really? Okay. Let me tell you some stories. Let's talk

01:22:07.320 about Ed Cohn. Do you know Ed Cohn? I sure do. The greatest powerlifter of all time. I was with Ed a

01:22:12.780 couple of weeks ago. I'll tell you a funny story about him if you like in a minute. But anyway,

01:22:16.820 Ed, when he would set a personal best, he'd take a couple of months off afterwards.

01:22:22.580 To set a personal best is so demanding of your body. There are actually, if you set a true personal

01:22:31.800 best, most people experience micro-fracturing just underneath the end plate of the trabecular bone.

01:22:39.800 If you look at the great strength athletes, they train deadlift. And again, if you go to our website,

01:22:47.920 look at the testimonials at the bottom, the number of world-class deadlifters who are on there.

01:22:53.780 So I've worked with quite a few of these people through their injuries.

01:22:58.000 Now, those micro-fractures could be a good thing or a bad thing. The professional powerlifter will take

01:23:04.700 a week off. They train heavy deadlifts or squats once a week because it takes a week for the bone

01:23:11.240 callus to not only attach through the chemical electro attraction, but to really scaffold on.

01:23:18.940 It takes a week. If you deadlift in another three or four days, the way some trainers,

01:23:23.280 they might deadlift a client three times a week. That allows those micro-fractures

01:23:28.400 to accumulate until finally you've got a full-blown end plate fracture or whatnot. So these are the

01:23:33.780 people that come here. And then I say, how about this for a goal? Do you have kids? Yeah. Do you

01:23:39.360 have grandkids? Yeah. How about this? I've since learned about your centurion decathlon, which I

01:23:46.920 love, by the way. I'll say, would you rather, as your goal, have the ability to play with your

01:23:53.760 grandchildren on the floor when you're 80 and get off the floor and pick them up? And they pause for

01:23:59.280 a minute and they'll say, yeah, I like that goal. I say, well, you can't have both. If you think you're

01:24:04.700 going to continue having deadlift personal bests, you will have artificial hips and all of these other

01:24:12.800 things. Because how many old powerlifters do you know? Do you really want to be like that group of

01:24:21.660 athletes? So I can talk them into changing their long-term goals. Now is the time to get on the

01:24:31.000 program and make sure you get there. If that's the case, we eliminate deadlifts. We had an athlete

01:24:36.800 here yesterday. They're at the end of their career. And I took them out and we went for a 10-minute walk

01:24:43.440 to a hill that we have. And I'll say, here's why you're not going to do deadlifts, but here's what I

01:24:48.300 want you to do. I showed them a monster walk. Okay, monster walk. Now we're going to the bottom

01:24:54.660 of the hill and I want you to lean back into the hill and we're walking backwards. You're going to

01:25:00.820 align your foot, ankle, knee, and hip and push through the knee, through the knee, through the

01:25:06.800 knee, backwards up the hill. Do you know after 30 meters, they were absolutely done. Here they are

01:25:14.560 doing all this deadlifting and they don't even have the leg strength endurance to walk backwards 30

01:25:20.020 meters. It's totally inappropriate stimulation of their athleticism to make it through to 80.

01:25:26.700 So good for you. Let's do it again. We walked down the hill. We did three sets. They could hardly walk.

01:25:32.840 And then we played the neurological grip, which I like to do a lot of. Now I said,

01:25:39.280 walk forwards up the hill, but pretend you have $100 in your butt cheeks. Don't let anyone take

01:25:46.320 it. Now walk forwards up the hills. And they say, I've never felt this before. The brain perceives

01:25:52.900 exhausted quads. It now has to go and get the glutes. It's the only thing left. So quite often,

01:25:59.520 we'll do an exhaustion focus to stimulate the thing that we really want to stimulate. And I convinced

01:26:08.260 that person after that, what they're going to do and train now to get a well-rounded and sustainable

01:26:16.260 athleticism that will spare their joints, still have great training capacity, but I think their

01:26:23.180 athleticism is going to go through the roof. I've taken some very accomplished power lifters and we've

01:26:30.900 taken out all the squats and just do sled work, backwards walking up hills. Some of these old

01:26:37.820 time techniques, their joints settle down, they get a sustainable fitness. They lose this idea of

01:26:47.400 maximum effort, squats and deads. And now they're thinking of the word sufficient strength,

01:26:55.800 sufficient mobility, sufficient endurance. And we've been doing this long enough now that we've

01:27:02.900 tracked them. And those are the ones that are getting through. Let's go get any one of our

01:27:08.240 colleagues who are orthopedic surgeons. Tell us who you're replacing the hips of. Well, 50-year-old

01:27:15.780 Caucasian women who have done yoga for 30 years. Okay. Men around 50 who've done deadlifts all their life.

01:27:24.400 Who are you not? The middle of the road moderates. Not the ones who've rusted out and not the ones

01:27:32.220 who've worn out, but the ones in the middle are the ones who are. So this idea of sufficient

01:27:36.880 fitness, because I still believe we are all called upon to do things in life at certain times,

01:27:45.700 I hope we're already enabled. It's more fun too, just to be able to continue to do those things.

01:27:52.140 So I'm like you, I don't do deadlifts, but I pick up a hundred pound bucked up logs as an example,

01:28:01.340 big oak log. So that's my stone lift. Load that into the log splitter, still split my wood. People

01:28:07.860 comment on my hands. This athlete who came yesterday, I shook his hand when he came to the door. He

01:28:13.060 couldn't fit his hand around mine. He said, whoa. When we were young, we didn't have dumbbells.

01:28:20.160 My dad would give us a cinder block, cinder blocks. Anyway, as you know, the importance of

01:28:27.560 grip strength, I will take any day over how much you deadlift. People often ask me, Stuart,

01:28:32.840 why do you think grip strength is such a great proxy for longevity? And I say it's the same reason I

01:28:38.560 think VO2 max is a great proxy for longevity. Those are probably the two best biomarkers we have. It

01:28:44.720 sounds crazy by the way, that your VO2 max and your grip strength are better predictors of how long

01:28:50.120 you're going to live than whether or not you smoke, drink, what your family history is for cancer.

01:28:55.080 Like those things all matter, but it's amazing how dwarfed they are by those two. My best explanation

01:29:01.260 for it is that those are the best two integrators for the work you've done. You can't cram for a VO2 max

01:29:10.180 the week before. If you have a high VO2 max, you have done the work to get it. If you have a strong

01:29:18.320 grip, you didn't just buy little grip squeezers on Amazon and filter away at them while you were

01:29:24.440 on calls on Zoom. You had to do the work. You had to be carrying heavy things, whatever it be,

01:29:32.040 chopping wood, carrying cinder blocks, doing farmer carries. And of course, that also speaks to

01:29:37.260 stability. That speaks to the stability that you have to be able to transmit force from the torso

01:29:43.280 right to the hand. So agree completely. Let's pivot for a moment to talk a little bit about

01:29:48.460 the amount of psychological trauma that exists in the patient with lower back pain. And I'm thinking

01:29:56.380 very specifically, even about some of my own patients or friends who have been in the throes of

01:30:04.420 lower back pain. And if nothing else, Stuart, I take a great degree of comfort from the injury,

01:30:12.260 the third injury that I had, the one in 2000, because it lasted so long and because it was so

01:30:18.900 debilitating. And because I'm here today without pain, my confidence around small recurrences is so

01:30:28.720 high that I don't tend to awfulize about it and work myself up. But I have great empathy for a person

01:30:37.440 who doesn't have that knowledge. And instead, I don't know how to help someone sometimes because

01:30:43.960 I can't tell what is mind and what is body at this point. And I suspect that there's a significant

01:30:49.640 interplay. So can you speak more about this phenomenon and what those of us who want to help

01:30:55.940 these patients can do? I am certainly much more conscious of the point you're making now than I

01:31:05.100 was 30 years ago. Absolutely. I'm going to start with a little story. This happens very often.

01:31:14.680 You mentioned earlier how MRIs don't show you the mechanism of pain. And I can give all kinds of

01:31:22.280 reasons why. But let's take this patient. This is true. He came to see me. He said,

01:31:30.220 hi, doc, I hear you're different. I've got this pain. I've been everywhere. I went to the pain clinic.

01:31:37.380 They gave me narcotics. And now they say the pain is in my head. I can live with the physical pain.

01:31:44.020 I cannot live with someone telling me the pain is in my head because that means I'm crazy.

01:31:48.980 And if I'm crazy, I don't deserve to live. You've got two weeks. And in two weeks, I'm blowing my

01:31:56.880 brains out. Now there's a heavy psychosocial challenge and a little bit of a story of what

01:32:06.640 the system does to people. And it's not unusual for someone to come here suicidal. So I said,

01:32:13.400 all right, you don't appear to have pain right now. And he says, no, I don't. And I said, okay,

01:32:19.920 what causes your pain? And he said, well, it's when I do a certain movement that I get a flash of pain

01:32:27.720 and it feels like someone has broken a beer bottle and have ripped open my hamstring muscles.

01:32:33.240 It's awful. And I said, oh, can you show me the pain? And he said, what? You want me to show you

01:32:40.660 how I create the pain? And I said, it's the only chance I have to understand it. I said,

01:32:46.480 you've been to 15 different clinicians. Has no one ever asked you to show them the mechanism of

01:32:52.840 your pain? Has anyone ever touched you? He says, no. I said, well, it's the only way I know. Peter,

01:32:58.820 I put on my instrumentation, which was muscle EMG over the torso, the glutes, et cetera.

01:33:04.460 We put on the spine motion monitor, 3D motion spine monitor. And then I said, all right,

01:33:10.320 let's see what causes this. So he stood there and he did a very weird thing. And he said, all right,

01:33:15.760 well, here you go. And he wound himself around in a circle like this. And when he got to 10 top dead

01:33:22.360 center, now at that time, I heard like a little cavitation, little pop come out of his back.

01:33:29.160 And that was the trap of the sciatic nerve. And he was in a bad way. I laid him prone on a table,

01:33:36.880 tried to give him a bit of decompression. And he went home and I said, I know exactly what the

01:33:42.960 mechanism of your pain is. Here's what you should do over the next three days, but I want you to come

01:33:48.100 back. But promise me you aren't going to do anything silly. Remember what the threat was hanging

01:33:53.400 over us. He said, I promise. I called him that night. I called him the next day just to make sure

01:33:58.760 then he came back. And I said, I know exactly what your mechanism is. Here's what the data showed.

01:34:06.260 As he was winding himself around, he was using muscle. Muscle is stiffening and stabilizing.

01:34:12.760 It's centrating of the joints. And as he got to top dead center, he shut all his muscles off.

01:34:18.300 He completely relaxed. And then there was a little sheer translation or a clunk. And that's what we

01:34:23.200 heard. And that's what scrapped the sciatic root. I said, okay, you have no pain. Push my fingers out

01:34:30.860 harder. Good. Hold that. Now talk to me and keep talking to me with that controlling.

01:34:37.580 We coached him through this in a minute. Very simple. Keep the tone now. And we're going through.

01:34:43.740 And as he came to top dead center, you could see him. I said, we're there. Do it again. Hold on.

01:34:53.700 Keep control. He didn't clunk. Now it took him about four months to wind down the ache. But he never had

01:35:03.420 another clunk or a trap. 10 years later, he brought his daughter to me. I saw her for back pain and he

01:35:10.520 brought me a case of beer. I said, I did my one-year follow-up with you. But how have you

01:35:15.780 been? He says, fabulous. I said, did you ever get another episode? Never had one. Now, some people

01:35:24.840 will think that that's a fantastic, impossible story. Pete, after that one coaching class and he gave

01:35:32.980 him, he was so coachable and he got it. He understood. He was a mechanical mind. He never had

01:35:39.000 another acute episode ever. So a suicide case from the medical system, not having a sufficient

01:35:47.080 evaluation procedure to really get at what the mechanism of his pain was to a point where they

01:35:54.440 defaulted and said, we've tried everything with you. It's not working. Therefore, the pain is in your

01:36:00.740 head. The key was to prove to him immediately that he had the ability. It's just he had to be shown how.

01:36:07.340 So it was a process of understanding the mechanism, giving him a strategy to address the mechanism,

01:36:14.660 and the psyche just changes. It empowered him. May I give you one more story?

01:36:20.840 Absolutely.

01:36:21.400 Okay. I was giving a lecture in England and there was a fella off to the side and he was slumped down.

01:36:30.360 Now, if you get a clinical psychology textbook, the picture of depression is this,

01:36:35.060 knees together, slumped down in that demeanor. Now, if you have a posterior disc bulge, that is

01:36:41.700 not a good position to be. So there we're starting with clinical depression, feeding a disc bulge.

01:36:48.360 Two don't go together. And he just sat there. And then in the break, he came over to me,

01:36:52.880 very quiet, spoken fella. And he said, I hear what you're saying. Do you have 30 seconds for me to

01:36:59.100 tell you my story? And I said, sure. He said, I used to be a police officer. Hurt my back. I went

01:37:05.700 through the NHS system. They only gave me exercises that hurt me more. Finally, they gave me a pamphlet,

01:37:15.040 how to live with your back pain. And he said, that book destroyed me. What? You mean I have to live the

01:37:21.580 rest of my life with my back pain and no one's ever touched me or shown me any of this? And I said,

01:37:27.420 oh. And then you'll remember that spot procedure that we went with the older woman that I described

01:37:32.760 earlier. I simply showed him that. And he went back and he sat down on the chair, nice and tall.

01:37:38.920 And then at the end of the lecture, I went over to him and I said, how's your pain? And he stood up

01:37:42.820 and he said, it's gone. And he started to cry because he realized now what the system had done

01:37:49.040 to him. In the meantime, he lost his job and he realized that he'd been stolen from. And those

01:37:55.900 are his words. He said, they stole my career from me, giving me that book, how to live with my back

01:38:00.940 pain. Why didn't anyone show me what my pain was like you just did in 30 seconds? I've been watching

01:38:08.420 this pattern for so many years, you could see it a mile away. Anyway, those are two stories to link

01:38:16.840 the mechanics. And ultimately, what we're trying to do is to empower people in showing them they have

01:38:25.620 the ability within themselves. They just need to understand the mechanism. And most of the time,

01:38:31.860 they are able to mitigate the cause and then build a robust foundation. So I wrote back mechanic

01:38:41.900 and I started the experimental research clinic at the University of Waterloo. Maybe you've heard of

01:38:48.640 this, but I've never heard of another clinic where they follow up with every single patient that they

01:38:54.460 ever saw. We did a two-year follow-up with every single patient who came in and we subcategorized

01:39:00.360 them because we assessed everyone into the mechanism of their pain pathway. We gave them

01:39:09.280 an appropriate exercise prescription. We followed up to see, did they even comply? Because some people

01:39:18.060 didn't. And then how are you doing after two years? If you were in the subcategory that everything

01:39:24.960 has failed, you've been told you need surgery. So you're at the end of the road now, you're a surgery

01:39:31.960 case. In the two-year follow-up, following the plan that I just described for you with this thing called

01:39:39.460 virtual surgery, which is part of it, 95% reported that they avoided surgery and they were glad that they

01:39:46.940 did. So that's my efficacy to the empowerment and psychology issue.

01:39:53.860 What stands out to me the most in those stories, Stuart, is your consistent, adamant drive towards

01:40:04.680 understanding the mechanism of the pain. So it's how do we break this down into a physics and biology

01:40:11.720 problem. And I guess my question is, which type of healthcare providers are most in line with that?

01:40:20.480 Is your PhD through the School of Kinesiology? Yes. I should back that up. Yeah, there's a lot of

01:40:26.760 mechanical engineering in there, but nonetheless, yeah, basically. But when we think of all the different

01:40:32.540 practitioners that interact with patients who have lower back pain, ranging from neurosurgeons,

01:40:40.960 orthopedic surgeons, chiropractors, physical therapists, kinesiologists, I mean, there are so

01:40:48.320 many people. And I never want to suggest that the profession determines the school of thought. Like,

01:40:55.320 I really think there are great people and there are lousy people within all of those categories.

01:41:00.500 But what are the characteristics that you see driving that type of search for a true mechanistic

01:41:07.720 understanding of the pain? Because I'll be honest with you, like, in all of my back bouts of misery,

01:41:13.700 nobody ever explained to me what was going on. I mean, nobody said to me, this is happening.

01:41:19.720 Even as a medical student, yes, I could look at the MRI, I could see the fragment.

01:41:25.520 It clearly had to come out, presumably, given that I was in such excruciating pain and the thing wasn't,

01:41:31.500 you know, it might have taken months for the thing to have been resorbed.

01:41:34.140 But there wasn't a sort of, we need to understand the why this is happening,

01:41:38.460 so that we're going to fix the underlying behavior that's causing it. That's the thing

01:41:43.920 that strikes me as the most interesting of those stories. And I guess what my long-winded

01:41:50.640 apologies question is, is that a function of the individual or of the school of training?

01:41:55.360 Both. So the elephant in the room here is there is no billing code that exists for an assessment

01:42:06.440 of back injury mechanism. It doesn't exist. You can't bill an insurance company and say,

01:42:12.420 well, I assess the person's back pain. When I started the experimental research clinic,

01:42:17.180 I set aside two hours to see a back pained person. And I'm a black guy, that's all I ever saw,

01:42:23.460 two hours. My medical colleagues who'd been through medical school training, which I had not,

01:42:28.620 I'd only have ever been a guest professor at a medical school, but I sure didn't even graduate

01:42:33.300 from one. My medical colleagues said, two hours, what are you going to do for two hours? Well,

01:42:39.400 I've been spending 30 years figuring out how I'm going to test shear tolerance to compression,

01:42:46.420 pulling a nerve root one way, pulling it the other way. Is it flossing? Is it friction? Is it stuck?

01:42:51.560 Et cetera. Again, I said a handful of people in the world that would take cadaveric spines and create

01:42:58.940 the injuries. So I knew how to measure them and what to look for in terms of the full pattern.

01:43:05.820 But that's the first political impediment to all of this. There's no billing code. Therefore,

01:43:13.500 you're left with clinicians who are billing for a procedure that they've been trained to perform.

01:43:23.100 Well, if you have nonspecific back pain, it's an absolute crapshoot, whether a manipulation for

01:43:30.660 mobility, an exercise prescription for stability, just a movement tool, not to create a stress riser

01:43:38.380 or a stress concentration on the tissue that is sensitized. Simple as that. So where I've arrived

01:43:46.720 at with all of this, we have to train our own clinicians. And that's what I've been doing through

01:43:52.780 BackFit Pro. And I do not care if you come from a chiropractic, physical therapy, coaching, training,

01:44:01.400 physiatry, neurology, radiology, even background. All I care is that you have passion. It's a 50-hour

01:44:10.960 online course of me going through anatomy, physiology, neurology, psychology, biomechanics,

01:44:19.900 et cetera. And then the probably 100 subcategories of pain mechanisms. And then how do you test for all

01:44:31.140 of these? And then how do you coach them? And then after all of that, we have three days together where

01:44:37.340 we do hands-on skills training at a table. So again, there's no subcategory in the medical rubric

01:44:45.140 that trains how to assess back pain from the perspective of biomechanics, psychology,

01:44:53.780 neurology, physiology, et cetera. They don't exist. So that was my challenge.

01:44:58.700 Stuart, what's the name of that course?

01:45:01.300 It's called the Summit Course, and you can read about it on backfitpro.com.

01:45:05.400 And is it only for practitioners or is there a variant of that course that an individual can take

01:45:12.180 to become sort of the master of their own domain?

01:45:16.180 Okay, good question. It's mostly for clinicians. It's only been clinicians that I know of that have

01:45:22.820 ever registered for it. I don't think we would stop a member of the lay public because some of them

01:45:28.220 are very savvy from taking it. However, the gatekeeper of all of this is there's a fairly

01:45:34.920 extensive exam at the end. It is a written exam. There's a practical exam where the person must assess

01:45:41.900 a real patient, usually online with one of our examiners. They have to come up with a written

01:45:49.560 explanation of the pain pathway, and then a program of what they're going to do with the person.

01:45:56.420 And then they have to coach elements of it. So they have to see the coaching scale as well.

01:46:00.980 So that's sort of a gatekeeper at the end that I think would only be for clinicians. But that's

01:46:07.260 the only way that I've found possible.

01:46:11.460 I'm like you. I'm very agnostic in terms of preparation. There are fabulous chiropractors,

01:46:17.020 it's the absolute opposite. There's fabulous therapists. There were fabulous professors and

01:46:22.660 terrible professors. It's just the way it is. It's a very interesting course. It's almost

01:46:27.700 something I wonder, I'd love to figure out a way to make the time. So it's 50 hours online plus three

01:46:32.580 days in person is what it sounds like. Correct. Yeah. Let's talk about the cases where you think

01:46:39.480 surgery is really the best course of action. And again, I think it should always be stated

01:46:45.140 that surgery without understanding how you got there and then making sure you correct it

01:46:51.880 post-surgically is not what we're talking about. So it should always be assumed that

01:46:56.640 you want to understand what got you there. But what are the indications in your mind for where

01:47:03.160 a patient is better off getting a surgical procedure and we could talk about what do you

01:47:09.000 think are the best indications for discectomy, fusion, et cetera, versus where would you take

01:47:13.960 a contrarian approach where many people would say, yes, surgery, and you would say, let's push a

01:47:19.200 little bit harder before. Wow. A lot of elements there. So I'll just start at the beginning and hope I

01:47:26.080 can create a logic story. I did mention the follow-up that we did where 95% of people who

01:47:36.140 were told they needed surgery, in fact, avoided it. And what we did there was I anointed them and said,

01:47:44.020 there is your virtual surgery. This worked really well on people who I'll paint the picture of,

01:47:50.720 let's take a stay-at-home mom with two young kids. Every day has to go to the gym and

01:47:55.980 ride the elliptical for 20 minutes, do something else as a stress reliever, otherwise she's going

01:48:00.600 to murder her husband. You've heard that story before. I'll say, good, go get your surgery.

01:48:07.240 Are you going to do that tomorrow? No, you are going to lay in bed. You're going to behave like

01:48:12.440 a post-surgical person. You're going to get out of bed and go for a pee three times. That is your

01:48:16.820 total workload tomorrow. And slowly, you're going to build yourself back. In other words, surgery may

01:48:22.020 work for you because it's forced rest. Now, I'm going to give you a tool that will mimic

01:48:27.240 the forced rest. It's called virtual surgery. Tomorrow, here's the plan. Here's how you're

01:48:31.800 going to behave. We are going to desensitize strategically the pain mechanism as we've

01:48:37.860 measured it. And we're going to retune your body with strategic mobility and stability plus movement

01:48:43.940 skill so we don't replicate the stress concentrations that caused your problem in the first place.

01:48:50.000 let's see how you are. Now, if they can do that, 95% will avoid surgery. So there's my first little

01:48:56.840 story for people in that category. Stuart, just to be clear, what are the patients who you would not

01:49:04.640 offer that virtual surgery to? Give me an indication where you would say, you know what, this is too

01:49:11.120 depressing. Right. Obvious red flags, which before we see a patient, we don't take patients off the

01:49:19.560 street. Never. They always come through physician referral. So I'm hoping they've been checked for

01:49:25.980 red flags. Do you know how many have not? Even though we state in the referral directions to the

01:49:32.940 referring medic, we've had cases of aortic aneurysm, lung embolism, cancerous tumors,

01:49:41.460 metastasized, all sorts of things that somehow these poor people got through the system. And we

01:49:47.840 were the ones that found it and saved their lives. I wish that wasn't the case. But all of those,

01:49:55.200 obviously, are surgery cases and they should never have come to us in the first place. So obvious red

01:50:02.020 flags is number one. Number two is when the pattern doesn't fit. So I was smiling when you were telling

01:50:10.860 your original story only because it was such a familiar, spot-on pattern consistency. You fit the

01:50:18.860 pattern. I knew exactly what it was. When the pattern doesn't fit, I'll say, no, something's

01:50:25.180 not right. I need you to go back to your doc. And here's the reason why there is a turgidness

01:50:33.800 under your liver. We're not able to move that pain by moving stress concentrations around your spine.

01:50:41.020 So it's not a nerve. It's nothing vertebral or facet. The pattern doesn't fit. It's something else.

01:50:48.280 So there is a person where we refer back and say something needs further investigation.

01:50:55.180 But now the last part of your question was about the need or when we would say for a person,

01:51:04.060 you're not our person. You need to see a surgeon. Surgeons, and by the way, we see far too many

01:51:11.100 post-surgical patients who they went through. Maybe the surgery was botched. When I see a horrible

01:51:18.300 scar on the outside of the skin, I think, man, if that's the pride that the surgeon took on the

01:51:23.700 outside, what carnage has gone on the inside? Or sometimes it's a shit happens story. The nerve

01:51:30.440 scarred in and adhered. Ah, that's rough. Or the post-rehab was terrible. Here's a person,

01:51:38.960 they went to a fabulous surgeon, and the surgeon says, oh, go do PT. That's your rehab. And the PT

01:51:44.700 goes and gives them toe touches or something after they've just had a microdisc surgery. And guess

01:51:51.240 what? They're re-herniated again, and now we're seeing them. But when would we say, no, you're not

01:51:57.200 for us? The surgeons are at their best in cases of a real heavy stenosis. So there's not much room in

01:52:07.460 your neural canal. The facet joints are thick in behind, so you've got encroachment from behind.

01:52:13.700 You've got a calcified disc bulge coming from the front. So a couple-level aminectomy to give the

01:52:20.920 nerve some space. That really is when the surgeons are at their best. Some of the spondylomalopathies

01:52:30.000 that we'll see in the neck. I think of a lead lawyer in the courtrooms. And the judges would

01:52:36.400 ask him, sir, are you drunk? And he said to us, well, when I stand, I start my presentation,

01:52:42.740 I'm fine. He says, but after two or three minutes, I'm losing my balance and falling over. And the

01:52:47.300 judges think he's drunk. And then we found it. It was a cervical spondylomyelopathy that was also

01:52:53.640 co-presenting with back pain. But no one had figured this out. So that was a surgery case,

01:53:00.220 obviously. So it's either post-trauma, and then that one's obvious. They need a little bit of

01:53:06.340 hardware to stabilize their spine. But it may also be spondylolisthesis. The listhesis or the sheer

01:53:15.100 translation is just choking off the autoquina or another nerve. We recommend surgeons.

01:53:23.640 We have really good luck with. And in that situation, if the spondylolisthesis is significant

01:53:29.820 enough, is the only treatment a fusion? I'm going to say yes. There's no amount of stability you can

01:53:37.380 generate in the paraspinous muscles, in the QL, in the psoas to compensate for that. I mean,

01:53:44.960 I realize that you have to forgive me because I'm not an orthopedic surgeon, but I would assume that

01:53:49.440 there's some threshold. One millimeter of spondylolisthesis might be tolerated. And at some

01:53:55.040 level, they would say, no, it's too unstable. I wouldn't agree with that, Peter. It's not the

01:53:59.620 distance at all. You go with the assessment. Again, the evidence I offer there is we're coming down to

01:54:06.320 the next Olympics now. So I don't know how many Olympians and people who are tapering now for the

01:54:14.400 Olympic trials we've had here over the past year. But this is every four years we're inundated with

01:54:19.720 these types of athletes. And they come in pairs where we might have two young women who are competing

01:54:26.880 for a place on the U.S. Olympic team in gymnastics. Both have the same spondy. One will say,

01:54:34.680 we need six months off here of gymnastics. And here's what we're going to do. We're going to do a

01:54:40.600 heavy stabilization program. The next one says, oh, no, we really got to make the trials. We're just

01:54:47.280 going to keep going with going to gym. And I can almost predict with 100% accuracy who's going to

01:54:54.180 make it. So I wouldn't say at all that we don't try a heavy exercise stability program, regardless of

01:55:03.920 the amount of slippage. And I've done that with people trying to make the special forces in the

01:55:11.440 U.S. You got to do a speed sit-up test. You got to do all of these things. Oh, but you got a heavy

01:55:16.140 spondy. Okay. Here is the program to try and get there. You might make it. What about nerve pain?

01:55:22.780 What about patients who are either having weakness, such as a foot drop or significant pain, like the pain

01:55:31.080 I had? We have them all the time. If I can get the nerve pain to move on the assessment,

01:55:37.080 please don't have surgery. Let us have a try at it. Most of the time, they will be pleased.

01:55:42.860 Wow. We have to play with certain rules.

01:55:46.020 Give me an example of some of those. So let's say your assessment comes out that

01:55:49.480 this person who's having intermittent sciatic pain, and you do an assessment and you say, look,

01:55:55.260 there is no doubt that you have a ruptured annulus here. You've got a protruding

01:56:01.640 segment of disc, and it is clearly at times, depending on your activity, getting nearer to

01:56:07.980 the nerve root. It's driving that sciatic pain. But during your assessment, I assume what you're

01:56:11.980 getting at is through some of those positional things, such as laying the person on their front,

01:56:16.580 manipulating the legs, getting the herniation to retreat into the annulus. So you're saying if you

01:56:21.980 can demonstrate resolution under a changing movement pattern, that gives you enough confidence

01:56:28.460 that this doesn't need to be removed surgically. Not resolution. Can I move the pain a little bit?

01:56:34.300 Can I make it worse? And can I make it better? Now I'm starting to understand the variables that

01:56:39.600 make it worse, make it better. And I play with those. I'm trying not to sound boastful. I'm trying

01:56:44.860 to be scientific here. There was a day not that long ago, I'm losing track of time. It was probably

01:56:51.600 well, it was the NHL playoffs. So there's our time marker. I don't watch TV really, but for some dumb

01:56:58.080 reason, it was Saturday. I flipped on the TV. It was the NHL playoffs. And I listened to the announcer,

01:57:05.680 the name. Oh, that's my patient. Next player, my patient. Two of my patients are now in the NHL

01:57:13.000 playoff series. A little bit later, I flip over to TSN tennis tour. I look at that, my patient.

01:57:23.000 And then that night, the UFC comes on. There's my patient again. So in one day, I see three different

01:57:30.780 pro sports. Every single one of them had sciatica when they came to me. That's some evidence that I

01:57:36.960 can offer. Now, I remember one of those players in the NHL, if he fully flexed, he would stir up

01:57:45.920 sciatica and increase the risk of a full-blown acute attack, as you and I know very well. So we got him

01:57:53.640 to move well. He played hockey, mindful of a skating style that he didn't get too flexed up. We didn't

01:58:02.140 allow him to tie his own skates. He said, tying my own skates really set my back up. I said, good.

01:58:10.480 Now, NHL players are very particular how they tie their skates, but they coached one of the training

01:58:15.940 staff to tie his skates for him. Now, I know some people will laugh at that, but that was all part of

01:58:21.900 the plan to keep the capacity as high as he could to utilize in the game. How he sat on the bench was

01:58:31.440 also instructed. The fellow in the UFC, this is no slouch. Jiu-jitsu really put his spine in a place

01:58:43.500 where it could fire off an acute attack. You do not want to be in the cage fighting for your life

01:58:49.500 and having an acute attack. That's the last thing you want. We would limit the mat time on jiu-jitsu.

01:58:56.640 He would do stand-up, all kinds of things to minimize the accumulative stress on the disc bulge

01:59:05.420 causing sciatica. He competed. I wish I could tell you who he was and what he did that night.

01:59:11.240 So, I'm not afraid of nerve irritation, sciatica, etc. And it certainly doesn't fall into the category

01:59:20.480 of you need surgery. We've proven that far too many times. But as I said, heavy instability. And when

01:59:28.960 we fail to arrest the shearing movements, trapping nerves, it's gone on for quite a time. We can't

01:59:37.560 hack our way around it. It's best to see a surgeon, a stenosis.

01:59:42.040 Yeah. And stenosis as well.

01:59:44.400 Yeah. And it's many, many different forms. Central stenosis. It might be a foraminal stenosis and a

01:59:51.820 bit of arthritic activity where they can just basically take a Dremel tool to describe it for

01:59:56.720 your audience and burr out around the foramen or the hole that the lateral nerve comes out.

02:00:03.000 Another one is, I know a lot of our medical colleagues say, well, a Tarloff cyst, a neural

02:00:08.380 cyst. Well, they don't cause pain. Really? I will prove to you very quickly whether or not that's

02:00:14.800 causing pain by pulling the nerve root one way or the other. Typical pattern recognition might be a

02:00:21.680 physio might do a slump test, which is you straighten one leg and you flex the spine and neck. But the net

02:00:27.960 stress in the middle of the cord is zero. You're pulling it one way, you're pulling it the other way.

02:00:34.300 It just goes into a little bit of tension. If that's a Tarloff cyst, that won't be triggered.

02:00:39.680 A Tarloff cyst doesn't like being pulled one way. So that patient on exam might say, well, I don't get

02:00:45.240 pain with a slump test, but I can't stand driving my car. Oh, tell me about your car. Well, I sit

02:00:52.160 upright, put my head back and extend my leg to push on the accelerator. You're pulling the nerve root

02:00:57.760 one way. Where's the pain? It's in my big toe. Aha. I am now going to inform my inspection of the MRI

02:01:07.980 because the radiologists missed it. They're not going to find a Tarloff cyst distal on the fifth

02:01:12.140 root. But I know that the symptom and the assessment took me there logically to say,

02:01:17.540 I know there's something hanging up there that's directionally specific. It's not a friction.

02:01:22.180 It's a direction specific tension. There's the Tarloff cyst. I found it. Now, boy, what's the

02:01:30.660 surgical procedure there? Typically, they'll try and drain the cyst and it comes right back again.

02:01:35.680 Typically. But there's a doc in Dallas who we send all our Tarloff cyst patients to. And he has a

02:01:43.740 reasonable rate, at least better than anyone else in dealing with those pesky cysts. Bit of an off the

02:01:50.100 wall. I can't do a damn thing about that cyst. It's eroding the bone. They're pesky little things,

02:01:56.540 but here's a surgical referral. That's great. Stuart, how often,

02:02:01.320 if you're doing a two-hour assessment on a patient, I assume you're also looking at an MRI.

02:02:06.160 Let me stop that. After the first year of the experimental research clinic running two years,

02:02:12.540 I changed it to a three-hour consult. Wow.

02:02:15.500 Yeah. I needed even more time. So now, if they're an old athlete and they still have

02:02:21.780 films on the film, remember how we used to get MRIs? I read them on the reader. I put them up

02:02:27.640 on the screen there. So yeah, no, full medical images we go through.

02:02:31.800 What are the things you're looking for in the MRI that maybe aren't as readily apparent? In other words,

02:02:38.880 what are you looking at in an MRI that isn't obvious to the radiologist? Because presumably,

02:02:43.340 yeah, you can maybe explain to somebody what the MRIs are showing, but you're getting axial cuts.

02:02:48.760 You're getting coronal and sagittal cuts. They're T1-weighted. They're T2-weighted. So

02:02:54.220 they highlight the disc. A nice, healthy disc looks white on the MRI. Of course, mine are jet black.

02:03:00.880 What are things you're picking up on that MRI read? Well, all of the things that you've mentioned.

02:03:07.640 I don't know if you looked at my CV and the number of papers and the topics that we covered over

02:03:12.540 the years. But the very last study that I ever published as a professor was exactly that. And we

02:03:19.280 took a cohort of whiplash patients. I didn't do very much cervical spine-specific work. Most of mine

02:03:26.480 was lumbar. But just to answer your question, we took whiplash patients. Every single one of them

02:03:33.380 had been denied compensation because they're now more than two years post-whiplash. They still

02:03:40.000 continue to have symptoms. The medical profession and the legal system was declaring them pain

02:03:47.020 magnifiers. They were exacerbating their pain for financial gain. Terrible. The MRs said,

02:03:56.680 there's no reason for your pain. Really? The MR is a static picture. What do you expect?

02:04:03.240 So we took video fluoroscopy, which you know is a real-time moving x-ray. So we're watching the bones

02:04:09.120 move now. And we would have them move through their pain. And their pain wasn't very rarely at the end

02:04:16.160 range of motion. It was actually somewhere in the middle of the range. And they would move their head

02:04:20.500 like this. And then the spine would clunk. And then they'd go, oh! And then they'd continue to move

02:04:26.920 through. On the video fluoroscopy, we'd watch the rotations occurring between every vertebra. But we know

02:04:33.680 what instability is. It's when the rotation stops and the shear begins. So the ratio of rotation and

02:04:41.720 shear is the marker of that cervical instability. So if I can just show with my hands, here would be the

02:04:49.920 neck moving, rotating well, and then it would clunk. It was the clunk that corresponded 100% with

02:04:57.400 a shot of pain. Now, you and I both know that when a muscle contracts, it does two things. It creates

02:05:04.240 force, but it also creates stiffness. The body uses stiffness to control motion. Okay. So if you just

02:05:13.400 want to observe me now, and you can play along and do this if you like, I want you to lightly stack your

02:05:19.380 ears over your shoulders and have a pitch to your head that's neutral. Stare straight ahead. Now,

02:05:27.380 lightly touch yourself under your jaw, just above your Adam's apple. Don't retract. You're too stiff

02:05:34.520 feet. Relax. Now, push your tongue hard to the roof of the mouth behind your front teeth. You felt the deep

02:05:41.640 flexors. Activate. Now, corners of your mouth grimace down. Do this to your neck. Now, keep that.

02:05:50.380 Imagine the person who's rotating and then has the clunk. Keep that, controlling stiffness, and repeat

02:05:56.780 the offensive movement. Would you believe in most people the clunk was arrested? It was gone. Proving

02:06:04.140 that the MR had no ability to pick up that dynamic pain trigger. We just proved what their pain trigger

02:06:12.520 was. You can imagine the psychological relief that they had to know that it isn't in their head.

02:06:18.920 The medical profession was wrong. And finally, they're empowered now because they have a strategy

02:06:25.160 to start learning just a little bit of a strategy to take the clunk out. If you arrest the clunk over time,

02:06:34.080 the joint will stiffen. The bad news is you don't move so well through that joint. The good news is the

02:06:40.140 pain clunk is gone. So, we all experience this, and you're going to be experiencing this now over the next

02:06:46.780 15 years, particularly. If you're in your early 50s, things are going to be stiffening in your body. The good

02:06:54.440 news is your pain will go. You know who really gets this? I've worked with a couple of former Mr. Olympians.

02:07:03.380 That's the top professional level of bodybuilding. They put a lot of mileage on their joints.

02:07:09.820 They don't really get joint pain when they're competing because the muscles are so big, so bulky.

02:07:15.800 They have enormous wrench handle moment arms, and the stiffness holds the joints together.

02:07:22.860 When we work with them, it's tapering down back to civilian life. Some of them don't look that

02:07:29.920 different than you and me. Believe it or not, what they look like in their former glory,

02:07:35.220 they ache like hell. All their joints have these shearing translations to them now.

02:07:40.200 So, the cure is getting a little bit of the muscle bulk back to add some controlling stiffness and all

02:07:49.620 their aches go away. Anyway, these are all sort of fun stories. I don't know if that's really

02:07:56.840 answered your question on instability, sciatica, brachial plexus nerve traps, numb thumb and first

02:08:06.440 finger. Whatever. They're not indicators for surgery at all. Try some of these voluntary

02:08:13.180 skills and let nature take its course. Most of the time, and I can with confidence prove it and say

02:08:23.520 most of the time, it will work out well with some patience and skill.

02:08:28.000 One of the really good spine surgeons I know, and you can always tell a great surgeon by talking to

02:08:34.460 them, and maybe I'm fortunate because having trained as a surgeon, you sort of learn what

02:08:39.740 the signs are of the hacks and the good ones. And as we can all attest to in our own respective

02:08:45.300 profession, we're pretty good at picking up who the good ones are and the bad ones are. But

02:08:49.600 speaking to this spine surgeon, it's just really clear she's a really good surgeon. And one of the

02:08:55.680 signs of a really good surgeon is a surgeon who's really happy to not operate. The really good

02:09:01.800 surgeons are really happy to not operate on somebody. Partly what makes them so good is their

02:09:07.140 judgment. It's their knowing who to operate on and who not to. We did a really fun exercise one day

02:09:13.200 where we went through my MRI. Every time I get an MRI for another reason, if it's going to get any sort

02:09:18.880 of back cut, I just send it to her, even if it's not a dedicated spine MRI. And I say, what do you

02:09:23.080 think of this? Does it look any worse? And again, we're always collectively amazed at how bad my

02:09:29.220 spine looks on MRI relative to the fact that I don't have any symptoms. One of the discussions we

02:09:34.560 had prompted her to contrast my back with that of another patient she had who has no obvious disc

02:09:43.280 pathology and yet is in debilitating pain. And she said, look at the difference. And again,

02:09:51.120 I'm not saying this to be boastful, but I'm just trying to make the contrast. She goes, look at the

02:09:54.580 difference in the musculature of your psoas, your QL, your erector spinae. Like these are big beefy

02:10:01.660 muscles here. And now compare it to this other patient. First of all, the muscles are about half

02:10:06.900 the size and they look like Wagyu. They're very fatty. And the way she was explaining it to me,

02:10:12.480 she goes, this is a person who's never lifted anything in their life and they don't have any of the

02:10:17.800 disc pain. Their discs haven't been decimated like yours have, but they're more debilitated.

02:10:24.560 Their inactivity has led to instability and tremendous pain. You've already sort of alluded

02:10:30.680 to this where we've agreed that the deadlift till you drop strategy and the do nothing strategy are

02:10:36.180 both bad. But can you speak a little bit to why that person might be in pain? Because what I don't

02:10:41.320 want anybody to come away from this podcast feeling is, oh, I better not lift weights because that's

02:10:46.360 clearly the wrong message. A hundred percent. Okay. I'm so glad you brought this up. I would

02:10:52.700 love to talk to her and I'd say, tell me about your training program or your daily routine or your life

02:10:58.540 in physical terms. I will bet she's a mobility monster. She keeps pushing the end range,

02:11:05.980 softening the joints even more. So on MRI, they look plump and pristine. I bet if we put her under load

02:11:13.040 or we put her in bed and she had this instability that I've showed earlier and she lays in bed and

02:11:20.500 the joints just fall like that a little bit, she'll get a hell of an ache to her back. My first question

02:11:26.180 would be, when you roll over in bed, do you ever have a sharp pain? That's a beautiful follow-up

02:11:32.640 question. It is so indicative of if she has nice plump discs, but micro movements. How many pillows do you

02:11:41.460 go to bed with at night? That is a wonderfully telling question. The more the pillows, the more

02:11:47.560 the joint instability. It's quite high correlate. Anyway, I'd love to have that conversation with

02:11:55.080 her and I will bet we will get some real insight from that versus the person who has a mature strength

02:12:05.740 history and the joints are held together. A little bit of arthritis and people are going to nail me for

02:12:13.000 this one, but a little bit of arthritis is good for adding certain amount of joint stability and

02:12:20.100 holding it all together. I had a fracture of C4 as a young fellow. Oh, I would have some terrible

02:12:28.240 episodes checking my blind spot or craning my neck to back a trailer up or something. I have zero pain

02:12:35.440 now. My neck is bulletproof again. It looks horrible on a CT or an MR, but my point is the

02:12:42.700 arthritis has now stabilized the joint. All the pain's gone. I don't move it very well, but I don't

02:12:50.380 worry about it. My sister's a vet. She sends me x-rays of a dog. Terrible. As you know, spine arthritis

02:12:58.620 and nerve compromise in dogs, which is very breed specific as well, they lose their hind end. It

02:13:07.000 just atrophies just like in a person. But anyway, she'll send me this x-ray of a dog. She says, what

02:13:11.980 do you think this dog's doing right now? And I said, well, it's just laying in its bed. She goes, no,

02:13:16.720 that just won the Frisbee championship, the Frisbee catching championships. So again, I just keep coming

02:13:24.520 back to the assessment. And between you and I, I don't ever want to see another MRI of my spine

02:13:30.460 until the pattern doesn't fit and I can't move the pain anymore. Only time I ever want to see an MR of

02:13:37.840 my own back. I'm like you. Doesn't look so good. However, I've got a few miles on my back and I'm

02:13:45.400 the person I am today. Because of that, I do everything I want to do with certain guidelines.

02:13:53.140 I'm not 16 and I don't have infinite capacity. So I play with that tipping point all the time.

02:14:00.700 What would you say to the person who's watching or listening to us right now? And I realize

02:14:05.460 that there's a pretty good chance that by now, because we're a couple hours into this podcast,

02:14:10.580 if you have never experienced back pain, you might not be listening anymore. Because the truth of it is,

02:14:16.420 there's going to be a lot of people listening because if you've experienced back pain, especially if

02:14:20.980 it's happened more than once or if it lasted more than a week or so, this is a riveting discussion.

02:14:26.980 But if you were talking to a person of any age who had yet to experience it, but in particular,

02:14:33.660 maybe a young person, someone in their 20s or 30s, what would you say to them? And how would you

02:14:40.100 counsel them with respect to what they could do to maximize the longevity of their spine?

02:14:46.600 What a fabulous question. If I was to say to you, a young fella comes into your office with a cigarette

02:14:54.440 hanging out of his mouth, what would you say to him that he hasn't already heard? I would love to

02:15:02.940 take you over to the cancer ward at the hospital. And I want to show you how your last days are going to

02:15:10.000 look. That might convince a few of them on the lunacy of what they're doing to themselves.

02:15:18.460 It won't be 100% effective. And I would hazard a guess it wouldn't be close to 100%. Their friends

02:15:24.540 and peer pressure is far more important for them now. That's how I'm going to answer the question

02:15:29.580 you just asked of me. I don't have very good luck when I see someone who's just all balled up.

02:15:36.620 A kid called me, not a kid, a 30-year-old called me last week. This guy was all balled up like this.

02:15:43.400 And he said, oh, he says, whenever I do exercise, I'm just exhausted. I said, oh, yeah. I said,

02:15:50.740 would you move away from your desk a little bit? And would you ask someone to come in and hold your

02:15:55.400 cell phone up so I can see all of you? And there he was. And I said, all right, would you now sit at

02:16:01.600 your stool, your chair, sit upright for me? Do you have pain? And he goes, no. And I said, good.

02:16:08.460 Drop your chest down and slouch and lower your head. Do you have pain? He says, yeah, I do.

02:16:13.960 Now, don't you think I just proved to him what caused his pain? He said, well, I've heard that

02:16:19.420 before. I've sat like a cashew. And that was his exact words since I was 14. I coached him. Okay,

02:16:26.200 sit up, lay on your tummy for a little bit. Let this thing calm down. By the way, what do you do when

02:16:31.280 you get up in the morning? Well, I go down and I get a coffee. And I said, how do you get to work?

02:16:35.700 He says, I drive. And I said, tomorrow, I want you to get up half an hour early and go for a walk.

02:16:41.560 And it was snowing here. So I said, it's snowing outside. You live in LA, get your, you know what,

02:16:46.860 out of bed and go for a walk for half an hour tomorrow morning before you get in your car.

02:16:51.080 Do you know he was bucking me on that? So to your point, I don't think I changed his behavior one

02:16:58.700 little bit. And he's going to have to suffer a little bit more before he comes to a realization

02:17:05.540 that he does have the power to do something. And I know your thesis loud and clear in Outlive.

02:17:16.640 We're identical. We're trying to get people on a program now when he's 30 and not wait to have

02:17:25.560 more misery and more misery. It's so hard to motivate someone. Maybe you have a hint for me.

02:17:33.560 I share your sentiment exactly. And that's why I've often referred to that third bout of back pain

02:17:42.560 that I had, the one that lasted for a year as the best worst experience of my life. It was the worst

02:17:48.740 experience in that I wouldn't wish that duration or depth of pain on anyone. But what was so good

02:17:57.340 about it is that it lasted for so long that it created a lifelong change in behavior and an

02:18:05.460 appreciation for something, which is without that experience, this idea of a centenarian decathlon

02:18:11.540 wouldn't exist. Because you have to sort of see what a life looks like with immobility and pain.

02:18:19.420 Because even though I was only 27, I lived that year as though I was 87. And a year is long enough

02:18:26.540 that it imprints. If it was only a week, no matter how bad it is, I don't think it would have imprinted.

02:18:32.080 But a year of that really imprinted in me. I've said this before many times, but to this day, I still

02:18:39.300 enjoy parking as far away as possible in the parking lot, even if there are plenty of spots close to the

02:18:46.000 grocery store or wherever, because I remember what it was like to not be able to walk from the car to

02:18:52.900 the grocery store. So unfortunately, that's probably the nature of our species in that it's very

02:18:59.900 difficult to make a short-term sacrifice for a long-term objective without a more pressing reason.

02:19:10.300 So instead, I'll turn my attention to who I think is the larger population listening to us,

02:19:16.060 which are the people who have experienced either personally or through watching someone they care

02:19:21.940 about, perhaps. Let's start with this. What are the best online resources we can point people to

02:19:29.500 that can help with the types of exercises, maybe some do's and don'ts around lower back pain?

02:19:39.000 I love that you even clarified around the big three, which is, hey, the big three are great if

02:19:44.280 you need stability, but if you need mobility, we might need some different exercise. So how can people

02:19:48.620 sort of navigate their way through that? I challenged myself with exactly the same issue

02:19:56.080 15 years ago, just as the internet was getting going. But here's the thing. There is no such thing

02:20:04.800 as nonspecific back pain. And if that's what the person operates on in their strategy, this nonspecific

02:20:12.440 thing, it will only be dumb luck if they're able to come up with a strategy to mitigate it.

02:20:19.460 They have to have an assessment. Well, they can go and see someone who is very knowledgeable

02:20:24.840 in converging on an understanding of their pain most of the time. Well, short of that,

02:20:32.420 I wrote back mechanic. Now, it's not on the internet. And the reason is they have to have some background

02:20:39.080 understanding of how their back works and then go through a series of self-tests. That's what the book

02:20:45.740 does. The first thing is it just says, draw a table. What are activities that cause you pain?

02:20:51.820 What are activities that either take your pain away or are neutral? Write them all out. Now, here is how

02:20:58.280 you pattern recognize those. All of those activities involve you bending backwards. Guess what? Change a

02:21:06.400 light bulb overhead, that triggers your pain. We're starting to learn a little bit about what

02:21:10.460 could the candidates be. Then we take them through some physical tests, sit on a chair, slouch,

02:21:16.520 extend, drop one shoulder back, hold five pounds out at front with arms straight. So that's a compression

02:21:22.140 test. Then we do a few self-sheer tests. Then we do some nerve tensioning postures to start converging

02:21:30.660 on subcategories of their pain. Then we say, if you have this subcategory, let's do a real simple one.

02:21:38.520 You get pain when you sit in front of your computer going for a walk is relieving. The next person

02:21:44.380 sitting in the computer is their relief and they go for a walk and that causes their pain. Probably

02:21:49.200 more in the stenosis, older person kind of category. The other one is a younger dynamic disc bulge. Okay,

02:21:55.780 sit with a lumbar support, number one. Number two, we are now going to have a strategic exercise session.

02:22:04.380 You're going to do it every day. You're going to do the big three. We'll mobilize the hips.

02:22:09.640 You're not going to sit longer than an hour at your computer. You just cannot reach a stage of

02:22:15.140 sufficient health if you continue with that behavior, etc. So that's why you won't find it

02:22:21.740 on the internet. You're going to find a lot of people who do not have the expertise. Oh, here's the

02:22:27.520 quick fix for your back pain. Well, good luck with that. So that's my answer to your question

02:22:33.940 and the solution. And just going back to listening to you as you started to answer that question,

02:22:41.760 I've got a little bit of good news for you in terms of your own back. And by the way,

02:22:46.520 I know who I'm talking to. So I know you get this, but this is for the listenership.

02:22:50.700 I retired early. I retired when I was 60. I reached a stage where I realized what my job was.

02:23:01.600 I started as a professor in 1986. Student meetings meant students came to see you and we would get

02:23:09.540 up and we'd work through things and we'd do things in the laboratory and whatnot. And then the students

02:23:13.880 started to migrate to this idea, oh, sir, could we have an online call for student hours? No, you can't.

02:23:19.280 You get down here and we're going to work through this problem. In other words, my job got turned

02:23:24.640 into a sitting job and it was killing me. And I realized that my health was declining. My fitness

02:23:32.400 was declining. I still walked to the university. I strategically bought a home right on the edge of

02:23:37.280 campus. So I would have a 20-minute walk to and from my office and laboratory. Still, I was

02:23:44.660 declining. So I walked away. I shut the door in my office. I said to the graduate students,

02:23:51.400 there's all my books. Go take them. To all the other professors, there's my lab. Go take it.

02:23:57.620 And I just walked away, never thinking that anyone would ever ask me again because I'm not producing

02:24:01.980 new data anymore. I was sort of wrong on that estimate. But anyway, my point is, Peter,

02:24:07.020 I'm healthier now than I ever was in the latter 15 years of my computerized work life. I hardly go on

02:24:16.900 the computer. It's fabulous. I can talk about my life now if you want and what I do. But my point in

02:24:24.720 this story is, I think you're going to look forward to a resurgence of your health. Maybe you've got it

02:24:31.640 dialed in with your seeing patients and traveling and everything else. Maybe you don't. But trust me,

02:24:37.240 when you retire, and that doesn't mean leaving your whole medical family and expertise. I mean,

02:24:45.380 I'm sort of working right now. I still see patients two days a week. It's a wonderful marker for my

02:24:51.700 week. I love it. But the other five days, I live a healthy life. Anyway, my point in all of that is

02:24:57.900 things are going to get really better for you. They're not going to decline more. I've heard you

02:25:03.220 say that. And I think, Pete, come over with me, man. Spend a couple of days and you'll see how

02:25:09.220 you're not on this decline as you think is a fait accompli.

02:25:14.140 You just said something a moment ago that I was going to ask you about. So

02:25:16.640 at the risk of overwhelming you, because I know that there are going to be so many people listening

02:25:22.300 to us who are going to say, you know what? I am not happy with the assessment or lack thereof that

02:25:28.920 I've received. I'm not happy with the care that I'm receiving with respect to my lower back injury.

02:25:36.080 I need to go and see Dr. McGill. What is involved in arranging that type of a consultation with you?

02:25:43.600 I feel awkward saying this, but that's why I wrote back mechanic. So I don't see anybody until

02:25:50.280 they've read the book. Most of them say, I don't need to see you now. So they've been through the

02:25:55.900 self-assessment. They've got enough out of it. Now, if they're not getting enough out of it,

02:26:00.440 on our website, backfitpro.com, we have two layers of clinicians. We have the certified clinicians who've

02:26:09.240 taken that 50-hour course. They've gone through the hands-on skills training. They've written the exam,

02:26:15.620 but I've never worked with them personally. But they are all there on a page. Then we have a

02:26:21.160 different level called master clinicians. I have worked with every single one of those people

02:26:26.140 and trained them. I've seen patients with them. They have my confidence now that I can send them

02:26:32.660 any patient and they will subcategorize them and know pretty well what to do with them.

02:26:38.360 I continue to train those individuals. I seek out stars or people who have the passion and the skill

02:26:47.900 and I go to them and say, would you now study with me? And I'd like you to become one of our

02:26:54.620 master clinicians. How many master clinicians are there in North America, Stuart?

02:26:58.580 Not many. I don't know. A dozen, 15, maybe something like that.

02:27:02.320 But they're all identifiable on the website, which was backfitpro.com?

02:27:07.560 Correct. And the certified, that's growing all the time. There's maybe 30 or 40 of them.

02:27:13.780 We add to that every couple of months.

02:27:17.080 Okay.

02:27:17.800 I think people in reading that book, it's quite a quick read. It was a very difficult book to write.

02:27:24.360 As you can imagine, I've written my medical textbooks for my medical colleagues. Those are easy to write.

02:27:30.660 You put in the references, you make your points, you show the strength of evidence, etc.

02:27:34.980 But you can't do that with the public. You have to give them enough of the truth to guide

02:27:43.060 a effective strategy, but you can't overwhelm them with jargon and all of that. So that's why

02:27:49.800 those things are so difficult to write. But people tell me that back mechanic in any case,

02:27:55.200 I sent you a copy. I hope you got it.

02:27:57.300 Not only got it, I greatly appreciated the inscription in it. Thank you.

02:28:01.380 Oh, yeah. Okay. That was special. Heartfelt. In any case, that is my solution to that conundrum.

02:28:11.960 And that's why going to the internet, as you know, it's the Wild West. You can get screwed up as much

02:28:17.240 as you can be helped.

02:28:18.800 Well, Stuart, this has been a really enlightening discussion for me. And given how much I've

02:28:25.900 thought about this topic, I think that says something. But it tells me that more than anything

02:28:30.800 else, a lot of people listening to this, which again, I think is a lot of people who can relate

02:28:35.300 to what we're talking about personally. I think this, I hope, offers more than just a glimmer of hope

02:28:40.740 and also a set of resources that people can look to. And I will take you up on this offer.

02:28:45.540 The next time I'm in Toronto, we'll make that trip up to Gravenhurst. Apologies for my poor

02:28:52.260 Canadian geography. I always thought Gravenhurst was just outside of Toronto. I didn't realize

02:28:56.780 it was that far North. Yeah. Huntsville, Bracebridge, Gravenhurst, if you know that area,

02:29:01.920 right in the heart of Muskoka. Yeah. So just from like Aurora, we're talking like what,

02:29:07.840 90 minutes, two hours? No, about an hour and an hour and a half North of Aurora.

02:29:12.940 Okay. Yeah. All right. Well, we'll make that happen.

02:29:17.260 Okay. Well, I hope so. Peter, I've looked forward to this day ever since we scheduled it a couple

02:29:23.640 of months ago. The leadership that you've provided is fabulous. I've spent many hours listening to

02:29:31.820 your podcasts and getting wisdom from your guests. And the level that you take all these issues to

02:29:38.300 is just the foundation I need for a lot of the things that I think about. For all you do,

02:29:47.720 thank you so much. The way you posed your questions today were not really typical. So I appreciate that

02:29:54.200 very much. But again, thanks for all you do. Well, thank you for what you do, because that's

02:29:59.060 where I'm learning today. So thank you, Stuart. Okay. My pleasure.

02:30:02.920 Thank you for listening to this week's episode of The Drive. Head over to peteratiamd.com forward slash

02:30:10.940 show notes. If you want to dig deeper into this episode, you can also find me on YouTube,

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02:31:14.400 and active list of all disclosures.

The Peter Attia Drive - September 01, 2025

Lower back pain： causes, treatment, and prevention of lower back injuries and pain ｜ Stuart McGill, Ph.D. (#287 rebroadcast)

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