Exploring the Root Causes of Chronic Back Pain and What to Do About It with Dr. Stuart McGill

This episode focuses on understanding the underlying causes of chronic back pain, debunking common myths, and exploring strategies for prevention and treatment.

1. Prevalence of Back Pain: A significant portion of the population will experience chronic back pain, often due to lifestyle and occupational factors.
2. Mechanostimulation: Proper stress on biological systems, including the spine, is crucial for maintaining strength and resilience.
3. Movement Variety: Regular variation in physical activities can help distribute mechanical stress and prevent localized damage.
4. Modern Lifestyle Challenges: Sedentary behaviors and lack of diverse physical activity are major contributors to back pain.
5. Practical Strategies: Incorporating targeted exercises, posture adjustments, and movement variety into daily routines can significantly alleviate and prevent back pain.

1: Introduction

Dhru Purohit introduces Dr. Stuart McGill, setting the stage for a deep dive into chronic back pain. They discuss the widespread impact of the condition and the importance of understanding its root causes. Stuart McGill: "Up to 80% of people will suffer from some form of debilitating back pain in their lifetime."

2: Mechanostimulation and Spine Health

Dr. McGill explains mechanostimulation—how applying the right amount and type of stress is essential for spine health. He emphasizes the need for movement diversity to prevent overloading specific parts of the spine. Stuart McGill: "Every system in biology, including the spine, needs stress to be healthy. It's about finding the balance."

3: Impact of Modern Lifestyles

The conversation shifts to how contemporary sedentary lifestyles contribute to back pain. McGill discusses how prolonged sitting and lack of varied physical activity can lead to chronic conditions. Dhru Purohit: "What is it about our modern lifestyles that significantly contribute to back pain?"

4: Strategies for Prevention and Management

Practical advice for managing and preventing back pain is shared, including exercises that promote spine health and techniques to improve daily movement habits. Stuart McGill: "Incorporating a variety of physical activities can help manage and prevent back pain effectively."

1. Regularly Change Postures: Avoid prolonged sitting or standing to distribute stress on the spine evenly.
2. Incorporate Stretching and Strengthening Exercises: Engage in activities that strengthen the back and abdominal muscles.
3. Use Proper Lifting Techniques: Always lift with your legs, not your back, to avoid undue stress on the spine.
4. Increase Daily Movement: Integrate more walking and light activity throughout the day to keep the spine active and healthy.
5. Mind Your Sleep Position: Opt for a supportive mattress and a sleep position that maintains spinal alignment.

This episode is brought to you by Birch, Plunge, and AquaTru.

Back pain is a common affliction exacerbated by our modern and sedentary lifestyles. This discomfort frequently hinders work and daily activities. Our guest today delves into the back's anatomy, identifying movements—or lack thereof—that contribute to pain and discussing factors contributing to its increasing prevalence.

Today, on The Dhru Purohit Show, Dhru and Dr. Stuart McGill delve deep into back pain. Dr. McGill shares insights into why back pain is so prevalent, dispels myths surrounding it, and discusses the types of repetitive stress and strain that can lead to chronic pain. He also outlines his approach to treating back pain and highlights the limitations clinicians face in treating their patients.

Dr. Stuart McGill is a distinguished professor emeritus at the University of Waterloo and the chief scientific officer at Backfitpro Inc. McGill has written more than 300 scientific publications on the topics of lumbar function, low back injury mechanisms, investigation of tissue loading during rehabilitation programs, and the formulation of work-related injury avoidance strategies. He has received several awards for his work, including the Volvo Bioengineering Award for Low Back Pain Research from Sweden.

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Dhru Purohit, Stuart McGill

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Stuart McGill

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Dhru Purohit
Stuart, such a pleasure to have you here. You know, today we're talking about getting to the root of back pain and some of the top myths that people have around this topic that you are most known for dispelling. And most importantly, we're going to be talking about what people can do to address it or potentially prevent it if they don't have it. Knock on wood. I hope they don't have it right now, but a lot of people do.

And on that note, I'd love to. Start off a little bit big picture about something shocking that I heard you share. And maybe I'm just not in the know, but I didn't know this statistic. So I'm going to share your quote. You just make sure that I got it right and then we'll talk about it.

Dhru Purohit
So I heard you share that up. To 80% of people in their life. Today will suffer from some form of debilitating back pain. So number one, did I get that right? And number two, what the heck is going on in this modern world that we live in, that 80% of people are going through this?

Stuart McGill
The word debilitating is interesting. I was a professor throughout my life and I could have quite severe back pain, but it wouldn't prevent me from standing in front of a lecture hall and giving a lecture. If I had a physical job, say I worked as a fisherman or a car mechanic or a construction worker, the same level of pain absolutely was debilitating. So the definition is it's a severe impact on work, severe impact on the person's occupation and on their enjoyment of life, whatever that might be in their current stage of life. Picking up a child, being a grandmother would be such an example.

So the often quoted rate of incidence and prevalence is about 80%. So to build on a little bit further, I feel like you were kind of going there, but just, you know, just to understand how vast the problem of back pain is, especially, you know, I'm 40 years old. Maybe some people that are in my age demographic or younger think that as I thought that this was kind of like a rare thing, people have injuries. But as you age and you talk to people, you actually find out that just because somebody is not on disability, just because somebody hasn't stopped working at their job, just because they aren't showing up in the world, doesn't mean that they aren't struggling with what still would be classified as debilitating pain. And that's partly what I feel like I'm hearing you say, yeah, again, it.

Depends on what the person does throughout the day. If they are a computer operator and they are unable to concentrate because of the pain, they're unable to sleep because of the pain. They're gaining weight because of the inability to move, and it's a major health compromise. You know, Stuart, on that note, the second part of the question was really sort of thinking about it a little bit bigger picture, and I'll, you know, feel free to chime in. I know you're very precise with your language, which is a big reason why we wanted to have you on, is that many individuals like myself are asking, what's going on in our modern world that is a big driver of this.

Dhru Purohit
And to the best of your ability, do you think that this has always been the case, or is this a trend that's heading in a worse direction? Do you have any thoughts on that? I do. Let me go for the first part of that question now. Again?

Stuart McGill
Yeah, I need some specificity sometimes for my professor's mind to be on cue. Think of every system in biology requires stress. Whether it's a cognitive psychological system, your endocrine system, your musculoskeletal system, which we're talking about here. If you don't stress your body, it's weak, not very resilient to life. But if you over stress it and cross what's known as the tipping point, more excessive load is catabolic for the system.

Micro trauma accumulates, pain occurs. Microinjury, that eventually goes to full blown injury. So an example of that. And then people might not really get this idea of mechano stimulation. Consider laying in bed.

Well, that's not stressful. However, if you lay in bed for a long period of time and don't move, you get uncomfortable. And if you ignore that discomfort and you don't move, you will eventually become injured. And it's called the bedsore. So there's an example of something where you cross the tipping point because not of high load, but of duration of load.

So load has a magnitude everyone understands. If you pick up a very excessive, heavy load, there's a chance you will create a stress concentration, and that tissue will damage or become injured. But I've given you an example now of duration, which might be sitting at a computer. Another one is repetition, another one is, well, all of those are mitigated by rest. So the key to all of this is variety of stress to make sure that you're below the tipping point.

Moving stress through different locations in your body by posture change and changing activities, being well rounded. If you want to think of that and not doing too much of any one thing. So you can imagine you can get away by splitting your firewood or whatever you boys down in La do. I'm not quite sure, but that's all. We'Re doing all day.

Dhru Purohit
We're splitting firewood here in Los Angeles. That's all we do. I'm just going to give an example of something where I live that would be a common seasonal activity. If you split wood on Monday, you've built up a little bit of micro trauma. However, if you rest on Tuesday, your body responds to that and rebuilds those micro traumas into something that is now more robust and more resilient.

Stuart McGill
Do it again on Wednesday. And now you've added a little bit more stimulus with very, very micro trauma. However, that's what the body thrives on. But if you split wood today, tomorrow and the next day, there is a good chance that if you're crossing the tipping point every day, the micro traumas are accumulating. And eventually I can give you many pathways specific for spine injury.

I know you mentioned myths. One myth is you may have heard people being told, oh, you have nonspecific low back pain. Well, that to me is a myth. There's no such thing as nonspecific back pain. It's all very, very specific, but it requires a fairly thorough assessment to figure out what the specific pain pathway is, and then we know what caused it.

And it's usually a violation of this principle of mechanostimulation that I was describing earlier. They've crossed the tipping point in whatever form it was. And now the key is to not go back to building that cumulative trauma and figuring out the pathway to give the antidote to keep feeding this system through mechanostimulation to create resilience and robustness and pain free abilities. So I don't know if I've avoided your question or I've answered it, but there's a little bit of a start on the scientific principle of why the widespread complaint symptom of back pain is. But if we can talk about specific individuals, we can certainly get into why person a has pain, why person b has pain, and they're two totally different pathways.

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Dhru Purohit
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$150 off. Cold plunges and their core products just go to plunge plunge.com dhru that's plunge.com forward Slash drew or enter the code Dhru to get $150 off today. So would it be fair to say that if we look at our modern world, we have, especially since the advent of computers, but really office work in general, we have a lot of repetitive type of stress or strain that we're putting on the body, even driving cars. And a lot of these things, not just that sitting is one component of it, we stand in the same way, we do a lot of the same things. And as a society, that could be one of the reasons.

Dhru Purohit
It's not the whole reason as to why we see a lot of individuals who have some of the pain that they do long term with back pain, because generally there's not enough variation and there's not enough equal distribution of different types of stress and strain. I don't know if I got the languaging right, but is that partly what I'm understanding? Yeah. Consider someone who sits at the computer for however many hours a day, but let's choose 7 hours. And then they go home at night and watch television sitting once again, and they wonder why their back is giving them signals of back pain.

Stuart McGill
Now, interestingly enough, when we take, say, a cadaveric spine, a young one, and expose it to the stresses of sitting, we don't measure stresses building to the point of injury. But here's what happens. If that person were to go to the gym and lift excessively, and that's the key word, lift excessively and cross their tipping point, and then they come home and they think, oh, I've got even more back pain now. It's so unfair. I sat all day and then I went to the gym and now I have even more pain.

If they sat less and trained more with less magnitude, shall we say, chances are they would say, oh, my back pain has now gone away. So what happened in the gym? If I could give an example, say a person lifts excessive load, moving their spine while they're under load. Well, the ball and socket joints of the hips and the shoulders are made to create power. It's a ball inside a socket, full motion, high load, that's what they're made for.

But the disc of a spine, which is the joint of the motion unit, is made of collagen fibers. Consider it to be a fabric. So my shirt is a fabric made of fibers. If I wanted to delaminate the fibers, I would create stress strain reversals, back and forth like this. And eventually I would work a hole in my shirt at the region of stress, strain reversals, collagen fibers running at different angles back and forth form concentric rings, like a onion skin.

Now, if you just move the spine back and forth, say you were a belly dancer. We don't measure delaminating stresses because there isn't very high imposed load. However, if you squeeze the spine and then do repetitive motion, the delaminating stresses between the fibers build. But here's the inside the nucleus, which is the middle of the disc. It's a gel composition, so a gooey, phlegmy fluid.

If you then squeeze the spine and bend it and allow some of those fibers to delaminate, the pressurized nucleus from behind will find and seek where the delamination is. And that's one of the major pathways, not the only one, but one of the major pathways to a disc bulge. So you can see the red mark in the collagen fibers at the end of my finger. Can you? Yep.

And remember now, inside the nucleus of the disc is a gel, so I can bend the spine back and forth, and I'm not going to create the hydraulic pressure stresses of the fluid working through the delaminations, because I'm not applying load. But now I'm going to flex the spine over and over again under load, create the delaminating stresses. Now I've created a weak spot, so to speak. Now I'm going to squeeze the spine and flex it, or bend forward under load, which would be considered poor form lifting. Now I'm going to squeeze and just watch.

Do you see the fibers delaminating and opening up? And then the pressurized gel working through the delaminated collagen. Now I'm going to change the hydraulics. I'm going to stack the spine nice and tall and I'm going to squeeze. You see the whole disc squeezing down, but the hydraulic effort of the, of the pressurized nucleus is equalized.

It's pushing all the way around and it's not focused where the delamination is posteriorly. So you could imagine if you had an orange seed and you squeezed it between your thumb and your finger. It just locks the seed if you create a thrust line right through the middle of the seed. But if you bias it one way, the seed goes out one way every single time. Do you follow?

So there is one very potent mechanism. So if a person has a disc bulge and they come into the clinic, you can find that mechanism in their past history, almost every time, but not always. And I can give some other examples. Now, let's take a person who doesn't do heavy lifting in the gym with poor form. And again, I don't want to be misquoted here.

Lifting with good form is important, as I just showed, and I'm all about that. So I don't want to create the impression that I'm anti exercise or anti training. I'm the polar opposite. But it's the way that the people train that get them into trouble. Now, let's take another person's spine, and this person doesn't lift heavy, but every day they go to yoga class or some sort of mobility training, or maybe it is that they just play pickleball and that's all they do.

So a lot of bending, but they don't do heavy strength type of training. These collagen fibers will adapt. They become a little bit looser to allow you to have more mobility. So if you keep stretching one way, stretching the other way, you get a little bit of mobility and laxity, shall we say, between these fibers. That's the adaptation that occurs.

And I should also point out, I'm not against yoga. Not at all. What I'm advising people is choose one, because the laws of mechanostimulation mean that there is always a trade off. So if you adapt your body to lift heavy, back off on the spine mobility a little bit. If you want a lot of mobility in your spine, probably better to back off heavy load type of strength training.

So a golfer, for example, we went through an era, 1215 years ago, where some prominent players got into heavy lifting. A, they didn't hit the ball any further, and b, they ended up with some of them quite disabling injuries. Although now you'll notice that the golf top players generally have backed off on the heavy load. So there's an example of the specificity, a little bit of mechanical stimulation. So here we have a disc.

Dhru Purohit
Can I ask one clarifying question about that? Yeah, sure. Just. Just as you're kind of going through. So you're saying pick one or the other.

A lot of people, as they're thinking about what really leads to. You know, most of my audience is not trying to be olympic level athletes or even perform in competitions, even if they are into resistance training. And a lot more of my audience is now into resistance training, since we've been talking about the importance of muscle when it comes to metabolic health, when it comes to glucose regulation, as well as the protective element and leading to ultimately improved grip strength, et cetera, et cetera. So when you say pick one or the other, I imagine that immediately the audience's ears are perked up and they're like, well, does that really mean, like, if I am not competing at a heavier level that I, who resistance trains, you know, three times a week to, you know, keep my body strong for my future years? Does that mean that I should be doing no yoga at all?

To what degree do we have to be, you know, careful of keeping in mind the sort of guidelines that you just shared with us? Right. I really appreciate you making that clarifying point. So I wasn't clear enough. You're correct.

Stuart McGill
Most people want to be generalists. They want to be able to play a round of golf. They want to pick up their grandchild or child. So they want a little bit of strength and load bearing ability. They want sufficient mobility.

So now we're talking about the middle of the road person. My message to them, would you put. Yourself in that category as well? Are you in that category or are you in one way or another just so I can get an approximation? It's changed throughout my lifetime.

As a younger man, I was all about strength. God gave me enough mobility. I didn't need any more. I wanted strength and speed. Now I want, don't let me get away from that previous question though, because it's very important.

Dhru Purohit
I got you, don't worry, I got your back. But now I want, if I walk in the woods and trip on something that catches my boot, I need to recover that fall because it hurts more. Now it's going to hurt my shoulders a bit more, etcetera. In other words, the risks to me have really changed. I'm in my late sixties now, so I work on hip power, get my leg out in front of me.

Stuart McGill
If I stumble to arrest that fall, I do well. I can tell you about my whole program now if you like. But anyway, my point is, I've really changed and now I'm. Do you want to talk about my training program right now or can we. Come back to that just so you can finish your other point about people who are in the middle of the road and you've mentioning that you have changed.

Dhru Purohit
You used to be more about strength and power. Now it's more about, what I'm hearing is you're more focused on longevity as you get into your later sixties, seventies, et cetera. It's not just about power for power, strength, you know, it's not just about strength for just the purpose of strength. You're really focusing on making sure that you can live a long and healthy life. That's what I'm hearing.

Stuart McGill
Right, exactly. I don't want to lose anymore. And obviously, each decade, you. You're not 16 again, you do lose a bit of resilience and athleticism, and you accumulate miles on your body, and we all have injuries that we have to manage. So, again, what works for me might not work for someone else.

And just to give some insight into this, I'm hip replaced. My knees aren't what they used to be. I've got a lot of things, but I don't know anyone at this stage who's had a good life that doesn't have to manage something. We're not 16 anymore. But going back to that previous issue, which, again, I appreciate you pointing this out, the more extreme a person wants in their athleticism, the more the trade offs are against other things.

So if we go into a physiologic realm, and again, I'm a spine guy, but I'm just going to use a physiologic one, because the audience might resonate with that a little bit more. It's very hard to be an explosive athlete and have a high vo two max. They are competing metabolisms. One's a fast twitch metabolism, and then the Vo two max comes from a slow twitch, endurable. So do you see how those.

If you really train one hard, if you really have a high Vo two max, you lose a little bit of your explosiveness, and vice versa. You can't have it all. And I know everybody wants to have it all, so training in a. And just one, one clarification on that just as we go through, and my apologies for the interruptions. You can always feel free to say, hey, actually, let me just finish my thought, but just one clarification on that.

Dhru Purohit
You know, my audience is. Is. Is not even the crossfit audience. You know, they'll. They'll be working out of the gym.

They'll be practicing regular resistance training there. A lot of them are just getting into that. So when you talk about having a high vo two max, you mean at an. At an athlete level, is that correct? Like, you're not just talking about high for your age group?

Stuart McGill
It could be, but we know that having the highest the Vo two max is, as you progress through the decades of life, chances are you're going to live longer and have a longer, what's known as a health span. Free of injury and debilitating disease, you're living better longer. So that is a health metric that's been established.

But I've already pointed out that I also want a little bit of explosive power to recover from a stumble.

It's nice to dance gracefully, it's nice to split my firewood. But I don't need to. I'm not on the gridiron banging like we used to or in a hockey rink. And I don't need that athleticism that in order to train to that level now, I would have to give certain things up. You can't have it all, so these systems compete with one another.

The more extreme you want to be, the more trade offs there are. But most of us want to be middle of the road. So my message in all of that is accept a level of sufficient strength, sufficient mobility, sufficient endurance, etcetera, etcetera, etcetera. And I think people will have a happier final decade, shall we say. So, going back to that analogy that led to this sort of clarification we had there, for somebody who has a level of moderate resistance training, let's say that's two to three times a week, where they're in particular, probably working with either bands in my audience, maybe, or weights with a trainer, potentially at a gym or at their home gym.

Dhru Purohit
If this individual also wanted to benefit from having some mobility pliability in their life, and they're thinking about, hey, is it okay for me to be doing yoga one or two times a week? I feel good. It makes me feel happy. Is that problematic? Or.

I know it's so person dependent, but we're obviously talking about on a podcast, we're talking about broad strokes. So for the middle of the road person who's working out two to three times a week, no debilitating back pain at the moment, but maybe some slight signs and cues, because a lot of individuals have that, even if they are pretty healthy, that something is going on that they need to address. Would that and yoga a couple times a week, would that be problematic in your eyes? What are your thoughts about that? I wish I could give you a very clean answer on this, but people are different, so I can't.

Stuart McGill
But an assessment would reveal the answer for that individual person. There's a book, it's called your yoga, your spine, and it's written by a fellow named Bernie Clark. He's a yogi, he's taken our courses, and he wrote another book, your body, your yoga. And the point of his books are to tell someone to do a general yoga program who has a bit of pain somewhere in their body is it's driven by luck, not by science. Say they have a right hip labrum sensitivity or joint capsule sensitivity, and then they do a certain pose or in a sauna, and it pushes that injury and irritates it a little bit.

But what Bernie does is he takes them through a few movement tests and he will identify some of these sensitivities and say, your yoga program should do this and not that. So you're tuning this broad category of yoga to suit the person because some exercises will help and some won't. They will probably do the opposite. So as a spine clinician, that's exactly what we do. We do an assessment to figure out what is the pathway to the person's current back pain.

It's not nonspecific, it's highly specific, but every single person is a bit different. So we eliminate what is the pathway to their pain. And it might be an activity, it might be their postures, it might be an excessive load in training, or it might be an underload. In other words, if they sat too much, we need to get them interval walking throughout the day to break up the stress concentration of sitting. So it's a matter of tweaking that mechanostimulation to achieve the goal.

But everybody is slightly different, and every person who comes through these doors has back pain. And sometimes the assessment is quite extensive. Jon, hear where that assessment came from and how it evolved? Yeah, absolutely. Let's talk about your origin story.

Dhru Purohit
And just before we get into that, just so that people are aware, you have an incredible book. I've been going through it over the last couple of weeks in preparation. This podcast, I want to show it here for those that are looking on YouTube. It's called the back mechanic and the secrets to a healthy spine your doctor isn't telling you about. And also, too, you're going to get into your story.

But you live in Canada. You're not really at the place where everybody who's going to be able to be listening to this podcast could see you. But you've trained a whole group of people in your methodology. And not only are you known for working with some of the top athletes that are out there in the world, you work with a lot of everyday individuals. And everything that you've learned from the athletes is completely applicable to the everyday individuals.

So I just wanted to add that into context here. As people are listening, there's a lot of resources that are there for us to go into the specifics because as people will see that so much of this depends on their unique situation. But let's talk to talk about how this methodology was developed. I think you were going to get into a little bit of your origin story about the assessment. This episode is brought to you by Aquatru.

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Stuart McGill
We've been working on this, and it's been evolving. I started with just one question, drew, and it was simple. How does the spine work? So we would investigate and measure people doing different things and measuring how they activated their muscles and how they organized their posture. Then I created a very sophisticated, anatomically sophisticated model of their spine based on their MRI scans, documenting their internal architecture and that kind of thing.

And then we would measure, with electrodes their own movement strategies. And then we would watch their computer. We called it their virtual spine move. And then we would measure the loads on the different tissues inside, the stress concentrations. And then we would measure things like stability and that kind of investigation.

As it turned out, most of the time, not always, but most of the time, the pain came from stress concentrations, either because of the way they chose to move, and maybe they were moving in a certain way because they had a sore hip and they had to stress their spine bending off kilter, so to speak, as they squatted down, or, or maybe the volume was, was just too much and crossing the tipping point, etcetera. After a few years, I realized I don't know enough about the mechanics of the parts, about the disc, the vertebra, the nerves, the muscles, etcetera. So we created a cadaver lab where we took mostly animal spines. But of course we had to calibrate the findings up to humans. And we would load the spines with the stress concentrations that we were measuring in pained people to see what the reaction was in terms of, well, is the bone cracking, is the nerve becoming irritated?

Is the disc bulging up? Etcetera. And then we did epidemiological studies because stress concentrations form from common exposure. So a certain job or an occupation would have a common exposure, and we would look at the clustering of types of pain pathways. Sports are the same, you know, why do gymnasts, when a clinician thinks of a gymnast, they will think, well, there are characteristic back pain mechanisms.

For example, a spondylolisthesis. If I said to a clinician, who gets that? And they would say, gymnasts, you know, it's because of these common exposures. And then the dean came to me and said, okay, hotshot. Well, he didn't use that word, but he said, why don't you put your money where your mouth is and let's start an experimental research clinic.

Well, I didn't really know how to do that because I hadn't been formally trained in medical school. But around this time, I was being asked to present our new findings in biomechanics to various medical meetings. And after I finished my lecture, medics would ask, could you come and see a patient with us who's resistant to whatever the intervention was? And I'd say, well, no, I'm not a trained clinician. And I slowly learned from them what their skills were.

And I realized I saw the world from a different perspective. It was much more from an engineering perspective. And if a person had pain, I would probe it, we would stress it, we would try and make it worse, we would try and do the antidote to make it better. We would play with loads, postures, motions, loads, study the commonalities of the mechanostimulation from like activities. And that's how we came at all of this.

And then when we started to see patients in the clinic, I set aside 2 hours to see a back pain patient. And my medical colleagues would say, 2 hours, what are you going to do? You know, Drew, after the first year, I changed that to 3 hours. And then when a patient came in, of course, they brought their imaging with them and all the rest of it. And I didn't say too much.

I welcomed them and I said, tell me your story. That's all I would say. And some people would give away why they have back pain. And then after 15 or 20 minutes, I might ask a little follow up question, and then they'll say, you know, doc, I've never told this to anyone before, but then it just pours out of them why they have back pain. And, you know, I learned that genetics, the type of spine that they have loads the gun, exposure to a certain stress or demand pulls the trigger.

And then the psychosocial milieu around them influences their pain Behavior. It affects their job and their Family Life. And then the next person is water off a duck's back. But when you understand and probe all of these things, and the stories I could tell you about people for the first time, they reveal to you, because no one came to the university experimental research clinic with fresh back pain. They were the failures.

They'd already been to ten different clinicians. They'd been conditioned to fail. We had to do a thorough investigation to find out what were the impediments that caused the failure of the previous nine attempts or ten attempts. So it was very different from anything in the medical milieu. It wasn't paid for by medical insurance.

There's no code in medical insurance to pay for a thorough spine exam, what clinicians are trained to do. So there isn't a profession that trains such a clinician. So I had to study techniques of interrogation, orthopedics, neurology, base anatomy, pain. Anyway, so it's taken a long time to hone down that assessment that starts with, tell me your story, and then we follow up with key questions. They might say I was reaching a certain way and I felt I had a little catch in my back.

That is an indicator spine instability, usually, and I'll just show one here now, here's the pelvis, the sacrum, l five, l four, l three, and there's three discs there. This disc is normal. L five and l three is normal. L four has been damaged. It's lost a little bit of disc height.

You know, when you let a little air out of your car tire, it bulges on the road and it's a bit sloppy to drive. Watch. Now I'm going to drive the car or load their spine. Watch the twist. You see how the twisting motion applied from the top is creating micro movements at the joint that's been damaged.

So that's called a joint instability. So if that person was laying in bed, there's a chance that that one joint, do you see how it's going to shift off in a sheer mode just a tiny bit? And then when they say, you know, when I lay on my one side, I get an ache just to the left of my spine right here, and they put their thumb on it right there, and then they shift to the other side and the pain changes, because now they have a little shift in that micro movement. Does that show on an MRI? No.

Does it show on any medical image? No, but it requires a thorough listening to the character of the pain. And now I can come up to them in the clinic. I can hold one iliac crest in their pelvis. I can put my shoulder over, lay their shoulder into my armpit, I give them a little squeeze.

There's your pain. Yep, that's the pain, doc. You found it. Do you see how that would never show on a medical image? And then I'll stay.

Dhru Purohit
Absolutely. All right, we've just identified the pain mechanism. I can see that joint is a little bit flat on a scan. Now, I poke my fingers laterally into their oblique muscles and I say, push my fingers out, and now fight me just a little bit. And I repeat the test.

Stuart McGill
And that musculature around their back and their sides and their abdominals in the front form a three dimensional muscular girdle. Now, when I probe them, I've arrested that micro movement. They say, oh, doc, you just took my pain away. Okay, so there is an example of a test that's quite an untraditional test, but it's very specific. It identified their pain pathway.

And even better yet, it gave us a clue as to the antidote to arrest that pain mechanism. Now it's nuancing. They just found that a little bracing engineered out that shearing motion, and then some people will react like a robot. They're stiffening, going around and not realizing that is way too much, and then they end up getting backache, because if you stiffen, you're actually adding compressive load to the spine and you're crossing the tipping point in yet another mechanism now. So now back off a little bit.

And so you see, first of all, the coach, the clinician has to be aware of. Remember that word I used being sufficient? Not too much, absolutely not too little. It's a nuance. And it's funny.

Then personality comes into it. And I'll say to one person, and, you know, their personality as a warrior, they're going to beat this out of their back by doing more exercise. And whatever you give them, they're going to do even harder. And those are the ones where you have to say, you're not going to beat this out of your spine, you're going to romance it out of your spine. So let's back off now and I'll just teach them a standing hover, very quiet, relaxed.

Now I give them a target and I'll say, reach and touch me. Good. Now I'm going to stress them a little bit more. I might give them a bit of load and then they have to keep tuning that amount of control so that they don't break to pain. Now they're building a movement repertoire or a wisdom, perhaps a catalog of movement techniques that they can now call upon and with more experience.

They just flow from one to another. And I.

Well, it's just wonderful to watch an athlete on the television, for example, competing in sport, and they were a client sitting in my waiting room two years ago in debilitating pain. And now I'm just watching all the patterns flowing together. What's fabulous is these combat athletes in the UFC and whatnot, and just watch them flow, you know, beautiful drop, step, pull, flow, pull into the navel, exactly as I told them. And they were avoiding the stress concentration, which is really just efficient movement. And that all came from that assessment.

And, oh, by the way, I retired from the university eight years ago and they won't let me retire. I still wake up every morning, you know, Drew, there's nowhere and you've never been able to find get an appointment with Doctor McGill, call list or, you know, do that. It doesn't exist. It never has done. And yet I wake up to these emails, would you see me as a client?

And some mornings I just have tears in my eyes reading through these and such heartfelt stories and misery that people, I've done this, I've done that.

Well, no wonder is what's going through my mind. I wouldn't say that to them, obviously, it. Anyway, sorry, that was. That was a long diatribe. No, no, it was great.

Dhru Purohit
It was great to give the origin story, but also you led up to what has been the combination, the unique combination. You know, why is it that a well trained surgeon might still be holding on to some of these myths about back pain and how they approach surgery? Or why is it that a PT who's well intentioned would be missing something or why would a MRI scan that somebody's gotten showcase or help them get to the root of why they may be facing debilitating back pain? And really, this example that you've shared is helping the audience understand that there had to be these unique things that all came together. The cadaver work that you guys were doing, the spinal models that were there, the fact that you had an outsider approach by being an engineer and sort of probing people's pain to see if you could recreate it, versus holding on to ideas that might be something that beholds that clinician or physical therapist or whatever, to not questioning certain things.

And the combination of all those unique things that have led you to be able to get results and help people who have been suffering, and ultimately the people that you ended up training, they have led to. And it's one of my favorite parts of your book. They've led to questioning all these different myths that people have had, and we. Hinted at some of them. You know, you mentioned the first big one, which was that you don't believe in non specific back pain, that everything is a specific pain.

Just pull on that thread a little bit more. You know, I'm not sure if everybody in our audience fully understands what that means. So who's out there arguing that some of the pain that people have or what is the advice that people might be hearing from people that might be well intentioned but is misguided, that, hey, your back pain is nonspecific and therefore we're going to treat you this way. Who's arguing for that and what are the implications for it? If you would take, you know, help us contrast it.

Stuart McGill
Well, I don't think it's anyone's fault. I think it is a subject to the politics of medicine. Clinicians now are terribly overworked and they're given time allocated per patient, which means you've got to see three patients per hour or some limit like that. And that might be insurance driven, it might be hospital driven or facility driven, but they don't get a chance to thoroughly assess a patient. So that's one limitation right there, and it's a systematic problem.

No single person's fault. So they just have had ten patients. They didn't have the opportunity to get right down to investigating their specific cause. So it's easy to say, oh, well, we couldn't find a cause, therefore you've got nonspecific low back pain, and it's. Just a byproduct of them getting older or you're too stressed out in your life.

Dhru Purohit
They're just saying things like that. This is a cop out. This shouldn't happen. They're dismissing people.

Stuart McGill
I know. I had a thought, and it was just escaping me. The other. And I think you started to allude to this yourself. Say a clinician has been trained in a specific procedure, and they have an insurance code to pay for that specific procedure.

So every single back pain patient that comes in, they get that specific procedure. So it's dumb luck whether that one's going to help them or not. And you can choose any procedure you like. There needs to be someone up front who can be thoroughly trained enough in all of these various aspects of assessment and then say, okay, with that particular mechanism, you will do better with this particular intervention. And there are some surgical groups that are forming around the world that are multidisciplinary, that are doing quite well at that, and they are their own entity, and they bill for time and that kind of thing.

So there isn't a pressure to apply a specific billable code, shall we say. So the patient shows up, they get a thorough assessment, and then that assessment will direct them onto a person who, look, what you really have to do is avoid the cause in the way that you're moving. It's the way that you're moving that's creating a stress concentration. So let's go to a person who understands how to coach you in pain free movement. The next person comes in, and I'm just picking on real live examples.

Now, the patient came in and I said, tell me your story. And they said, well, it's driving. I can't stand to drive. I get this terrible pain down my leg, and it actually sometimes moves up my spine in the middle as well. And I said, okay.

And I did the typical physical therapy slump test, which is where the patient sits on a chair and they slouch. Forward and they pull their knee into extension, which pulls the whole spinal cord and neural tract like this. And if they have nerve tension issues, that will reveal that. But here was the person who, they did a slump test, and there was no pain triggered, and they were deemed as having, well, nonspecific back pain, meaning the clinician couldn't find their pain. But I don't accept that.

And we keep going. Okay, you said in your interview that driving is your problem. Well, what is peculiar about driving it is the head is now up. It's not in a slope test, but you extend the knee so that the foot can touch the accelerator pedal. That triggered the pain.

Stuart McGill
What is it in that particular person? See the spinal cord and all the nerve rootlets, they're like a rope. They're all connected and they slide up and down based on head and neck posture and where your legs are and that kind of thing. So when they it looked up, it released the nerve root and allowed it to drift down. And then as they extended their knee, it drifted down even more.

Then I tried to floss the nerves and that was the very minor irritant, but there was something very peculiar about that. Now they said the pain went to their little toes. If that's the fifth lumbar, five root that goes to the big toe, it's not that one. L four goes to the little toes. So now I'm informed.

I'm informed to look at the radiology, the mister, and there's something on that particular nerve root when it's pulled that way, that causes their symptoms. Now I go back to the MrI and I find what's called a tarlof cyst, a nasty little cyst that was on the nerve root just outside the foramen. I found it. I was informed by listening to the person, I reproduced the pain clinically and then I went to the mister and found it. So the radiologist, without that information, probably would miss the Tarlof cyst because like you said earlier in school, they're taught in many schools, tarlof cysts don't cause pain.

Well, I can absolutely promise you 100% in some people they do. They can cause very miserable lives. But anyway, so with my skills, I can't do anything about a Tarlof cyst. The typical surgical intervention is to put a needle in and drain the fluid, but they usually grow back. So there's a surgeon who I refer people with Tarlof Cystis to who's developed a technique where they rat the nerve and he has about as good as any success rate than any other.

So do you see? I will refer out as well. But it was that approach and dogged. Don't give up. If I can't find it, it's my fault.

It's not the patient's fault. And I say that to my students regularly. You miss their pain, go back and look again. You miss something. We don't give up.

And no, I can't fix everything. And nor can some people. However, there's just another example that came to mind, that it took several layers, one informing the other. So a radiologist on their own, in their own silo, go to the radiologists and have an mister. They have no chance to find it.

Did you see, it had to be informed one after another. So teams that are put together, it's. Precise, it's precision work. It is. Yeah, it is.

Dhru Purohit
And what are the, you know, because of course, you know, and this is partly why, I'm sure, you know, the university, you're such a wealth of knowledge and you don't want this to just be, you know, your knowledge, you've written about it, but you've also trained people. Just a quick little teaser, if we could, if somebody wanted to find somebody who you've trained that can help them go through this precision assessment so they can get to the root of it and then find the appropriate referral, where do they go or what type of practitioner or coach are they looking for? Well, the ones that I've trained. And again, Drew, I didn't want to do this. I was asked, would we create a certification system?

Stuart McGill
So if you go to our website, backfitpro.com, comma, if you look under the tab, master clinicians, those are the clinicians that have been formally trained in their home discipline. And then they come and work with me and we see patients together and I train them to do the type of assessment and treatment regimen that I'm describing. There's also a second category on there of certified clinicians, because I just don't, it takes a long time to train a master clinician. It's a big commitment on my part as well. And I have two other teaching master clinicians that greatly assist on all this.

But we have limited time. But we also have the certified clinicians now, they've taken a 50 hours course with me, which is more than many clinicians get on back pain in their entire medical training, for sure. And then after those 50 hours of listening to me online talking, then they come to my home here and we study together for three days. And that's the day that we work on hands on skills, techniques and really develop them. Sorry.

Those are the, they can then challenge the certification exam. And now I don't work with them personally with patients, but they do the 50 hours plus three days together here. They challenge a written exam and then they have to get a patient. And this is usually online, sometimes it's live, and they have to assess the person and then in front of the examiner's program what the intervention is going to be, and then carry it out, which is usually a very specific exercise program. So those are the certified clinicians, not as elite as the master clinicians who I've worked with personally.

So I, and again, I was asked to do it. So, yeah, no, it's an incredible resource. I mean, at the end of the day, if you've developed a precision program, having people who know and can carry on that legacy, because ultimately, the more people that are trained in that, the more people that will end up getting resolution. And as we know from the statistics that we shared in the beginning, a lot of people are in pain. You know, Stuart, when I've heard your podcast and I've heard you talk about your various degrees of work and education that's out there for my landscape, I've seen it as, okay, there might be individuals that are suffering to some higher degree.

Dhru Purohit
As you mentioned, a lot of your methodology came out of helping people who had had many failed attempts of being helped. And then finally, through this precision approach, this assessment, then potentially referral, some stabilizing exercises, etcetera, they were able to get, you know, resolution and ultimately reclaim their life. And then there's another part of your work, also in your books and also in your education, that is focused on people who might have these signals. And if we all continue to get older, even at, you know, in our. Thirties, forties, fifties, we might start to.

See some of these signals that our body is sending us. Now, it may not even be close to debilitating, but we can start to notice that there's something maybe sticky, as I like to call it, that's going on in the body. And you have methodologies and exercises that are for that person to incorporate in addition to your big picture principles to hopefully, knock on wood, help them avoid being that person that long term. Might be some of those treatment resistant individuals that end up in your clinic. Is that a fair way of me sort of, of talking about some of the landscape of your education and your work?

Stuart McGill
Well, that's certainly the goal. I don't want to give the impression that we have 100% success rate, because we certainly don't. I can give you our success rates based on the specific pain mechanism of the individual. Some things were very successful and uniquely successful with, and some things were not. Got it?

Dhru Purohit
No, that makes sense. So I'd actually love to shift for a second and we may come back to. We'll put a pin on sort of where the conversation's been so far. I want to shift a little bit to make sure we give some love and attention to individuals who are listening, who are very fascinated, but they might be listening today because like me, they don't have anything maybe major going on in their life, but they're trying to make sure that they're aging and taking care of their spine and their back in the right way. So when somebody comes to you and says, okay, hey, stuart, I really get the big picture methodology to the degree that I can, as somebody who's a layperson, who's listening to you, and I understand the importance of why it's so key to be taking care of my back and my spine as we age.

I understand the statistics of people who end up in problems when they don't. What are some of the things that you would have me incorporate into my world in my life? Exercises, et cetera. Things that I'd incorporate in my schedule that would help me best take care of my spine as I age. What would you recommend to that individual who's listening today?

Stuart McGill
For me to be best in offering an opinion, I would need to understand you, and I would need to understand your pain history, your injury history, your age, your current level of fitness, your fitness goals, your jobs, other demands in your life, and then I can start to give good advice. So you're asking for a generic answer that doesn't exist. You will get a very middle of the road, probably ineffective program doing that. So if I were to ask you some questions, I would hone in on that. But there is an algorithm that converges on the most healthful practice for your spine.

Dhru Purohit
No, that makes complete sense. And maybe we could go down that route, even with me, with some of the questions. But let me take a step back. One of the things that your work is known for is you coming up with these big three. Can you just talk about those for a second?

What the big three are and why somebody might want to be incorporating these movements into their life. Okay, now you've given me something a little bit more specific.

Thank you for being with me. I have to start with a little bit of an essay on, please, where all this comes from and why it's important. So we are a mechanical linkage. We have segments with joints. The joints have different architectures, and the muscles are all designed based on the particular joint.

Stuart McGill
So it's not a just coincidence that we have a ball and socket joint at either end of your core. So, my first principle of a linkage, moving well is proximal stiffness and control to unleash distal athleticism. You're familiar with a backhoe, which is a tractor, an arm out the back with a bucket. The first thing the operator does is put down stabilizers to lock the tractor into the ground. Proximal stiffness, which now allows the arm to move and grab dirt and pull.

Failure to do that means you just pull the tractor all around. So if I was going to open a door and I failed to create proximal stiffness, it would just yank my back. But I don't. I'm very strategic now in that I can walk up to the door, use a hip hinge, reach for the door. Now watch my fist grabbing the door.

I'm going to pull the door into my navel. The most spine conserving, athletic way and powerful way to do it is I do a drop step. I drop step, and I pull it back, and I waltz through the door. So people will say, well, I don't. Have to do that on my bedroom door.

That's a walk in the park. I said, all right, but you told. Me in your story you hurt your back pulling on the church door or a door in the, in that shopping mall. So do you see how they're giving me clues as to where the flaws were and why they ended up with disabling that pain? So let's establish that principle just a little bit further.

Stuart McGill
Assume I'm going to create a very effective, efficient push. So people will say, well, I'm going to do bench press, and they may build up to, I can bench press 300 pounds. Good. If I'm in a standing posture, I can only bench press half my body weight in a push, and then I knock my own self over. Consider the bench press muscle.

It's the PEC major, connects the rib cage, crosses the ball and socket joint to the shoulder, and connects onto the humerus of my arm, distal outside of my shoulder joint. The PEC major creates the push, the desired athleticism. But look what happens on the proximal side on the rib cage. It collapses my shoulder. You see what happened on the inside of my joint?

So half of the muscle is collapsing the athleticism, the other half is propelling it. But I arrest the collapse by creating core stability. I lock my core. Now, 100% of that PEC major bench press muscle goes to the athleticism. So this is called an energy leak in an engineering sense, or an eccentric, unwanted eccentric contraction.

If you're a muscle physiologist, do you see why now you have to have proximal stability, and this works out joint by joint to give distal athleticism. So if I want to push, punch, kick, run, pull, carry my shopping bags, it all goes back to the mother of all proximal in your body linkage, which is your core. So that's, that's principle number one. What is the most effective pattern to ensure core stability, well, you contract all of the muscles appropriately, not too much and not too little, just so you can navigate, open the car door, get into the car, etcetera, freeing your hips and shoulders. But, you know, if you watch someone.

Run without a sufficient core, you'll see a little hitch every time they run. And then they wonder why, when they. Run the marathon or the partial marathon or something, that now it may be a hip impairment that's causing a little hitch going into their back. Hip asymmetry, as an example, is much more predictive of back pain when you run long before something like having tight hamstrings, believe it or not, it's the asymmetries that turn out to be more important. So, what are the best exercises for training that core girdle that I'm talking about to create proximal stability?

Stuart McGill
We measured all kinds of exercises and those that were claimed to create core stability, but the ones when we measured it, remember, we had the virtual spine that allowed us to do all of this was the bird dog. A form of the side plank and some form of abdominal exercise. Whether it's a walking out plank, a push up is a form of a front plank or a modified curl up. Not one that bends the spine repeatedly under load, but more of an isometric style, etcetera. So they spared the spine of compressive load.

Remember, these people already have some compromise to their back. That's why they're a back pain person. But we're guaranteeing that. Do you know what an engram is? Or muscle memory?

A muscle memory. A wise way to activate those muscles, and then the final bit is to transfer them to real life. How do you know what you're doing in the gym? Transfers to picking up your child. So it checked the boxes.

Those exercises were the most superior for most people. So that's where they came from. If I can give. I've already mentioned the second type of stability requirement, and that is a joint that has been damaged or injured in the spine needs a little bit more control. And again, the big three was fulfilling that requirement.

And the third example is something that I can show with this model. Here is a mock column, and it's held together with stiffness. Now, some people hear the word stiffness, and they think, oh, that's a bad thing. Not necessarily. I can stand here without muscle, just having a little bit of stiffness.

I don't need any muscle. Did you follow what I mean? So joints have stiffness. Your car tire, when it's inflated with air, has stiffness. If you let air out, it goes wonky.

So here is a column of the spine. Let me put a nice little lordotic low back curve into it. And there's the thoracic curve. It can stand upright, so I can sit and talk to you without any severe muscular control requirements. But now I'm going to take the stiffness away and it collapses.

But I needed to release the stiffness to tie my shoe to get dressed in the morning. So, do you see, it's a little. Bit of a game where you're all the time modifying mobility with stiffness and control. Now I have to pick up my. Child out of the crib, gather the child with a hip hinge, organize a curve of my back that doesn't create a stress concentration.

Not humped up like a camel, but not to sway back or extend it. And then just middle of the road, which is the less stressed, shall we say, slide the child to the crib, hold them so they don't fall, pull the hips through. And now you've executed a very efficient movement. But it was a dance. It was a blend between sufficient muscular control, but not too much.

Stuart McGill
It was appropriate. But now, when you pick up the groceries or a wheelbarrow full of yard earth or something much more demanding, you might be in the gym, you need much more stiffness to control the spine and make sure it doesn't develop a stress concentration. I mean, years ago, we were video fluoroscopy monitoring power lifters, and we measured an injury. We saw an actual injury occur, and just at one level of the spine, it bent forward a little bit to pick up the load and then just did a single joint. It suddenly kinked, if you know what I mean.

So it was an instability. The lifter didn't have enough stiffness and control, and that's when the injury occurred. So, you know, I can go at this from a tissue perspective, I can go at this from external load perspective, but it keeps coming back to that idea of sufficient control and then dialing in just the right amount. So those exercises, the big three, start off the training, and then I think it's a little bit of a myth. Oh, McGill's approach is just the big three.

There's a lot more to it than that, as you know. There's the efficiency of moving. There's training patterns in pushing, pulling, lifting, carrying things, applying force through long levers, you know, measures and pulls. So the awkward things in life. But anyway, does that give, that does a bit of a background as to where those exercises came from, why they were converged on and how we might start to train them.

Dhru Purohit
It does. And the way that I understand it is that you have these big three, and I might have you just repeat them one more time. Right. These things. When I zoom out a little bit more.

Right. We're zoomed in a little bit. When I zoom out. We live in our modern lives. We are so far removed from a lot of the sort of regular training that we would have just happened from living, picking up water, fetching water, fetching wood, doing this, doing that, all the things that we'd be doing it even from a young age and spending time largely outdoors, squatting, sitting, you know, squatting, getting up.

A lot of those things. It's not that our ancestors were necessarily. I mean, who knows what they were doing or not doing, but I don't think that they were training in the way that we are. Obviously, we know that to be true. But because their lives were so dependent on being outdoors and moving in this way, they didn't have to study the technicalities.

It's just that they adapted to those because they had a lot more of that healthier level of being in the middle of the stress and strain where they understood how to engage their core, how they. How they understood to create the pressure that was there because life demanded of it. Now, because we've been removed from a lot of those things and we sit a lot more, we have to actually go out of our way to train these things uniquely because our modern lifestyle is not necessarily baked into training it into us. Do you think that that's a correct understanding that I have? I do.

Stuart McGill
And the evidence I would use is when we interview patients and we'll get into discussions what activities make your pain, what activities actually make you feel better and are restorative. How do you feel at the end of Friday night after sitting at your job for five days versus Sunday night when you got out and had a lot of fun and moved your body, how did you feel after the last two week vacation? These are things that reveal patterns and you can then relate the exposures to them. And when you do that often enough, I think you'll strongly agree with yourself. A variety of movements means you're continually migrating stress concentrations.

Yep. So to your point, I think some wisdom was there. Would you mind just repeating those exercises? And what we'll do is we'll on YouTube for those that are watching, we'll link to. You have a lot of these videos that are available that people can watch where you've demonstrated how to do these exercises, actually.

I don't know. There's a lot of people on YouTube who have no clue, and it's very rare to see a reasonable bird dog. Now, my colleague Brian Carroll has done a fabulous job with a YouTube video on them, but may I just mention the bird dog for just a moment, please? Please. So, a bird dog, I've just noticed the lunge that I did, and now I'm on all fours.

I'm going to extend one leg, the other arm, and there's a bird dog. Now, here was my patient this morning who came in and said, bird dogs hurt my back. And I said, would you show me one? And this is what they did. Now, do you see how they were freeing their hip only to this point?

And then their hip ran out of room and they lifted their leg by extending their back. And when I sat them on a chair and I said, what causes your pain? And they said, moving back. So you see, they exactly created their spine trigger, unbeknownst to them, with lifting past the point of what their hip would take them, they lift with their back, raise their leg. They just went right to their pain driver.

So my cue was, lower the leg and push your heel away. And all of a sudden they said, oh, my pain's gone. They've controlled their core. The gluteals and hamstrings are now doing the movement. And the spine is.

The musculature in the spine is stopping the movement. Now we've got exactly what we want, a stable core, unleashing the hip. And now the next one is squeeze the fist. Really get some radiation of these muscles into the upper back. So there might be just a little bit of a start.

And then what I learned from.

Dhru Purohit
I. Have to credit, the Americans won't like this, but I had to credit, credit the Russians here. And have you heard of strong? First, my good colleague Pavel Sotsu Lin, who runs. I haven't, no, I'm not familiar.

Stuart McGill
Pavel taught me some of the original russian science. And the american way to build endurance is to hold the posture or repeat it for reps in a long period of time, and you get tired. The russian way is to hold that for 10 seconds, touch the floor with your hand and knee. Excuse me. And then hold another 10 seconds.

In other words, you're building up endurance without getting tired through repeated ten second bows. That was so clever, because now it became tolerable for back pain patients. So we find when I did epidemiological surveys of groups of workers, all doing the same job, say they were in a manufacturing facility, all doing the same job. Those who had repeated acute episodes of debilitating pain every year. In other words, they had to take four or five days off, but the rest of the time their back was okay.

What do you think the difference was between the ones who had repeated back injuries and the ones who never did in terms of mobility, strength, endurance, etcetera? Well, most people would say, oh, they were weak. No, the ones who were more strong had more acute bouts of back pain. And here was what happened. The ones who were more strong lifted with their back.

The ones who were less strong on their back lifted with their hips, and they just stiffened and controlled their back without a lot of back motion. So they were using their legs and hips. The difference was endurance. The ones who got hurt were stronger, they had less endurance. They broke form soon and they got a bit tired, then stopped using their hips.

And then after that, I just used their backs over and over again. And it was so blatant when you saw it. We had a patient, just for a bit of fun, who was an athlete, and we always say to the athletes, would you bring. Most of the good ones are on YouTube. We study them playing their sport before they ever show up here, whether they know it or not.

But this person sent their game films and we watched their opponents, who were just moving so efficiently without stress concentrations, and our client was moving because they didn't have sufficient endurance when they got a bit tired, back pain. So are we going to. Now, we've identified this specific variable that gives them resilience. It wasn't strength, it was endurance. Now, that's not always the case, but I'm just giving you some examples where knowing that we are now going to program that bird dog on a endurance, but not an american, typically an american profile, but more of an eastern european Russian.

And that was one of the keys for prescribing it in a way that was more suitable for back pain. People needing endurance. It's a bit of an essay. I'm sorry, it's a bit of a long thing, but no, no, no, it's super helpful. So on that note of prescribing it, how often.

Dhru Purohit
And I thought that was very helpful. Again, for those that are watching on YouTube, you can see the demonstration by Stuart. I thought it was very helpful to talk about that example of doing it correctly, incorrectly. So how often would somebody be incorporating that into their, you know, weekly routine? Is that something that you do?

Yeah. How often? If I said to you, what's the answer? Just what would you say? I'm curious.

It depends. Yes, thank you. It depends. And here's why it depends. For a start, let me give you a generic start.

Stuart McGill
We need to train in cycles because of, remember my opening little mini essay on mechanostimulation? So let's work with biology here. And we're going to train in cycles. The first cycle is two weeks long. So you said.

How often in the first two weeks? Let's go for week one. Do the bird dog six days out of seven. Why the 7th day off? That's the day where you just allow adaptation to occur.

Don't allow any naggling, snag or anything to grow. Do it again for the next six days, cycle number one. And then before you go into cycle number two, take three or four days off. That's the deload, just to let everything settle out again. Now, start off.

You might repeat that same cycle, or the next one, we might add more exercise or different loading or whatever. So that's the science to it, to begin. To answer your question, most people do it every day. Now, let's have a client here and we show them the bird dog, the side plank and a modified curl up, and they do two reps either side of each of those exercises. And then they stand up.

And I say, compared to five minutes ago before you started that, right now, are you better, worse or no different? You'd be amazed at how many people say, my pain is gone or I feel better. Good. Your programming is going to do half the exercises mid morning, do the other half mid afternoon. Now you've guaranteed two periods of respite in the day where you have less pain.

The next person is struggling. And we might have to say, let's. Say they had a funky hip or a knee replacement or something like that, stand at the kitchen counter and do a bird dog like this. And, you know, we'll just keep modifying it as required to try and engineer. Out what is limiting their ability to get what we need from that particular mechanostimulation tool.

So does that help you a little bit? It depends. I've given you one example, training in cycles, another example of twice a day. And then there will come a time when that person is so robust. We move on now, and I know you know this, but some of the people who've now gone back to set world records in various strength things, winning golf tournaments, winning weight divisions in combat sports or many, many olympic sports.

So they then get quite beyond doing a bird dog, obviously, and the level of mechano stimulation that they need a to perform and b, to be resilient will change, but that's the beginning of it. In any case, does that help with the programming? It's a science. It's a science for sure. No.

Dhru Purohit
Then there's a lot of specificities and unique things that are there. So generally speaking, these, the big three, they're going to be things that are going to be helping people get back into activating certain parts of their body. And then you might graduate from that if you have a appropriate training routine that still incorporates the different end goals that those things are doing, but for what load and stress and strain you want to handle based on your unique goals, is that correct? Absolutely. Yeah.

So for somebody like me who is going to the gym probably three to four days a week doing resistance training, plays pickleball probably like once a week, goes on two 1 hour hikes every week, has a moderate level of activity in my life and averages about 10,000 steps a day. I don't have any knock on wood pain that would be in this classification that you've expanded on that is debilitating. And I work with a trainer and he's very technical. Would you say that I could potentially be benefiting from incorporating these big three into my life? Or is that maybe not what's going to be appropriate for me?

And my main focus is, again, just healthy longevity, continuing to maintain a good vo two max on the benchmark that I've had so far in terms of my long term fitness goals. And I still want to add in because I grew up vegetarian. I under ate on protein, I didn't resistance strain. And when I turned 40, I finally woke up and realized how I've been doing it wrong. Even though I've not been vegetarian since I was 26, I want to add probably at least about another ten to twelve pounds of muscle in my early forties because I know that I'm going to be losing that over a period of time and I know that I'm undermuscled.

So that's why a lot of my resistance training and dietary focus is focused on prioritizing sort of lean muscle mass. So. So, yeah, you know, should I be thinking about incorporating these big three in my routine? Any thoughts on that? I'm doing pattern recognition.

Stuart McGill
As I'm listening to your story, Drew, it sounds as though you've got it dialed in now that that might surprise you. So you don't have any goal that you're not currently meeting. You have some overarching philosophies that you're trying to satisfy and you don't have any pain. Sounds pretty good to me. Now, if you came to me with pain, pain would guide me as to, I have to find out what the mechanism is, and then we would do things to reduce the pain and retune your body to get back to a pain free state, if possible.

But if you came to me with specific goals, which you didn't really give me there in terms of performance, I'd really like to do this. Then I would say, okay, what are the demands of that activity? I want to surf. There's a good la example for you. I want to surf.

Okay, well, I know on a surfboard you need a certain amount of extensor endurance and core endurance to paddle the board out. Then you need hip mobility and speed imbalance and flexion to pop up on the surfboard. And after that you need footwork, a sense of balance and all the rest of it. So do you see how I'm defining in physical terms the demand of the sport? Okay, now I'll take you and I measure you.

Do you have the hips that will allow you to pop up on a surfboard, or are you, you've got back pain, flexion driven back pain. Is it possible for you to use your hips and spare your back? Because if you can't, I can guarantee you that more surfing will only cause you more pain. So do you see? That's where we're going to go.

We're either going to make your spine more resilient, your hips more mobile, or hopefully both. So now that we're measuring what you currently have, we know what the demand is. We train difference. So now that's the program, if in the program we just described, we'll try some hip mobility. I'm pretty good at that, but I might bring in a hip mobility expert.

There's a good one in LA, by the way. And then I would say probably the big three will help you with your back pain to get the pop up and the ability to paddle out surface.

Does that answer your question? So for you, in that example, I need to know the demand, I need to know where you are, and I know what the pain mechanism is. Now I can start going and choosing my tools, because exercises to me are specific tools. One's a hammer, one's a screwdriver, one's a bolt extractor, etcetera, for specific things. I don't have this generic exercise.

If there's pain now, you know, in a thing, and it sounds to me as though you got it dialed in. So I'm going to keep my, my opinions to myself on you. That might surprise you. Well, let me, let me add a little bit more to that because I think this would be helpful for the audience, even though it's my unique story is that I've had periods where I've had a little bit of pain. So under my left shoulder after, let's say, in particular, maybe like a strenuous time period of lifting weights, just being in my normal routine, but sort of increasing my load.

Dhru Purohit
I've felt periods of time where there's a deep sense of tightness and pull and through a combination of taking a little bit of a break and also getting some chiropractic as well as some massage and doing some, you know, fascial release exercises that was, that were taught to me. I've seen an improvement that's there and to the best degree that I can. I didn't have any imaging or anything else done. It wasn't that bad, but it was enough that it was annoying. I couldn't sleep on that side.

I couldn't sleep on my left side of my shoulder. I would feel some pain in the evening. I saw that. Wow. Okay.

As I progress in sort of the load that I'm bearing in my, you know, three times a week, you know, workouts with my trainer at the gym. Yes, I'm getting stronger and I'm adding lean more. I'm adding more lean muscle mass, but something I'm doing is causing some sort of, you know, pain that sort of a specific section. And I've never been able to get to the root of it. I just know that whenever it pops up and it's pretty mild, I, I take a break, I kind of go a little bit lighter, and I get some, you know, work done or I'm paying more attention to it or more stretching that's there.

You know, the thing that comes up for me is that watching some of your content, seeing your conversations with other people, even though I'm working with a trainer who I feel is very technical and pays attention, you know, very precisely to my form, I'm thinking about, oh, okay. As I progress and I'm doing things like squats and deadlifts once a week, not anything more than that time period with proper form with my trainer. Should I be worried about these activities as I continue into my mid forties and then fifties and sixties and beyond? I guess the question there would be is that I have a routine that I'm working on to continue to become stronger. I don't have any benchmark of exactly, you know, what type of strength goals that I'm trying to do.

I'm sure I could break it down for activities, but should I be, you know, yeah, what would you be thinking about? Is it worthwhile for me to be working with one of these practitioners or master clinicians that you have to look at and sort of identify what am I uniquely doing? Or do I have some proper incorrect form that is causing this situation to flare up so that it doesn't become a bigger issue later on down the line? Well, I have two thoughts listening to that. The first one is understand what the stress concentration is that's leading to the symptom and hack your way around it.

Stuart McGill
It's either an inappropriate exercise with an inappropriate volume or an inappropriate technique for the. It might not be the exercise, it just might be the way that your performing that exercise that's leading to the stress concentration. So if you can have that done for you, that is an avoidance of the cause thing. But then the second part of the logic is knowing what the mechanism is. Now, is there something that we can do in a pre upstream sense to build more resilience?

So what is it about that stress concentration? Is there a muscular weakness? Is there existing damage to the joint? It could be. Some people have a fascia complex around the muscles that if it was addressed, they would have more resilience.

Or believe it or not, some people are too loose, they've stretched too much. And if they tightened it up, it's like putting a tensor bandage around that area of the body that can sometimes add more resilience. So figure out the mechanism and through mechano stimulation, you make it more robust. No, that's super helpful. When we did our pre call and we were chatting a little bit about topics to cover today and how to make sure we covered all the things that.

Dhru Purohit
That I thought my community would be interested in. You talking about sort of things from your perspective. One of the things that you mentioned that I found really interesting that I want to go into now, and you hinted at the beginning of the interview was you were talking about your sort of approach at the stage that you are at in your life, and you talked about this sort of essentially like this biblical approach. Right. The seven day approach that you have now, now that you've updated your plan for your unique goals and focus on in life, could you walk our audience through that, knowing that this is your situation?

This is not necessarily going to be the thing that applies to everybody else, but I think the methodology of how you've created it and why you've created it for you would be helpful for people who are thinking big picture. How do I design a movement routine in my life that supports my goals for longevity, which is a lot of our audience today. That was a really nice preamble. A lot of base notions in there, so appreciate that. Drew.

Stuart McGill
When I was younger, as I mentioned a few minutes ago, all I wanted was strength and speed. I was a canadian kid. I liked playing hockey and american football, and that's what it was all about. But you build up miles on your body. And when I started as a professor, computers hadn't even been invented yet.

So the job rapidly changed through the nineties and the two thousands, and I became a sedentary worker, which is something I never signed on to. It's not in my makeup. So my professor's job became sitting at a computer. And even in the end, students didn't want to come to office hours. They wanted to do it on Zoom.

And I said, no, you come down here because we're going to do some demonstrations to figure out this whole thing about optimal movement. Anyway, I retired in pain. I retired when I was 60. I was not healthy and in pain. I worked hard at night and on weekends, but that sitting job just didn't suit my physiology.

I got back to the rural life. We, for the most part, heat our house with wood, do a lot of wood, splitting and preparing firewood and carrying it in. Just living life, all that sitting pain went away. Then I worked on optimizing the variables, and it goes like this. And I called my week now the biblical training week.

This wouldn't have worked when I was in my late teens and twenties, when I was heavy into sport performance. Every major religion of the world has one day per week off the Sabbath. When you think of it from a mechanical stimulation point of view, it's valid, it's perfect. You take that one day just to deload and allow all your systems to dispel accumulative stress. So that leaves six days a week to work, two days a week.

I strength train, and I very strategically strength train. I work on things like core stability. I train in patterns. I have push patterns, pull patterns, a lift pattern, a carry pattern, and then I have all the auxiliaries. I do wrist work with an iron bar.

It's called sword blade, just to keep the hands and grippers in good shape. I'll do things like one legged rear leg, elevated split squats, and things like that for my posterior chain. And by the way, I'm hip replaced.

A few things I have to manage. Years ago, I broke my neck. It requires a certain amount of maintenance strength. Two days a week, another two days a week. I do mobility training, which I never did when I was younger, but my hips need work, my neck needs work, my shoulders need mobility work, and my thoracic spine needs a little bit of work as well.

If I don't, reaching overhead hurts. But with thoracic mobility, all of a sudden I can manage those patterns. Two days a week I work on my ticker. Cardiovascular training. So living where I live now, in the winter, I cross country ski, in the summer, I ride a bike, swim, etcetera.

So say, let's go back to that splitting wood example that checks all three boxes. I'm picking up hundred pounds, bucked up logs, oak logs, putting them on the splitter. I might be using a splitting maul, acceleration, speed, etcetera. I check the boxes on all of those, so I don't need to train that day, I've done it. But the next day comes along and I'll say, oh, no, I need more mobility.

Okay, that's my mobility. The next day, I'm not doing mobility. It has to be either strength or cardiovascular. The next rule is don't do two things. Don't do, sorry, don't do the same thing two days in a row.

So I, if I split wood Monday, if I do it Tuesday, I'm getting a little bit sore by Wednesday, so I back off. And I allow that to adapt. So those are some of the things about what I call the biblical training week. And I'll tell you, Drew, I feel fabulous. I'm obviously the oldest I've ever been, but I've been the most pain free and generally healthy than I have been for decades because of what the computer did to my profession.

It's not the computer's fault, obviously, but anyway, does that. So for your older audience, give that a thought. And I think they will converge on what is very doable and will result in a really nice, pain free, able, resilient life. That's great. I'm, look, I'm listening to that approach, and I'm thinking, you know, that could, that could potentially be working for me, too.

Dhru Purohit
I don't see anything inside of that routine. Do you see anything that you're doing there that couldn't be something that I could maybe bar from and how I approach stuff, because I'm not at the stage in my life where I'm super focused on strength at all cost or speed or, you know, explosive performance at all costs. I want to be healthy, mobile, flexible, pliable, but also strong in that sort of middle of the road to just support, like, a healthy life. Could I borrow from that routine that you have? I'll go along with you if you use the word sufficient sufficiently, strong, sufficiently mobile, etcetera, because sufficiently, yeah.

Stuart McGill
What comes through the door here are people your age and even people my age, and they say, oh, you know, I want to set my next personal best in deadlift or in bench press, or I want to run the marathon. And I'll look at them and I'll say, okay, can you explain to me why who's paying you $2 million to go out and run the marathon when your feet are really arthritic, the cartilage of your right hip doesn't have that much resilience left in it. And they'll look at me, and I'm the first person who isn't encouraging them to go for their next personal best, because the stresses that they would have to go through will probably shorten their athletic career, not lengthen it. So I'll say to them, let's discuss the goal of, you want to be able to pick up your grandchild without pain. How does that grab you?

And they'll say, yeah, yeah, that's my goal. I don't know why I didn't quite think of that before. So, you know, it's okay to set personal bests, but there's only so many, really in your body if you want to hang on to that and meet your objective of having a really nice last decade, in my opinion, I base that on being quite familiar with the scientific literature, but also being around this game long enough. Now, I've watched people over 40 years to see who has met that end goal successfully and who hasn't. And there's no guarantee in life, but on average, you're stacking the deck in your favor.

Dhru Purohit
This is probably outside of your world. But because you are in this unique place and you have such a view of how all these things come together, my audience is very interested in things like other factors like diet and hydration, etcetera. Beyond the typical guidelines that you might see out there of people saying, generally steer towards whole foods, stay away from processed foods. Make sure you're adequately hydrated. Is there any unique viewpoints that you have of how our diet or supplementation has any impact on some of these factors that you deal with with pain, avoiding pain, building resilience inside of the body?

Stuart McGill
I will say this, you're getting outside of my area of expertise. And at this point, I will get to the spine specific part. But let me just start generically. That's why I listen to people like yourself, Peter, Attia, Kuberman, etcetera, because they I really have made conscious effort for my own behavior change, and I'm feeling better for it. When I worked, I drank far too much.

And I look back and I think I would have recovered from jet lag faster. I would have slept better. And even though I knew what I knew, I didn't change my behavior. So hats off to people like yourself and Doctor Attia and Doctor Huberman, who've motivated all of us to just use common sense. But it isn't so common to.

I mean, this is really low hanging fruit when you think about it. Have you read the book the comfort crisis? I have, yeah. Have you ever interviewed Michael Easter? I have.

Dhru Purohit
He came on the podcast. Okay, stop. I've known Michael for years. He used to interview me quite often for men's health. And I think he's really onto something else.

Stuart McGill
It shouldn't be comfortable. There should be a certain discipline in life that you have to meet, and you just can't go and eat all the great food that tastes wonderful, but it is just, to use a euphemism, crap for your body. So that's my generic answer. But when we get down to back pain and are there supplements and certain nutritional rules that will help people, let me put it this way. If you're not moving well and exercising appropriately, you won't overcome any of those deficiencies through diet.

So eat well, exercise well, move well, think well, be a good person. All of these things I can tell you at this stage of life matter. Some people will say, well, if I lose weight, will that help my back pain? Whats the answer? It depends.

And I can give some examples where ive had some people with a heavy torso and they lose weight. Now all of a sudden they have these symptoms of spine instability. They've got movement catches. So when they were heavy, the gut acted like a pneumatic cushion to stabilize their spine. So when they lost the weight, the guy wires shrunk, so to speak, and the spine instability existed all the time.

But now it's become clinical. Do you see what I mean? We'll see. Sometimes massive professional bodybuilders and they put a lot of miles on their joints. And then when they retire and return their bodies back to civilian life and they lose all that mass, now they ache and they wonder why their joints are aching.

And now because they have a little bit of laxity and micro movement to them. I'll say this will surprise you, but if we get a little bit of muscle back on your torso, that will actually reduce the specific symptoms you're showing me that are due to the instability. So that's a surprising thing for some people, and yet other people, they are just crushing their spine. So when we measure their particular mechanism, it is a compressive intolerance to their back. That's a difficult one to get away with if you're heavy.

So losing weight will help them. So do you see why there's two contrasting cases where losing weight will help one and not the other? And that's primarily diet. Is there a supplement?

Again, nothing is coming to mind. That's magical. We'll have some intransigent cases where the pattern doesn't fit, and I'll say to them, we need to investigate this further, but it's not me who's going to do it. Have you had a really thorough blood workup? And then I encourage them to go and do that.

I might even refer them. And then it turns out they have Lyme disease. That was the cause of not only their back pain, but their achy neck and knees and everything else. So, you know, but deficiencies. It may be just eating crap, but again, that's not the primary intervention for their back pain.

Dhru Purohit
Absolutely. Yeah. That's super helpful. Yeah. Realizing that I am not the nutrition expert.

Yeah. Stuart, both in this interview and previously, as I've gotten more and more familiar with your work and having had the pleasure to meet you, and thank you again for coming on the podcast today. The way that I'm looking at this is that, you know, like a lot of my listeners, I want to be in optimal health compared to the population. And, you know, the population right now, especially if we talk about North America, but in particular the United States, you know, most people are overweight and obese. Most people have metabolic health issues.

Most people are not fit. They're living a sedentary lifestyle, et cetera. And if we go back to these core aspects because of our modern world, which has come with a lot of beautiful things and has put us in this place where we are in this comfort crisis, nobody's ever really taught us how to lift properly. Nobody has taught us how to sit properly. Nobody's taught us how to take care of our spine.

I'm looking at your work, and because, in a beautiful way, so many of your answers are contextualized based on, well, what is your unique situation? And circumstance. I'm like, I don't want to end up in a category where I'm one of the 80% who has debilitating back pain in the future, is it worthwhile for me to just preemptively meet with one of your practitioners or one of the people that you've trained as a master clinician and just do an audit? I am somebody, probably, again, like a decent amount of listeners. There's some disposable income, but more importantly, there's reprioritized income.

Instead of spending money on this luxury good in one way or another, I know, like, a lot of my audiences like me. Well, I'd rather like to be proactive about things like my spine, which is going to be a huge part of how I age. So is it? I'm thinking after this interview, I'm motivated to do a little bit of an audit and what little pain I've been dealing with. At least work with one of the practitioners that are there and get a sense of, am I heading in the right direction?

Is there anything that I need to be thinking about or correcting based on my unique situation so that I can, knock on wood, continue to age in the direction that I want to is? I understand that not everything is available to everybody. There's location, there's finances, there's other things, but generally, my audience has some resources that are there. Is it a bad idea to be proactive and go and find somebody that's been trained in your methodology and at least take the step in the right direction of seeing am I moving and am I treating my spine in a way that's going to be beneficial in the future, or am I heading in the wrong direction? What are your thoughts on that?

Stuart McGill
My answer might surprise you. I'm not the type of person who tries to make everybody the same, and sometimes that is that person's movement signature, and there might be a reason for it. And I'm not an over corrector, if you know what I mean by that. Oh, you are. You've had no pain history.

You're 40 years old. You're having a lot of fun. There's no symptoms yet, but I see this in you, and you should fix this.

I might surprise you, and I'll say I'm more tending just to let it be. Now I'm going to give you some science. We had a PhD student, Joan Scannell, who was a very good clinician. She was trained in the McKenzie system, and when she first came to work in the lab in the experimental clinic, someone would come in with a lordotic back. In other words, they would stand, but their butt was stuck out.

So they had a lot of curve in their low back. And she'd say, oh, we should fix that. And I said, why? How do you know if that's causing their pain or not? And then the next person will come in with a flat back.

Stuart McGill
And she'd say the same thing, oh, Mackenzie system says we should correct that. And I said, well, I'm not so sure about that. So what she did was she screened 150 undergraduate students who hadn't got any back pain yet, and she took the six most hyperlordotic biggest curves and the six flattest backs. Now, there's a school of thought. It was popularized by a czechoslovakian neurologist, Vladimir Jan.

And he said, in order to change the curvature of a person's back, you stretch what is weak and you. Sorry. You strengthen what is weak, and you stretch what is tight. Those were his clinical words. So if a person had a lot of hollow in their low back, they would strengthen their abdominals and stretch their extensor muscles.

And someone who had a flat back, they would do back extensor muscle work. And they would stretch the front. But before we started with all of that, we measured elastic equilibrium, or what's called the neutral zone. So let me just explain the science there. Here's my elbow.

Stuart McGill
If I could become anesthetized and fall into a swimming pool, my joints would go to the position of least stress. So there is elastic equilibrium for my elbow, and if I extend it, I would get flexor stress. And if I flex it outside of that neutral, I would get extends for stress. You get it? Elastic equilibrium is the least restful position.

So then we measured the six flat backs and the six ones with a lot of curve. It was so interesting that they were very different of where they stood in elastic equilibrium. The ones with a lot of curve in their low back, they stood in elastic stress, but the flat backs stood with less stress. Ah. And then when the flat backs sat down, they flexed, causing more stress.

And when the ones with a lot of curve in their low back sat down, they relieved stress. They moved into their neutral zone. So, do you see how interesting this is starting to get? In other words, do you really want to change their costure? Well, on six of the people, you'd be right.

On the other six, you'd be wrong. So you had to measure elastic equilibrium, because the goal of me looking at how you move and whatnot is to try and unstress you. But I don't even know which way that's going to be until we measure where your stress is neutral is. You follow? I do, yeah.

Okay. It's getting. It depends. So then she trained them under yonder's system. With the two approaches, she got the ones who had flat backs.

I never thought this would work. I didn't think physical therapist could change the standing posture into a more correct one, so to speak, but she did. The old professor was wrong. Got the ones who were flat back but not stressed in standing. She gave them a little bit more extensor curve.

But guess what happened when they sat down. Now, they had less stress in sitting down, but more stress in standing. And the lordotic spines were the opposite. So here's my point for you. If I gave you a corrective exercise to fix a flaw, we are not reducing stress in one area without cost.

The stress had to go somewhere else. Do you see where I'm coming on this? There's no freedom. So you want me to. You don't have pain?

Not yet. That's why when I say my tendency is just to let sleeping dogs lie until there's a problem, that's how I would answer that question. But now I'm going to give a different point of view. I've worked for different professional sports organizations over the years and I remember, you know, I'll attend training camp and do some assessments on some of the back pain players and on some of the non back pain players as well. And then I, I've brought this up a few times with the medical staff.

Let's watch each player. We know what their medical exam and our specific exams show. And now we go watch them play out on the basketball court or on the hockey rink or whatever it is, and we're watching them move now. And then I'll say to everybody, write down on a piece of paper who you predict is going to get injured this next season. Now let's put it in an envelope.

We're going to put it in the chief medical officer's desk, sealed. And we're going to open it up at the end of the season and we'll see how good we really are. Isn't that an interesting one? And do you know that we could quite often predict which ones we're going to get? A back injury or they were landing funny on the court and it was going to be a right knee or whatnot.

So that's how I would answer that on the other side as well. But those are extreme conditions of exposure. Do you follow? It's not Stu and drew just getting through life. So I'm kind of.

I can go either way on that. But it's all if you gave me a symptom, I'm locked on. And now I have guidance. I figure out the mechanism of the symptom, try and remove it, and rebuild your body to handle it. That's the easy thing.

Pain is easy for me. It becomes a different game and it's much more difficult. So I hope those two stories. I'm not trying to avoid the question, but that's why I'm answering it in the way that I am. No, it's super helpful.

Dhru Purohit
And again, I always appreciate the precision. That's why we wanted to have you on. It is a topic that is deserving of precise language and all the nuances that are there. Stu, this has been fantastic. I want to just give you any opportunity here to leave our audience with any closing thoughts.

We'll make sure to include your fantastic book back mechanic in the show notes for those that are watching. You can also see a copy over here. It's a great question and answer format that walks you through all the basics of your methodology. And my favorite part about it, it. You may not be able to see it here as I put it up, but there's a bunch of drawings inside of there that give you perfect illustrations of how people often are doing things incorrectly, basic movements, lifting things, chopping stuff, carrying heavy weight, holding suitcases, et cetera.

That will give you some sense of, maybe preventively, how to avoid a lot of these problems that people end up with later on. But stu, back to you. Any final closing thoughts and anywhere you want to direct our audience to? I don't think so from a spine perspective, but I would like to say back to you, thanks for all you do. I've listened to many of your episodes over the years.

Stuart McGill
I'm very interested in some of the metabolic issues, the cardiac issues that you tackle, and the quality of your guests. They're fabulous. And in your interview and podcast today, your logic and follow up and the way you posed some of the questions was perfect. So you made it easy on me. Anyway, thank you for all you do and changing lives.

Dhru Purohit
I just get to do the easy job. I get to interview experts like yourself who have put in the years of work. It's a lot easier to come up with the questions than obviously do the work that you're doing. So thank you. And thank you for your continued effort.

I think that the fact that you have provided this resource of writing material being on podcast. I really enjoyed your interview with Peter Attia and then also training other clinicians to continue the work and legacy that you've set up is fantastic. So thank you for that. That, and it's been a pleasure today. To have you on the show, well, myself included.

Stuart McGill
So thanks so much, Drew, and I hope I never have to see you for your back. But if you do have a back symptom, let me know, we'll assess it, and we'll see if we can sort out some path to resilience.

Dhru Purohit
Yes. Knock on wood. But if I do end up there, you'll be the first person I call. Stuart, thank you so much. Okay, thanks, Drew.

Hi, everyone. Drew here. Two quick things. Number one, thank you so much for listening to this podcast. If you haven't already subscribe, just hit the subscribe button on your favorite podcast app.

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