97: Back At It: Back Pain Revisited (with Stuart McGill)
Episode Transcript
Summary: Til Luchau and Whitney Lowe welcome back special guest Dr. Stuart McGill, a distinguished professor emeritus at the University of Waterloo and one of the world’s leading experts in back pain and spine health. They discuss:
• Common misconceptions about back pain
• Stiffness and mobility in back pain, and the role of bodywork
• Inflammatory factors in back pain
• Traction and movement techniques to mechanically “vacuum” extruded nucleus and alleviate disc bulges
• The McKenzie prone press-up exercise, and its potential effects on disc bulges and facet joints,
• and more.
Overall, this episode sheds light on the complexities of back pain and offers valuable insights for manual therapists and bodywork practitioners.
- Til Luchau’s Advanced-Trainings.com
- Whitney Lowe’s Academy of Clinical Massage
Resources:
- Dr. McGill’s previous Thinking Practitioner conversation: Episode 69: Back Pain, Stiffness & Fascia
- Dr. McGill’s site: Backfit Pro
- Dr McGill’s patient models and teaching aids: Dynamic Disc Designs
- Til Luchau’s upcoming Boulder Colorado, Puerto Rico, and Camino de Santiago events
Whitney Lowe:
Welcome to The Thinking Practitioner where Books of Discovery has been a part of massage therapy education for over 20 years. Thousands of schools around the world teach with their textbooks, e-Textbooks, and digital resources, Books of Discovery likes to say, “Learning adventures start here,” and they see that same spirit here on The Thinking Practitioner Podcast. They’re proud to sponsor our work knowing we share the mission to bring the massage and bodywork community and the livening content that advances our profession.
Til Luchau:
Check out their collection of e-textbooks and digital learning resources for pathology, kinesiology, anatomy, and physiology at Booksofdiscovery.com, where Thinking Practitioner listeners save 15% by entering, “Thinking,” at checkout, and we have a very special guest today, the return visit of Dr. Stu McGill, Stuart McGill. Dr. McGill, you are a distinguished professor emeritus at the University of Waterloo, where you were a professor for 30 years. You have researched issues related to the mechanisms of back pain, how to rehabilitate back pain people and enhance both injury resilience and performance. You work with high performance professionals and patients from all over the world who seek out your help for musculoskeletal back pain issues.
I happen to know that people who could do anybody, see anybody, afford anything chooses you often as not to work with their own back pain on. You have produced over 245 peer reviewed scientific journal papers, several textbooks, and have won many international awards, including the Order of Canada in 2020 for leadership in the back pain area. You are the author of Low Back Pain Disorders and the Back Mechanic, which is the one I really want to underline for our listeners, Back Mechanic, and you continue as the Chief Scientific Officer for BackFitPro. Welcome.
Stuart McGill:
Well, thank you very much, Til, and good day to you, Whitney. I believe you’re Pacific time or Mountain Time?
Whitney Lowe:
Yeah, Pacific time for me and Mountain for Til.
Til Luchau:
One of each.
Stuart McGill:
Okay. So two and three hours behind. You’re going to be getting hungry.
Whitney Lowe:
Yeah, that’s right. All right. Well, we want to thank you again so much for taking some time out to hang out with us here again today. I have to tell you, we had so much wonderful feedback from the previous episode that we did, and I have to say myself personally, I went back and listened to it multiple times too, just to try to see what more pearls and great things that I could to pull out of there. So we wanted to kind of take off from where we left off last time and dive deeper into a few other issues here as well today. So thank you again for your generous time of joining us here today. The first thing I wanted to-
Stuart McGill:
Well, I will say it’s my pleasure, and I really enjoyed having dinner together in Montreal. That’s the fun of what we do, to meet new colleagues, and share a few ideas, and have a beer and a laugh.
Whitney Lowe:
Yeah, absolutely. All right.
Til Luchau:
This was at the Fascial Research Congress, and we were lucky enough to be seated at your table and have some great time to get to know you better and get to know your work better, so it wasn’t honor.
Whitney Lowe:
Yeah.
Stuart McGill:
Yeah, same here.
Whitney Lowe:
Yeah. So where I wanted to start off today is just looking at we have a variety of questions and things that we wanted to dive into. So one of the questions I wanted to start off with are what might be some common misconceptions about back pain and spine health that some of our audience in particular, manual therapists, should be aware of?
Stuart McGill:
Well, that’s a very broad question. I would have to say in terms of a misconception and rather an impediment as well is using this diagnosis, nonspecific low back pain. I don’t believe that it exists. I think with a thorough assessment, and I believe the science shows this in spades, that if the assessment is thorough enough and competent enough, it will reveal some of the cause pathways of the pain. The clinician can apply some antidotes or some treatment in that they themselves will become part of an understanding of the pain pathway, so it becomes very specific.
In the last part of that is if you were to read a paper in the literature on non-specific back pain, and they might compare a manual therapy with chiropractic, with exercise, or whatever, the results are never very impressive, and the reason I believe is the groups are non homogeneous. Well, it’s a statistical precondition of validity, actually, that the groups are homogeneous. So if you have someone with pain that is caused by too much motion, and the next person is caused by a pathway that they don’t have enough mobility, and you do some kind of an intervention, some will get better, some get worse. On average, there’s no effect, and that’s the conclusion of the paper.
However, if the scientists or the people conducting the study got past non-specific low back pain, they would see that if they categorized those who thrived on mobility and were given mobility as the intervention, now they see the efficacy, those who are having too much motion and needing more stiffness or stability and control, and if they were given that intervention, the efficacy would go way up. So without studying the full spectrum of variation, oh, pardon me, then staying with this idea of non-specific low back pain is a real impediment. So that would be the answer from me on that issue.
Til Luchau:
That’s a great answer because you’re saying that because the studies have such a mixed group that they’re pulling from and then they’re averaging the results, it’s hard to tell which modalities, which approaches might be effective, which might not be, and you’re saying that if we really took the time, and you have some amazing stories about taking time to really understand people’s back pain, we could be a lot more specific as practitioners.
Stuart McGill:
No question and that goes not only for back pain, but just about every other search mission where statistics are used.
Til Luchau:
Okay. Now this is a question that’s in danger of asking you to reduce your life’s work to one or two sentences. That said, how would you guide our manual therapy audience toward that discriminatory process in their intake, people with the background say in massage therapy, body work, structural integration?
Stuart McGill:
Well, I would answer it, but-
Til Luchau:
I would love to hear your thoughts on that. Yeah.
Stuart McGill:
Yeah, I have some validity in the answer that I’m going to give you in that it’s very difficult for me to find clinicians who understand the breadth of mechanisms that cause back pain. So I find we have to educate them ourselves because if you came from a manual therapy background, or an orthopedic surgery background, or a neurology background, you wouldn’t have the other bits. So when we put together an education package and then that person becomes familiar with our approaches, they are able to conduct a thorough enough assessment that leads them to the specific subcategory of their back pain, and that gives them a guidance on what the intervention should be. So it’s a little bit of education. It’s a little bit of taking the time to conduct a thorough assessment, subcategorize the person, and then match the intervention to what is required for that particular pain pathway, whatever it may be.
Whitney Lowe:
Yeah. One of the things that I read-
Stuart McGill:
That’s more than two sentences Til.
Whitney Lowe:
It’s always going to be a bit more complex, but one of the things that I read in your book, Low Back Disorders, that’s something that I have seen also clinically a lot, and just maybe this is kind of a follow-up to what we were mentioning here, because I certainly, I think that there’s been a proliferation of this where certain individuals, if they can’t find an easier explanation for what’s going on, I think you said something like they default to something like psychosocial issues or some other kind of thing as a general broad sort of wastebasket. Well, let’s just put it in here because I can’t figure out what’s going on with it there. I see that as frequently an impediment to a more detailed evaluation of what really is happening with them.
Stuart McGill:
I finished a patient half an hour ago. He had quite involved pain pathways. He had a disc replacement in his neck, and he had two disc bulges in his lumbar spine. It turned out he had a double pinch point on the spinal cord and a nerve roots, and there was a nerve friction. No one had the ability that he had seen thus far to diagnose the pain. I got him to lay prone, and he had the terrible pins and needles, hot and cold in his feet, and then face down I said, “Turn your head so you’re resting your left cheekbone on the table,” and I got his wife to pull his arm up like this, and he started to cry, and he said, “Well, my symptoms are gone,” and I said, “Yes, you’ve got an underhook with neural friction.” I was precise as that, and I knew that if we could pull the brachial plexus off the under hook, we had a chance to move the pain. So it wasn’t unknown.
So to answer your question, he had seen a dozen different clinicians. He’d been sent to the pain clinic, and they concluded in the end that he had psychosocial disorders, he was a pain magnifier, and it broke the man down psychologically, his psychosocial diagnosis. He said, “I must be crazy because I know after I got my neck surgery this is when the symptoms in my feet started, and the docs say, ‘Well, there’s nothing wrong with the nerve roots going to your feet. They’ve done EMG studies and all the rest of it.'” And they just through… I’ll just say this, and I’m going to get in trouble for it, incompetence that they defaulted and blamed the poor man of having psychosocial disorders. He had psychosocial disorders because of their inability to tell them what was causing their pain and address it. Sorry, that’s going to irritate a few people, but that’s the way.
Whitney Lowe:
Well, that’s the reality. I mean, I’m in 100% agreement with you. I’ve seen that kind of process happen over and over again, and I think where a lot of us are trying to just chip away at that idea of we need to do a better job of educating the clinicians to be more accurate and effective at finding those things, because there’s a lot of people really in dire need of more specifics around that.
Til Luchau:
I-
Stuart McGill:
When I… Sorry, Til.
Til Luchau:
Go ahead, yeah.
Stuart McGill:
I just going to say, when a clinician reaches the end, and they tell me, “I can’t find the pain. I think this person is they have some psychological component,” no doubt they do have a psychological component, but… Now I’ve lost my line of logic there that I was building for you. Oh, I’m sorry. Yeah.
Til Luchau:
You were saying that there may be a psychological component, but is it cause or is it effect? Is it the result of the pain they’re in, or is it the thing that’s causing it?
Stuart McGill:
Yeah. Well, of course, it could be either, but this idea to… Oh, I know what I was going to say. It just came back to me now, and I’ll say if you can’t find their pain, you missed something. You better go back and look again, and can you probe with your hands, see with your eyes, and get the pain to move? Can you increase it? Can you decrease it? Can you get it to change locations? And if you can, you’ve just proved that there is some mechanical component to this, but again, no doubt there’s some psychological issue. Pain is an awful thing for the brain to reconcile and all the rest of it.
Whitney Lowe:
Yeah.
Til Luchau:
You have been a proponent of a biomechanical emphasis, and what you just described is a really practical way to assess the pain and see can we change it, can we get it to move, including, maybe, can we… Well, no it’s not- I was going to say, can we make it worse? Sometimes when we use our hands, and we find that we can actually make it worse, at least I’m thinking, “Okay, so there is something mechanical here that’s affecting it. Now can I shift and I turn that around so that I can hopefully make it better like we all want?”
Stuart McGill:
Well, what a fabulous assessment. You just proved what causes pain, and if you understand what you did with your hands, you might have… Say you did a shear test, you probed one vertebrae, and you triggered the pain. Now give an antidote. Okay, well, if that probe is moving something, let’s stop the movement with some stabilizing stiffening strategy. If it’s in the lumbar spine, we might try an abdominal brace, or we might try and centrate by pulling down with the pecs and lats, or here’s an interesting one for you, and we did this morning with this patient I was describing with the disc replacement, and he had this demeanor as he stood up, and he said, “Yeah, my feet are tingling,” and I said, “Could you retract your neck,” and he retracted his neck, and he said, “Oh, my right toe just went on fire.” And I said, “Humor me now,” and I watched the mechanics, and I said, “Open and close your jaw, but before you do that, retract the chin and push your tongue hard to the roof of the mouth.”
So now I’ve created a kinematic pattern plus a kinetic pattern of stiffness with the deep flexors pushing the tongue hard, and don’t let it go, open and close it. Now retract the chin, push your tongue hard to the roof of the mouth and just touch your teeth lightly together. So now I’ve added some posture, some gliding to the joint with an appropriate stiffening controlling field. Pain was gone in an instant. So there was the experiment. We created the pain. We made a couple of observations, and we formed a hypothesis. We tested the hypothesis with the antidote. What a beautiful process of assessment.
Til Luchau:
I’m torn here because I wanted to ask about inflammation next, but you just brought up a really important point, which is stiffness, where you’re actually creating a stiffening experiment to see if that changes the pain. What’s the next logical thing to talk about there? So can you say more about the role of stiffness? You just told a story where you had someone pressing the roof of their mouth, doing various things that created a kinematic stiffness through their body. A lot of manual therapists don’t think about stiffness except as something to eliminate, something to soften up. So there’s a potential paradigm clash there, at least at the superficial level between the goals of a lot of manual therapies and plain massage. How would you help us with that? What would you say about what you’re saying compared to this superficial thought that we’re reducing stiffness in our work?
Stuart McGill:
Oh, that’s interesting. You used the word paradigm clash.
Til Luchau:
Yes.
Stuart McGill:
Well, that now takes my brain to a line of logic. I don’t know if I see a clash, Til. Well, let me start out this way. If you were to take your car to a car shop, and you said, “My car has nonspecific sickness. It’s not functioning well,” and one guy in the car shop was a welder, and another guy was a carburetor guy, or maybe these days it would be fuel injection. Okay, so the fuel injection guy gets the car and does something on the fuel injection, and the welder does something with welding and then gives you your car back, because it had a nonspecific disorder. What’s the outcome? It’s not very good. So when a person with nonspecific back pain sees a clinician, and the clinician has the tools of let’s say manual therapy with the philosophy of loosening things that are a bit stiff.
Til Luchau:
Let’s say.
Stuart McGill:
If the person has pain because of something being stiff, the outcome is probably going to be pretty good, but let’s say they already have joint instability. Adding more looseness or taking away some stiffness will increase pain, and I can give you probably 10 off the top of my head such scenarios. In fact, I just gave you one this morning where we added stiffness by pushing the tongue, or I might have someone prone on a table, and they say, “Oh, yeah. My right toes on fire.” Good, push your eyebrow. “Oh, my pain just went away.” We just added anterior chain stiffness, or we met at the Fascia Congress. Think of the number of patients where… I had a fellow a couple of weeks ago with the weirdest pain. Again, he was accused and defaulted of having psychosocial disorders. His pain was that when he opened up his hip joint, he thought… Well, he really had facilitated psoas muscles because of back and hip pain. And as he stood up, it took him a while to straighten out, and then when he straightened out, his rectus abdominis went into spasm.
Now, I don’t think that’s a psychosocial sign, but nonetheless, he was told that he was a pain magnifier and he was crazy, and this was driving him nuts. As it turned out, when we opened up his hip and performed some sort of a hip stretch, yes, the symptoms fired right off. I laid him on a table, and I opened up the hip join, and I pulled on one arm, and then… We did this in Montreal. You’ll remember we pushed the heel of the hand to the ceiling. Tom Meyer was there, so that was why I thought of this, and then you internally and externally rotate the hand and shoulder, add even more tension through the fascia. Wouldn’t you know that that triggered up the rectus symptom and that took it away?
He didn’t have anything close to a psychosocial disorder. There was something in his fascial train connecting the arm through the frontal line into the psoas, and it was as plain as day what triggered and what took the pain away, and then I just put him on his back, and then did this with his wrist that fired off his symptom. Where did this begin? He was with a chiropractor in 2018, so that’s almost five years ago, and he said he had mild symptoms up to that, but he went to this chiropractor, and the chiropractor did two very small comfortable manipulations, and then completely surprising him, the chiropractor, as he described it, brought his knee and his heel way up in the air, and it was at that instant something popped in his back, and he’d been very disabled ever since.
And I’d like your opinion now, both of you. When you see a patient with a very fascially linked symptom as I’ve just described, he was described as being bizarre that you do this with your hand and it fires off the rectus abdominis. How often those have been the result of something traumatic, physically traumatic and emotionally traumatic? Now think of the people who’ve been in car wrecks and the person beside them has died or something along those lines, and now they’ve been labeled as having this bizarre, but no question about it in the assessment, fascially linked symptom. Do you have any recollections of patients where there was something at the time where all of this began that was traumatic?
Til Luchau:
Yeah.
Whitney Lowe:
Yeah, I would say we see that kind of stuff a good bit, and what’s interesting, and this kind of relates to something you were saying earlier too, is that a lot of times this doesn’t happen or doesn’t come up until somebody really starts digging into the history and really starts probing for those things, and then all of a sudden there’s like, “Oh, well, there’s this other thing that happened, but I’m sure that’s not related.” I’m like, “Oh, yeah, it probably is,” and so I think I’ve seen that quite a number of times where things just never came up, and again, if you have other health professionals who are only taking six minutes to do an interview with somebody, there’s no way they’re going to catch that stuff anyway.
Stuart McGill:
Right. So what you’re bringing up is something that’s been close to my heart for a long time, and that is you have to spend the time with someone and just let them talk and tell their story, and they will so often reveal these sorts of historical things that as a clinician you start doing pattern recognition, and then the patterns get stronger and stronger as you become a more experienced clinician, and after a while, it teaches you to ask about these sorts of things when you see certain patterns of, shall we say pathology during an assessment, but so often these fascial and fibromyalgic syndromes and whatnot come back to a traumatic event where there truly is some neural rewiring. Now we can get back to a soft tissue guru who understands now that it isn’t all about stretching and mobilizing.
Now, I haven’t worked with either of you two, but I have worked with Anne Frederick, and how much time she will spend she calls it romancing the joints, romancing the fascia around it and the tissues, and she actually worked on me probably 15 years ago, but how important the understanding of all of this, and adding a layer of expertise to the soft tissue therapy. Anyway, that was a ramble, and I’m sorry about that, but that might stimulate something on your side.
Whitney Lowe:
Yeah, I want to just real quick sort of call back to a second from what Til was asking about, the stiffness thing, because I was curious if you think this is mainly about just the skill on the clinician to make, or is there some kind of pearl or easy thing that you can maybe point us to, like how does a clinician make that distinction about do I need to increase stiffness, or do I need to decrease stiffness in a tissue, or is that just going to be a matter of they have to have a lot broader understanding of the whole biomechanical complexity of what might be doing that?
Stuart McGill:
Well, all of that. You need the understanding of function mechanically, neurologically, physiologically, and you probe it in the assessment. So say you do a prone instability test, so you might have someone prone on the table, and you will probe L5, L4, I’ll come around this way, L3, and let’s say L3 is a doorbell. It triggers the symptom to the great toe. Well, that’s a fifth lumbar root, but the doorbell is on the third, and then you might say, “Squeeze your buttocks and raise your legs,” and you hit it again and say, “Oh, that’s worse. That’s worse.” Okay, we’ve moved the pain. Squeeze harder, elevate your legs a little bit higher. “Oh, the pain is gone, Doc. Your magical.” Well, no, it isn’t. We changed the stiffness of the joint.
So if you look at this particular model, these are made by Dynamic Disc Designs, which are about the most biofidelic models of different pathologies going. This joint is normal. This one is normal. This is not. So do you see if I just create a general twisting torque, the majority of the motion is at the joint that has lost stiffness? So you see, you don’t want to mobilize that joint anymore. You may want to stiffen it. So-
Til Luchau:
Just for our listeners, we are seeing Dr. McGill’s model there where one of the joints is twisting quite a bit more than the others.
Stuart McGill:
Yeah, this one, just observe that one. Now go back to the facet joints at that level. These facets are not moving much, nor are these, but these ones are painted red, and when you do an assessment, you’ll find that those are the triggers. Please don’t mobilize them anymore. Give them stiffening exercises plus a set of movement patterns that when you bend over, just don’t bend over and touch your toes, but if you added control through the abdominals and bend from the hips, pain might be gone, and then they’ll say, “Oh, well, you can’t live life like that.” And I say, “Well, really? Did you watch the UFC on Saturday? You know the fellow doing that Jujitsu move? He was a fellow I worked with and showed him that to give him that capacity to eventually do that, so I don’t need to hear that, ‘Oh, they’re going to be stiff old men.'”
It’s a progression, and once you reestablish the control, then all right, we can have discussions about adding function, if you want to call it that back to the joint. But anyway, I don’t know if that is getting closer to the discussion that you wanted, Whitney.
Whitney Lowe:
Mm-hmm. Yeah.
Til Luchau:
Yeah. Just for our listeners, we do have video of this demonstration that Dr. McGill has just given us. You can go check that out on our website or on YouTube to see the joints he was pointing to and to see the movements that were happening there. Now back to-
Stuart McGill:
Here’s an example… Not to interrupt.
Til Luchau:
Go ahead.
Stuart McGill:
The final studies I did just before I retired was a whiplash study, and I did it with a chiropractor who had dynamic video fluoroscopy, so a real-time moving x-ray machine. All of these patients had been whiplashed one to two years prior to the study. Every single one of them was told they had psychosocial disorders because pain doesn’t last longer than a year, at least mechanical pain doesn’t. It would’ve healed by then, therefore, they are magnifying their symptoms, but obviously the insurance company was not too happy about this, but anyway, every single one of those patients was told by the medical community that their MRI images were fine. There was no physical reason for them to have symptoms, and on an MR it’s a static picture. Great, it’s like looking at your telephone and then saying, “Oh, well, is it ringing?”
Well, you have to have a dynamic detector to know if it’s ringing or not, but anyway, we then had them… We viewed the sagittal plane in their necks, and it just went through the range of motion, and interestingly, the pain wasn’t at the end range, because at the end range, the joints stiffen up and they control motion, but as the person worked through the flexion and extension movement cycle, somewhere in the mid-range, we saw this on the video fluoroscopy, if you can just watch my fists being the two vertebrae, they rotated, rotated, and then clunked, and then-
Til Luchau:
We’re going to try to describe this verbally too. So the two-
Stuart McGill:
Pardon me?
Til Luchau:
We’re going to try to describe this verbally too for the listeners that just have audio, but we have the vertebrae rocking against each other, and then one shears forward off of the other, the clunk.
Stuart McGill:
It’s a clunk, and it’s somewhere in the mid-range. That correlated a hundred percent with the shot of pain and the symptoms that the person was saying, “This is disabling.” It could only be seen in a video fluoroscopy, and obviously now you couldn’t deny that these people had true mechanical neck pain through tissue disruption, lasting tissue disruption because of the insult of whiplash. So it was a loss of stiffness, and we did try some of the drills that I mentioned earlier about working on the flexor motor control patterns of the neck by pushing the tongue, and retracting, and these sorts of things. Does it work on every patient? No, there’s nuances of how you might coach that, but anyway, there’s a little bit of a thought on losing stiffness and how.
Probably the most simple example would be a drawer test for a knee. So a drawer test tests sheer laxity. If you’ve damaged the ligaments, you will see the translations and probably replicate the pain. So a good knee clinician would work on muscular control patterns to organize out the shear as the person moved.
Til Luchau:
In my education as a rolfer one of the most common things that was said about hypermobile joints was, “Let’s mobilize everything else. Let’s make sure that the places that aren’t moving as much can match the evenness that we want to see through the whole system.” Your illustrations there showing one joint moving quite a bit could suggest that, but it’s also suggesting there’s a limitation to that approach, that at some point we may be able to see even more improvement through something that offers stiffness than just mobility everywhere. Is that a fair statement?
Stuart McGill:
I’ve seen both. I’ve seen it go both ways, Til. The assessment becomes the living experiment to test that hypothesis, but if we think at a more gross level rather than it’s called adjacent segment syndrome in the spine, let’s think broader than just the adjacent spinal segment. Let’s take something like hips and lumbar spine. Think of the number of people who they now have stiff hips. They sit too much. They don’t walk enough. Their hips lose fitness, and now when they bend over, they stress their spine. They bend down to feed the dog. What should have been coming out of the hips is now forced into the spine, and they have back pain. So if you could go back and address the underuse syndrome of the hips, you would free the stresses of the lumbar spine. So that’s thinking more in a bigger linkage perspective on the layers of strategic stability and mobility.
Whitney Lowe:
Yeah. Mm-hmm.
Til Luchau:
And, Whitney, your question is too about what are the hallmarks for discerning which way to go? Is it just experiment? What you’re making me think, Stu, is this, you’re doing an elegant process of history taking, noticing clues, what makes it better, what makes it worse, putting together hypotheses in your head, then you go test them. Does the doorbell light up the pain? And then you try to further experiment to see if we can change it from there. So you’re describing a elegant process of weaving together both the history taking, your hypothesis, and actual pragmatic in the moment testing to test all those things. I think we can all learn from that.
Stuart McGill:
Yeah, exactly. Yeah, I must admit that sometimes that is a little bit too much for a patient, particularly one who’s quite fragile and easily triggered, or they’re elderly, or they have some comorbid feature. So now an additional layer comes onto this is can I organize this assessment, this living assessment, and just do the minimum to gain the most information? Because if I have too many tests, I just stir up a hornet’s nest, and then everything becomes disguised. So your idea of the efficiency of the assessment is very important for some people as well.
Til Luchau:
Dr. McGill, tell us about your thoughts on inflammatory factors. We’ve been talking about biomechanics. You mentioned even a traumatic event that could trigger it or larger connections that might be mediated through fascia, things like that, but what about direct inflammatory factors like leakage from the nucleus pulposus or overall systemic inflammatory load on back pain complaints? Is that a factor and are there ways to assess or identify when some of those factors might be present?
Stuart McGill:
You’re out of my wheelhouse of expertise now. So when I get put into that situation, I have to give the rider, “I haven’t personally investigated that.” May I give you maybe 10 sentences on what I have read recently about it?
Til Luchau:
Would love to hear it.
Whitney Lowe:
Yeah, absolutely.
Stuart McGill:
So what we do know is that the nucleus, since you used that as your example, it gets fused up on the day of neurulation. So it’s ended the first months after fertilization of the embryo. That nucleus never sees the mother’s immune system after that. Once the person has a disc herniation and the nucleus comes through the annulus, the immune system of the body attacks that as a foreign body and sets up this massive inflammatory response. This we know. If you followed the literature on this in the last five years or so, the studies of then taking oral anti-inflammatories seems to suggest that this actually prolongs the time that the inflammation takes with macrophage activity, and white blood cells, et cetera, to help digest some of the extruded nucleus. So the inflammation is there for a reason, to help digest and reduce the extruded material. So there’s a little bit of an interesting take on it, and that’s about the extent of my knowledge and expertise.
Til Luchau:
Maybe inflammation isn’t something to just suppress in all cases, that maybe in this case, maybe there’s a cleanup process going on that could be leading toward diminished pain.
Stuart McGill:
That’s what they’re suggesting. That’s what they’re suggesting.
Whitney Lowe:
And I guess one of the difficulties is there we can do a lot more with some of the things that you were talking about in the detailed assessment process of looking at mechanics to see how mechanical loading might be transmitted. But it’s, I would assume a lot more difficult to identify something like is there enzyme leakage from the nucleus that might be doing this, like the way to provoke that or to really pick it up might be more difficult.
Stuart McGill:
Well, I can move back into my sphere of expertise now that you’ve gone that way. We would measure on cadaver spines, and these were mostly animals because we needed young discs that would herniate. Older discs don’t, so human cadavers, it’s very rare to get a nice pristine young human, but at least on the animal ones, we learned techniques to mechanically vacuum in the extruded nucleus. Permit me to get another model here, and this model shows the laminated collagen at the end of my finger. Can you see that little red mark on the annulus? So if you were to look through this see-through vertebrae, you can see all the red in ingrowth of vascular tissue along this posterior lateral root that I’m showing you with my finger. So this is a posterior lateral disc bulge through collagen delamination.
So watch that red area, and I’m going to deflect and squeeze the nucleus, and you see the delamination occurring, and the nucleus pushed out posteriorly. In other words, it’s a hydraulic effect. When you flex and squeeze, it directs the hydraulic effort posteriorly. Now we’re going to be tall, and I’m going to squeeze, and you’ll see the whole… Let me pull that nerve root out of the way. The whole joint squeezes down, but notice nothing is directed through the delamination posteriorly. So the nucleus does not get directed posteriorly.
Now, what we then learned to do was if we put a traction load… And the manual clinicians will love this. Let’s put a traction load on the spine and then add a little bit of motion. We would track the nucleus as it is progressing through the annulus and is now outside of the annulus. We could vacuum that back in, and you lay the patient prone, pull on their legs about say five pounds per leg. It’s not much, and then you do a windshield wiper action on the ankles. You’re watching their pelvis just so you get a nice little rolly motion in the pelvis, and that was the fastest way to vacuum in. In other words, you’re reversing the hydraulics to vacuum in the disc bulge.
Til Luchau:
I got to try that. It’s fascinating. Let me just see if I can summarize. You showed us this model and a little bit of flexion how the hydraulics actually pushed-
Stuart McGill:
Well, it’s not a little bit. It’s actually a-
Til Luchau:
A lot of flexion.
Stuart McGill:
A lot of flexion, yes.
Til Luchau:
Showed us a lot of flexion, how the hydraulics you were saying could push things backwards toward the spinal cord. When you headed in a more neutral position, there wasn’t that pushing even with compression. So then you’re showing us some traction, and how that you’re saying that could vacuum things back into the place where they’re not as irritating.
Stuart McGill:
Well, it’s not only that it can. I’ve proven that it can.
Til Luchau:
Okay, tell us about that. How’s it been proven?
Stuart McGill:
Well, it was a study. The first author is Scannell. Scannell was my PhD student at the time. That’s Joan Scannell and myself, and do you know the McKenzie prone press-ups?
Til Luchau:
I was about to ask you about that. Yeah.
Whitney Lowe:
Yeah.
Til Luchau:
Yeah, uh-huh.
Stuart McGill:
Okay. So now we get into some more interesting controversy.
Til Luchau:
Well, maybe I should say something about that for listeners who may not be familiar. McKenzie exercises are commonly given to people with diagnosed disc issues. They often involve back bending to a place where the client comfort, and the patient is taught to use that back bending with different motion to the putatively bring the nucleus forward and reduce irritation, and there is controversy around that. How did I do for a summary?
Stuart McGill:
Well, it’s not bringing the disc forward. It’s actually vacuuming in the nucleus, and interestingly enough, when Robin McKenzie was alive, he and I would discuss this at great detail, and he had never tested the mechanics and nor had the McKenzie Institute. We did the first probing of these mechanisms to see if we could explain was the hypothesis actually true? And there was this idea, “Oh, you would pump the nucleus back in.” Well, actually you can, but there was some riders on that. If the disc was flattened, it wouldn’t work. In other words, the disc had to have 70% of its original disc height remaining or more. So it still needed a fair amount of juiciness in the disc, so to speak, but if you pull in traction and then give that little wiggle I was talking about, that was the fastest way to vacuum in the disc bulge if it had 70% of its disc height remaining or more, but here was the problem.
Doing prone press-ups over and over again, the disc and the joint has now lost stiffness. There’s more load on the facet joints, and the problem was the patients who were told to do prone press-ups every day by their therapists, within a year or two, they now came back with highly irritated facet joints. So originally they couldn’t flex because of the disc bulge without triggering pain. Now they are extension intolerant because they’ve got sensitized facet joints, and as you know, a disc if you stop bending forward can settle down quite quickly. To wind down the pain sensitivity of a facet joint can take two or three or more months. It’s quite a long wind down to stop the irritation. So we were concerned using prone press-ups to vacuum in the disc. Was there another way?
We simply had the patients lay prone and breathe. You’ll find this is kind of funny. Lay on your tummy, breathe in, and as you exhale, relax your low back, take all the tension out, and that as you exhale brought back a very gentle extension to the back. Til and Whitney, it was just as effective at returning the nucleus in the animal study as the prone press-up without the trauma to the facet joints. Now you’re going to love the next bit.
Til Luchau:
I love it already, but I want to hear the next bit. Yeah.
Stuart McGill:
There are some people who they need a little bit of help. There’s a little bit of a stuck antalgic joint. So you asked me earlier, is there a… What did you call it now?
Til Luchau:
Paradigm clash.
Stuart McGill:
That’s it, a clash, and my brain just sparkled after that, because I don’t see it as that. You know that there will be some people with an antalgic joint, one joint that is splinted off now into flexion. So when they lay on their tummies, and you’re breathing that lordosis back into their spine to equilibrate the stress, that antalgic joint doesn’t want to go. I don’t have manual skills like you two. So then I bring in my manual guru, and they just gently help it a tiny little bit. We’re done.
Til Luchau:
That’s great, and I bet some of our listeners can think of occasions when we lay people face down, have them breathe and relax, and create antalgic conditions, conditions that are relieving to a pain induced issue, or immobility, or change in motion. I love this example. I love this story.
Stuart McGill:
And a still hand targeted to the right location matters. It matters if you work and probe up… As a rolfer, you know this, I know, or you probe the other way. The mechanical effect and the efficacy changes. It’s finicky stuff.
Til Luchau:
One of the things I’m curious about-
Stuart McGill:
Working the spinous process to the right working the spinous process to the left. One way hurts like hell. The other way says, “Oh, I can fix that.”
Til Luchau:
And maybe similar to your story about or your example of averages negating any differences across large populations, maybe some of that applies to manual therapy or manual therapists as well, that ability to feel, or follow, or deduce, or test and refine what we do has a lot to do with the efficacy too, of course.
Stuart McGill:
I can prove that. I don’t have to put the word maybe on that. I can prove it. So when we get into challenging patients, and they’re challenging because they’ve already been to five therapists, and they were either had no effect or they were made worse, and then comes along a therapist who makes the difference, and there was a reason why they made the difference. So the manual skill, the ability to feel, we talked about this at dinner. It makes a huge difference, and I’m hip replaced. I broke my hip, and I’d go to different meetings, and there would be the full spectrum of spine experts at some of the meetings I would go to, and invariably over dinner, someone would come up to me and say, “Oh, let me work on your hip. I can really help you here,” and more often than not I was crippled afterwards. It was terrible.
And I won’t say the names, but some of these names we all know, and they crippled me, and yet there would be someone else who would come in, and it was subtle, and it was targeted, and you could see them probing and feeling the reaction. I know I haven’t worked with either of you two, but you know there are some of the colleagues that they don’t need to ask a patient if pain was caused by that. They can feel the muscles spark off with a little reaction if you hit that pain. Even I with my stone hands can feel that if I’m present, and they were magic. They would take the pain out of my hip by very strategically knowing exactly with precision what to work on and release or relieve, and then what to leave alone. Don’t go near it. And those are the ones who were magical, and they could repeat it again.
Til Luchau:
Maybe there’s a kinesthetic or non-verbal example of this hypothesis test adjust cycle that we’re describing in your assessment too. Maybe we do that with our hands as well.
Stuart McGill:
Yes.
Til Luchau:
Maybe we’re feeling and adjusting the whole time.
Stuart McGill:
100%, but I think we can formalize it like that, and you as a teacher may want to formalize it into a teaching system, but if you go to a guru, that’s what they do. That’s exactly what they do.
Whitney Lowe:
I have one more question that I want to get into, but I can’t leave this, because this is on my mind. I just want to get some clarity here. When you talked about sort of vacuuming the disc back in, a lot of the stuff that I have read about the biomechanics of discs speak of them as being more of like a colloidal substance that can take large amounts of pressure over a short period of time, but then gradually degenerate from moderate levels over long periods of time, but what you’re saying sounds as if the disc actually can modulate it’s sort of shape or whatever in a short period of time when these kinds of forces are applied to it. Is that correct?
Stuart McGill:
Yeah, it is, actually. Go back to the model. Remember I showed you as you deviate it and create a hydraulic stress and bending it at the same time, you’ve forced some of the nucleus to go through the laminations in the collagen fibers. If you can vacuum them in and then avoid that posture, it gristles up in that new combination.
Whitney Lowe:
Yeah, interesting.
Stuart McGill:
Yeah, and people will then ask me, “Well, how long does gristling take?” Some people are looking at 10 years, and others, it’s much more rapid. One of my colleagues at the university, Professor Jack Callahan, has been studying the variety of collagen in people’s discs, type 1 and type 2, and learning with a bit more precision on which ones delaminate faster with motion, which-
Whitney Lowe:
Oh, interesting. Uh-huh.
Stuart McGill:
Yeah. Yeah. So again, we get back to this variety of response. There’s a reason for it, and if they’re savvy enough to figure out the reasons that they know how to test it. I do not know anything about type differentials of collagen. This is what the young superstars are doing these days.
Whitney Lowe:
All Right. Yeah. Well, I want to get back one question too that kind of goes back to the clinical case that you were talking about at the very beginning with the gentleman with the neck pain, and this is something I get asked all the time, and I would like to just hear you sort of weigh in on a little bit. Do you have any sort of clinical pearls or ideas of things that you could share that will help clinicians in distinguishing between radiculopathies, so nerve root problems versus a peripheral neuropathy that’s causing similar symptoms, let’s say like that in a lower extremity from back pain, making that distinction between a nerve root issue and something that’s a peripheral neuropathy, or compression, or damage farther along the length of that nerve.
Stuart McGill:
Right. Well, we have a lot of tests. I can’t give you one. Usually it’s the interpretation of the results of several, but if you can… Say you’re doing a straight leg raise test. Okay, it’s a general sciatic nerve root tensioning test. Play with the posture of the neck. In other words, pull the nerve roots from the other end, so now you’ve got more of a tension. Does that make a difference? If it does, I’m going to be looking at something more in the lumbar region than something further downstream as an example. If during the leg raise test you bring the foot more medially over the other leg, that puts more tension preferably on the L5 root versus a fourth as an example. I might differentiate some of the femoral root tests from the sciatic.
Let’s say you’re thinking of something a bit more like a vascular claudication, something further along. I might have the person stand in a swimming pool up to their mid-thighs, and then we repeat the offending test, and they’ll say, “Oh, my symptoms have gone away.” Bingo. It was the hydrostatic compression of the water, which if you go down about four feet… I’ll use American dimensions here, and down four feet, over a meter for the rest of the world. Now you’ve equilibrated out blood pressure 120/80.
Til Luchau:
Interesting.
Stuart McGill:
So if it’s a vascular claudication, and it goes away with the hydrostatic pressure, you’re starting to get closer. Now play with the nerve root at that water depth. Oh, darn, it’s there, so it’s a nerve thing, or we just keep working at it. Remember I said earlier, “If you can’t find it, you’ve missed something,”? Don’t give up. Keep working at this darn thing until you can understand it. Put a tourniquet on the thigh and tighten it up. Did that change the symptoms? If immediately it makes it worse, I’d be thinking something more distal, and things create clusters. That won’t be the only system, pardon me. There will be a cluster around that, or maybe they’ve got lipomatosis, or maybe there’s a nasty little nerve cyst that is hanging up the nerve that no one has seen yet, but the tests… Maybe you do a sitting slump test, and extend the knee, and slouch down from above, no symptom.
Then the person goes and drives a car, and they say, “This drives me crazy. I can’t stand the pain.” What’s the difference? They extended the knee. So there was something that you migrated the nerve roots coddly when they’re driving the car that isn’t seen in a slump test because the slump test pulls the cyst from either side, if it’s a lumbar cyst, and you say, “I know there’s something hanging up that lumbar nerve root. Let me go back to the MRs. Oh, shoot, they didn’t go lateral or down for enough.” Order another set and say, “I want to follow that right down to the hip joint.” Bingo, there’s the nerve cyst. You knew it was there. The assessment was showing you that there was something there.
Odd thing, these things pop into your head as you’re talking. I had a patient, and then everyone by previous to me were given the x-rays, old school x-rays, and then I looked at the x-rays, and I thought I had blurry vision. I looked at it again and again. They had I forget how many extra segments, something like eight extra segments on their tail. The tail curled around their anus, around their vagina, all the way around their bladder. The poor kid had a tail.
Whitney Lowe:
Wow. Wow.
Stuart McGill:
An internal tail.
Whitney Lowe:
Wow. Wow.
Stuart McGill:
And it was there for everyone to see, but they weren’t thinking that way. So what they saw, they didn’t even register.
Til Luchau:
I got to say that’s one of the things I get at every conversation I have with you are these amazing stories and examples of you doing this test, hypothesize, adjust cycle, but also just the out of the box nature of it, your creativity and your just willingness to try stuff, like tourniquet on someone’s leg, for example, see if that changes it. So I always gain a lot both in that detail level but also in the inspiration level from my talks with you.
Stuart McGill:
Til, people ask me a lot about that. Particularly whenever we have a patient here, I always invite the clinicians, “Please bring your doctors,” and they’ll say, “We’ve never seen anything like this before. Where did you learn it?” And I said, “Well, I’m not a graduate of a medical school. This is just engineering troubleshooting 101.”
Til Luchau:
Well, we could go on for a while, but on the way out do you want to share with us any upcoming research or projects that you’re excited about, and especially how they might affect the world? Whitney and I are in the manual therapy world.
Stuart McGill:
Oh, you’re not going to like this answer.
Til Luchau:
I’m ready. Thanks for the warning. I’m ready.
Stuart McGill:
Yeah. Well, when I was a professor producing new data and new results, it used to irritate me a little bit listening to people say, “Oh, this is what we’re doing, this is what we’re going to do,” Lottie-Dottie-da, and then I always thought I never by policy mentioned anything until I had the data in my hand. I was done, and I was willing to stand by it. So that’s still a little bit part of me. I’m involved in a few projects around the world, some really offbeat ones that I’m very excited about, but I will tell you when the data is in, and I can give you something that I can stand behind.
Whitney Lowe:
Well, there’s the automatic trigger for a new podcast episode for when that comes out.
Til Luchau:
Okay, great. It’s wonderful. Okay. No, you’re right. I’m not crazy about that answer, but I completely understand it and accept it. Thank you for that. All right, how could people find out more about your work? We mentioned your book, Back Mechanic, which again, I want to recommend. Any other-
Stuart McGill:
Right. Well, we have the books. If they go to our website, which is BackFitPro, you enter the website through one of two portals. If you’re a clinician, you enter through the clinician’s portal, and then it shows some of the books and materials that we have to enhance understanding of how the back works, how to assess it, and these sorts of things. There’s some course material on there, et cetera. If you’re a patient suffering, you enter through the back pained person’s portal, and it’s the same thing. There’s a different set of resources, and then we have a list of clinicians that have studied our material, they’ve taken our courses, they’ve been through our exams, and we can vouch somewhat for their competency, and we list them there regionally, and people could find a clinician close to them who follows a little bit of the way that we would recommend.
Til Luchau:
We’ll get all that into our show notes.
Whitney Lowe:
Yeah, great.
Til Luchau:
I want to personally thank you again for the time. It’s very generous of you, and like I said, I learned so much talking to you. I’m so glad you’re willing to share that with all of us.
Whitney Lowe:
Yeah.
Stuart McGill:
My pleasure.
Whitney Lowe:
Yeah, absolutely. It is absolutely remarkable the things that you have been able to compile and put together for clinicians that obviously are helping so many people in a way that the rest of the healthcare system just isn’t quite doing yet, so let’s keep dragging them in that direction, hopefully.
Stuart McGill:
Okay, Whitney and Til, I gained two new friends that night in Montreal, and I thank you very much for that, and thank you for all your support, and you two, keep doing the fabulous service that you both do. I saw the respect that you two garner from the profession, from all of the delegates in Montreal, so all kudos back to you two.
Whitney Lowe:
All right, thank you so much.
Til Luchau:
Thanks much. We’re going to read our rollout here, our ending sponsor. The Thinking Practitioner Podcast is supported by ABMP, Associated Body Work and massage professionals. ABMP membership gives professional practitioners like you a package, including individual liability insurance, free continuing education, and quick reference apps, online scheduling, and payments with PocketSuite, and much more.
Whitney Lowe:
And ABMP’s CE courses, their podcast, and the Massage and Bodywork Magazine always feature expert voices and new perspectives in the profession, including Til and myself, and Thinking Practitioner listeners can save on joining ABMP at ABMP.com/thinking. So thank you again to all of our listeners for hanging out with us, for communicating with us, and we do also thank all of our sponsors. You can stop by our sites for the video show notes, transcripts, and any extras. You can find that over on my site at Academyofclinicalmassage.com, and, Til, where can people find that for you?
Til Luchau:
Advanced-trainings.com. We’ll put again links to Dr. McGill’s site in there as well. If you have comments, questions, or things you want to hear us talk about, just record a short voice memo on your phone and email it to us, or you could email us your regular email at info@thethinkingpractitioner, or look for us on social media. I am Whitney Lowe. Actually, no, I read that wrong. I am Til Luchau. Who are you, Whitney?
Whitney Lowe:
Yeah, I’ll be Til today. Yeah.
Til Luchau:
That’s okay.
Whitney Lowe:
And I’ll be Whitney Lowe. So you can rate us on Apple Podcasts as it does help other people find the show, and you can hear us on Spotify, Stitcher, Google Podcast, or wherever else you happen to listen. So please do share the word, tell a friend, and thank you again so much for joining us. Dr. McGill. We had a wonderful time here with you today.
Stuart McGill:
Me too. Thanks, gentlemen.
Whitney Lowe:
All right.
