Lower back pain: causes, treatment, and prevention of lower back injuries and pain | Stuart McGill, Ph.D. (#287 rebroadcast)

Stuart McGill discusses the complexity and importance of spinal health, providing insights into the spine's flexible nature and its role in movement and force transmission.

Spine: Flexible, Stable, Enables Movement and Force Transmission

Spinal Vertebrae Separated by Shock-Absorbing Discs

McGill elaborates that the spine is a series of vertebrae, likening it to a flexible rod that allows us to move and perform actions such as dancing or tying shoes. Each vertebra is separated by shock-absorbing discs, which McGill describes as biological fabrics that shape the spine by offering both flexibility and stiffness.

Facet Joints Guide Spine's Motion Range

Facet joints extend from each vertebra, guiding the range of motion during flexing, extending, and twisting. These joints provide motion guidance and can bear increased load and become thicker over time following a major disc injury, signifying altered spine biomechanics.

Spinal Stability Is Achieved Through Balancing Flexibility and Stiffness Enabled by the Interplay of Muscles, Ligaments, and Other Soft Tissues

McGill highlights that spinal stability is a balance between flexibility and stiffness, where muscles, ligaments, and soft tissues play a crucial role. The spine can stiffen to bear loads, such as picking up a child, and must maintain healthy end plates to ensure long-term mobility.

McGill also explains that concentric rings of collagen in the discs hold a pressurized gel, creating a hydraulic pressure that contributes to stability and function. He notes the spine's special design and the evolutionary efficiency that minimizes the need for more extensive musculature.

Understanding and Maintaining Spinal Health

McGill stresses the importance of spine health, likening the attention to end plate care to the care of knee ligaments, which are vital for later life mobility. He warns that repetitive heavy loading can damage the spine over time, as discussed with Peter Attia, who mentions his own experience with a disc fragment injury.

McGill describes the spine as akin to a willow branch, designed for bending but not compression, and illustrates how the spine adapts differently to various physical activities, such as deadlifting versus yoga. He contrasts deadlifters' adaptation leading to posterior disc bulges with yogis adapting for more flexibility, which may cause the front of the disc to buckle under compression.

The Role of Discs and Facet Joints in Spinal Adaptation and Injury

Individuals may experience disc damage that allows for the ingrowth of nerve and vascular tissues, leading to increased pain capacity. McGill de ...

The importance of a truly individualized assessment to identify the root cause of low back pain is a key point emphasized by spine biomechanist Stuart McGill and reflected upon by Peter Attia through personal experience.

No "Non-specific" Low Back Pain: Individualized Assessment Crucial to Identify Root Cause

Stuart McGill, a world-renowned spine biomechanist, asserts that there is no such thing as non-specific low back pain, and a detailed, individualized assessment is essential before any therapy can begin. He suggests mapping out movement triggers like prolonged sitting, flexion, sheer, and heavy lifting to guide rehabilitation effectively.

Peter Attia reflects on his personal struggles with lower back pain and his surprise at experiencing it, despite being active, diverging from his belief that it solely afflicted inactive individuals. Likewise, McGill states that he expects to find facet joint thickening in an MRI at the level of a disc bulge, thereby underscoring the need to correlate specific spinal changes with the cause of back pain.

Assessing Pain Triggers and Patterns via Physical Examination

McGill shares a teaching anecdote about an elderly European woman with a defeated posture, illustrating the psychological aspect of back pain. Her fear of becoming unsteady and potentially having to leave her home and cat behind if she fell was alleviated when McGill coached her through a movement pattern to stand from a seated position—showcasing the impact of individualized coaching and assessment.

In his experimental research clinic, McGill sets aside two hours to assess the back injury mechanism of each patient, evaluating their sheer tolerance, compression, and pulling of nerve roots. He also considers everyday micro-movements in the joints as a possible cause of pain and explores how a patient's lifestyle could contribute to their discomfort. For instance, the sharp pain experienced while rolling over in bed can indicate instability in healthy discs which can be linked to the number of pillows used at night.

McGill stresses the significance of understanding an individual's experience of back pain, such as examining posture changes and assessing which activities worsen or relieve pain. By guiding a 30-year-old man through an assessment over the phone, he demonstrates the value of recognizing specific activities that cause pain and those that provide relief.

Imaging Tests Show Changes, Severity May Not Match Symptoms

Peter Attia discusses the discrepancy between imaging and symptoms—despite MRI appearances suggesting severe pain, his actual experience does not corroborate this. A free fragment's pressure on the S1 nerve root was assumed to be the culprit behind Attia's extreme pain, highlighting that while imaging helps diagnose specific causes, the severity shown may not align with symptoms.

McGill explains how tracking the changes in facet joints after a disc injury is crucial, as symptoms differ in presentation, with facet pain typically emerging as a gradual ache. He further discusses the complexity of potential back pain causes, such as the presence of nerve roots and the termination of the spinal cord around L2, which signifies that herniation-related pain doesn’t u ...

Conservative treatment strategies for back pain typically involve specific exercises crafted to restore core stability without overloading the spine. These exercises adapt to different individuals for maximal benefit.

"Mcgill Big Three" Exercises Restore Core Stability

The “McGill Big Three” exercises formulated by Stuart McGill, which include the modified curl-up, side plank, and bird dog, have been recognized as effective protocols for relieving lower back pain and enhancing performance when scaled appropriately.

Exercises Boost Proximal Stiffness and Force Without Overloading the Spine

McGill's research underlines the importance of developing proximal stiffness to achieve efficient force transmission, which enhances athletic power and prevents injuries. Through the application of isometric holds seen in these exercises, subjects have experienced increased core stiffness, with benefits ranging from reduced pain to enhanced performance in athletic activities.

Tailoring Exercise Scaling and Progression Maximizes Individual Benefits

Tailored adjustments to exercises are crucial in building muscular control and stiffness around affected joints. McGill elaborates on the need to personalize exercises and activities to accommodate each individual's unique conditions, preventing exacerbation of symptoms like sciatica or back pain. Even daily habits are adju ...

Peter Attia's experience with nerve compression and the discussions with Stuart McGill reveal the nuanced approach toward surgery, emphasizing its role as a last resort and the importance of careful patient selection.

Surgery as Last Resort For Nerve Compression or Spinal Instability

Clinicians Manage Back Pain Conservatively, Avoiding Invasive Interventions

A conservative approach to managing back pain is preferred before resorting to surgery. McGill emphasizes non-invasive interventions like exercises and muscular control. During a follow-up, McGill mentions that 95% of patients advised to undergo surgery were able to avoid it by mimicking post-surgical behavior through a regimented approach to rest and gradual activity resumption, which is referred to as "virtual surgery."

Attia's discussion about his path to recovery, which included two surgeries leading to further damage requiring more repair, underlines the importance of caution before surgical treatment. Similarly, McGill explains that conditions like sciatica and nerve irritation are often managed conservatively and do not necessarily warrant surgical intervention.

Selecting Patients Carefully Is Critical for Surgical Treatment Benefits

McGill implies that careful patient selection for surgery is vital, with many cases resolving without surgery through desensitizing pain mechanisms and retuning the body with strategic mobility, stability, and movement skills. He also indicates that if he can get the nerve pain to move during the assessment, he usually advises against surgery. This cautio ...

Chronic Back Pain's Psychological Impact: Depression, Anxiety, Helplessness

Chronic back pain has profound psychological effects, potentially leading to depression, anxiety, and feelings of helplessness. Kaya Henderson, Myles E. Johnson, and DeRay Mckesson delve into these effects, probing the implications for those who consistently experience severe back pain.

Crucial for Long-Term Management: Education, Counseling, and Empowerment

Stuart McGill and Peter Attia discuss the necessity for patients to understand the mechanisms of their pain and to engage proactively in their care. They suggest that patient outcomes improve when individuals are informed and empowered. For instance, McGill mentions a patient whose psyche changed dramatically for the better upon grasping the mechanism behind his pain, thus feeling more in command of his condition.

Clinicians also experience emotional responses sharing in their patients' breakthroughs, demonstrating the deep interconnection between understanding one's condition and improving psychological health.

Empowering Patients to Understand Pain Mechanisms and Actively Engage In Their Care Improves Outcomes

McGill emphasizes the importance of educating patients about their spine mechanics and individual injury impacts to empower them towards better pain management. McGill's approach, through his course at BackFitPro and his book "Back Mechanic," equips both clinicians and patients with the knowledge to manage chronic back pain effectively.

For patients like the one who after years of pain, finally experienced relief by applying the strategies provided in "Back Mechanic," the educational aspect proves transformative. A two-year follow-up at an experimental research clinic showed that the vast majority of the treated patients managed to avoid surgery and vastly improve their quality of life, indicating the success of empowerment strategies.

McGill shares stories that highlight the psychological impact when patients understand the physical cause of their pain and are given the tools to manage it. For example, patients with whiplash who were previo ...