When it comes to talking about back pain, and more specifically what causes it and what are the best exercise strategies to treat it there is nobody better than Dr Stuart McGill. His books and endless research into this chronic condition are referred to by experts in all fields from all over the world and rated as best practice for helping people find long term solutions to their pain. I first read his books “Low Back Disorders” and “Ultimate Back Fitness & Performance” back in 2007 and was blown away by his approach and this changed the way I trained clients and my entire training philosophy. In 2016 I read his latest book “Back Pain Mechanic” and lastly in 2018 I read “Gift Of Injury” and also completed a two day training course on how to implement this with clients. Even though I was using most of his methods and philosophies in our back pain rehabilitation programs, it is not until you spend time hands on with this that you “really learn” some of the finer things and gain a greater understanding of the reason behind his methods. This article I am going to share with you what I found to be some of the best lessons I learned from him.
I have to admit I have always been a bit of a research geek and I found his books years ago a fantastic read and could not see how many of my trainer colleagues could not get into it as much as I did. Even when we moved into our training facility and I was teaching new up and coming trainers our methods and assessments I could not understand how they were not as excited about reading these books and watching his detailed lectures as I was.
I have read his books at least 10 times and continually refer to them to this day. The 4 books I am referring to are below if you are curious to read them and you can get them from Backfitpro.com
What was the key takeaway from these books and the two day training course I attended? The first lesson I learned in all of these books and the one thing that what was constantly repeated during the course was……
“IT DEPENDS”.
Lesson 1: It Depends
What do I mean by this?
Well if you ever see Dr McGill speak and anyone asks him a question like, “what is the best exercise for a bulging disc” or, “is it better to strengthen the core first or the glutes” you will often find he answers with, “it depends”.
This means that you cannot have any template program to follow and treat cases of back pain the same way. There is only the best way for your own body.
He also did not want us to be carbon copies of himself either, but to take the information he provides and merge it with our clinical experience, research, and learning from other courses or areas of expertise. As trainers we all come from different backgrounds and have many different elements of expertise and experience to call on that can influence how to implement a program.
Having said that there was some guidelines, (not rules) to follow that can help you navigate the path from pain to pain free that are invaluable.
I can tell you myself that I have seen hundreds of cases of bulging discs but never done exactly the same program with any of them! In some cases stretching and improving mobility worked well, in other cases it made things worse and it was strengthening with deadlifts and squats that worked!
See my testimonials page for examples of this.
What Are These Guidelines?
1.Make sure you have the right diagnosis. This does not just mean an MRI, but determine the motions, postures and loads that CAUSE the pain.
2.Remove the cause
3.Choose the appropriate rehabilitation strategy that includes movements that avoid pain and heal damaged tissue
4.Enhance and broaden pain free activities.
I found this to be a very important lesson to keep in your mind and why it is CRITICAL to use tests and assessments in guiding you on what to do as opposed to using the same approach you used last time.
The testing process ensures you remain unbiased, keeps you honest and helps you to treat each case as if it is the first time you have ever seen it before.
Lesson 2: Understanding Injury Mechanisms
I already had a fair understanding of this before but I really understood the difference between many of the variations of disc bulges and how their tolerance and pain trigger can differ greatly, even though they are technically the same injury!
Recognizing and avoiding the pain mechanism as McGill likes to call it is essential to pain free life. By understanding your pain trigger you can begin to understand how to get rid of it for good or even avoiding more damage to begin with. But how do you find your trigger?
The simple answer is to TEST and ASSESS.
McGill’s approach to finding the trigger is to more or less PROVOKE pain using various postures, motions and movement.
When you identify the motion or position that causes pain it becomes much easier to design a corrective strategy to change and eliminate future damage.
To do this you need to complete tests
•Seated compression testing
•Lying prone
•Standing with load in flexion and extension
•Standing with rotation
•Standing with dynamic heel drops
•Standing with load in front of body as a lever
Each of these assessments can reveal different triggers and your job is to identify if these motions make your pain worse or do they make your pain better.
Below are some videos that gives you some examples of this works.
One of the most interesting tests I really liked the seated compression testing shown below.
There is three reasons I really liked this test.
- The main one is it helps to narrow the focus of what is the TRIGGER of their pain.
- The second one is it really makes a big impact on the client if sitting is a big part of their occupation and helps them to see where a big part of the CAUSE of their problem is found.
- Lastly it is a very low intensity low risk test to use to provoke pain for this is really what it is doing.
Some of the tests I used prior to this were too aggressive and the results were misleading at times as a result.
This is a perfect way to help someone feel where their true trigger is coming from. This is one of those tests I thought nothing of the first time I saw it for I did not really understand it. Now that I have experienced it I can appreciate it more.
Lesson 3: Picking The Scab
I wouldn’t say this was a new lesson I learned as I do already encourage it, however I did begin to see just how much importance McGill places this with his patients. Sometimes we can get caught up in prescribing exercises and thinking of all the corrective strategies and forget to really drill home to the client that they must change how they move in life.
Many times we go through intense assessments, provide home exercises, stretches, stability drills for the client to do and after a few weeks the person has not changed much with their pain.
Why?
In 99% of these cases the trigger that is causing their pain is still at play and has not been changed and it is a DAILY ACTIVITY they think nothing of. Any of the corrective work we have done in the gym is instantly wiped out when the person continues to move with poor postures, motions and methods they had before.
Dr McGill refers to this as “picking the scab”.
A great analogy to use to explain why so many people never respond well to their treatment, even when the treatment or exercise program is exactly the right thing. For the minute they get home or go to work they move exactly the same way that created the injury in the first place.
Below is a great video to watch that shows you many of the ordinary daily activities we take for granted that can be the hidden trigger behind many back pain injuries.
Lesson 4: Why People Have Sore Backs In The Morning
When we have pain our instincts tell us to rest and not move and many will lie in bed or on their back thinking this will help.
In reality lying for long periods actually causes back pain! I have always wondered why people with back pain often feel worse in the morning. I put it down to their muscles being cold and stiff but it is much more to it than that.
Here is McGill’s explanation.
“A little known fact is that we are actually taller first thing in the morning than we are before we go to bed. This comes down to our DISCS! The discs in between each of our vertebrae are packed with concentrated protein chains that love water. In scientific terms this means they are hyrdrophilic.
When we lie horizontally, the discs fill with fluid and gently push the vertebrae away from one another lengthening our spine.
The reason our backs are stiff in the morning is that the discs are so full fluid, like water balloons ready to burst. When we get up in the morning, and our spines are once again vertical, the excess fluid in each disc begins to seep out and after an hour two we have returned to our normal heights. This natural ebb and flow is healthy and what allows the discs to obtain nutrition.
Problems arise when the spine remains in horizontal position for too long. While 8 hours in bed is healthy any longer allows the spine to continue to swell and cause disc pain.”
What does all this mean to you?
This tells you that you that is more important to WARM UP in the morning than stretch.
In fact stretching is often detrimental to back pain and I have found in recent years is actually a big part of the problem and in some cases the trigger. In particular Yoga poses that demand excessive spinal flexion.
Below is a great video of how to warm up if you have back pain and also a video of what stretches to avoid if you have back pain.
Lesson 5: Hip Structure Matters When You Squat
Have you ever been told that we ALL should be able to squat ASS TO GRASS!
Or have you wondered why some people can squat really deep with no effort and others can barely make 90 degrees no matter how much stretching they do?
This has a lot to do with hip anatomy and how we vary dramatically from one pelvis to another.
Forcing someone to squat ass to grass who has a hip structure that does not allow for this, will create back pain and most likely a herniated disc!
Unfortunately, many people who undertake gym training on their own without this knowledge, or participate in fitness classes, boot-camps, F45 style training where technique is not analyzed carefully, and usually sacrificed for more reps and fitness, will try to squat this way leading to an inevitable back injury.
Now this is not to say squats with great depth are bad for everyone, (remember “it depends) or that there is even a depth we all should be able to do. This is the big problem with the way people interpret the FMS that try to force people into deep squats to improve their score.
I often see Asian clients squat ass to grass with relative ease, but very rarely do I see anyone else be able to squat like this. This has a lot to do with the Asian culture, but also has a lot to do with their genetic hip anatomy.
Take a look at the image below that is taken from one of Dr McGill’s lectures at Stanford University that compares the pelvic ring of various people and highlights how different our hip anatomy can be.
This research showed that Polish people had the best pelvic and hip anatomy for deep squatting and it is no surprise that many of the world’s best weightlifters come from this region of the world.
A shallow roof does not allow for deep squatting needed in Olympic Weightlifting, but will allow for tremendous power with kicking as seen in martial arts.
What does this mean with relation to back pain?
This means that we cannot force people into deep squat positions as they may anatomically never be able to do much in this position.
Same thing with deadlifts, bent over rows or anything that requires the pelvis to move into a slight anterior tilt. There will be considerable risk with loading too heavily, or training under fatigue for the person is unable to maintain optimal positioning to handle this stress. However what you will find is this person will demonstrate considerable strength into lunges and step ups and positions with similar demands of a posterior tilt of the pelvis.
We need to always evaluate carefully each person and let the tests determine what we do next. By all means we can try to improve the mobility and positioning with corrective exercise, but we also must appreciate that there is often an anatomical limitation with movements in deep range of the hips and some people will never improve their depth.
We know that lack of hip mobility can cause back pain for a loss of mobility here forces the spine to lose stability. This is why the person with a good lunge and limited squat range is often more at risk of a bulging disc back pain than the person with great depth. The person with great depth can often experience back pain with extension related problems like SIJ dysfunction or Spondylolisthesis.
See our article – Are Tight Hips The Cause Of Back Pain
Below is a video that shows you how we might teach someone how to improve their squat depth and also what to look for that highlights the danger of going too low.
Lesson 6: Learn To Bend Correctly
Again this is not something new or something we did not know before but reinforced just how important it really is. In daily life the action of BENDING is nearly always associated with back pain.
In the two day course we spent over 3 hours just reviewing this one movement in finite detail.
The importance of learning to use your hips to hinge, and not bend your spine is massive and for some people this is very confusing and takes considerable coaching to change. In the gym world this is known as the deadlift and it is a critical exercise for developing strength for lifting objects safely and being able to bend correctly.
A real fear or re-injury is present with this movement as it closely mimics the action they possibly completed when hurting themselves, and also may bring on the pain symptoms quickly.
See video of me picking up firewood and how it relates closely to the deadlift.
But it is for this reason you MUST learn how to do this exercise.
It is important to see the relevance of how this movement relates to so many real life movements. Which is why learning how to do a deadlift with your rehab program will supersede any other rehab method such as Pilates, massage, acupuncture etc for all of these methods do not address this problem.
Over the last 10-15 years we have seen a big shift in this mindset as workplaces spend a great deal of money and time into teaching their employees how to lift and move objects safely. Most governments around the world have also made it a law for companies to teach their workers safe handling techniques.
Unfortunately, some of the training in this area has not really helped as the method often taught and used to protect them is more likely to hurt them.
The current method most often taught is to keep the object close to the body and use your knees. While there is good intention with these instructions anyone with half of an idea of how to lift correctly will instantly see some massive problems with this simplistic way of lifting. Keeping the object close to the body is a great instruction, but make sure you use your knees is not.
Learning how to set up correctly, how to use your breathing, how to activate your inner unit in combination with the outer unit to brace the spine prior to the lift are all things you will need a lot of practice to master.
Below is a video explaining the various exercises I might use to improve the bending action.
Lesson 7: Learn How To Brace The Core
I already had quite a good understanding of core activation but had at times been confused with the different methods used such as Pilates with the hollowing method and the “suck in your belly button” cues, and always wondered, what was the best method?
McGill’s research had spent considerable time looking into this and they found was lumbar compression forces and the amount of gross lumbar spine movement minimized were greatest with the abdominal bracing technique, not hollowing. McGill’s team then concludes that this technique gives greater stability of the spine.
In this research they found that posterior loading of the lumbar spine while semi-seated mainly activated the abdominals rather than the back extensors. The problem with this is that when they applied load unexpectedly the out of balance workload between the anterior abdominals and back extensors produced a faulty loading. The activity of latissimus dorsi and the thoracic erector spinae was considerably higher during loaded movements in healthy people.
This suggest that abdominal activity in regards to their stabilizing function should be retained with the lumbar spine moving into extension and not into lumbar flexion as commonly practiced in Pilates and in many rehab settings. It also shows that thoracic extensor strength and control is vital when trying to retrain dynamic lumbar stability into extension.
The video below gives you a good demonstration of this.
You can read more about this in the article – How to brace the core correctly to protect the spine from damage
Lesson 8 – Use Walking As Part Of The Rehabilitation Program
I never really appreciated the value of using walking as part of an exercise program and believed it did very little to help and that everyone should be doing it anyway.
My thoughts on this changed when I read the book called the “Gift of Injury” by Brian Carroll and Dr Stuart McGill which is about a powerlifter who suffered a severe back injury that almost crippled him and how he rebuilt his body through exercise with the help of Dr McGill.
There was a part in the book he refers to the use of an interval walking program during his early stages of rehab that made a big difference to his treatment.
Dr McGill prescribed him to walk 15 minutes at a brisk pace with swinging arms 3 times per day.
Here is what he describes as the reason behind this.
“Walking is the best tool we have in the essential early training of the muscles in the frontal plane. This simple movement engages and exercises the core muscles required to counterbalance a recovering back, and takes some of the load off the rear muscles. Pained individuals tend to carry an unnatural tension in their shoulders. Laxity is required in the shoulders to reduce spine load while walking which is why we encourage a jaunty arm swing to loosen those shoulder muscles as you stride.” – Dr Stuart McGill
This really stuck out to me as something that I should encourage clients to use more and I began to put this in programs for my clients stressing to them the massive value to the hip and core that it provided.
I recently wrote a detailed article about this you can check out – Walking is great for back pain and core stability
Do You Need More Help?
If you would like to follow our Step by Step approach for assessing back pain and applying the lessons here and many others, make sure you get a copy of our Back Pain Secrets online program below by clicking here.
With over 90 minutes of video and a PDF instruction manual complete with over 60 exercises this is a great addition to the person looking to get rid of back pain for good.
Conclusion
Now there was a stack more I would love to talk about, but really this gives you some insight into why we rate Dr Stuart McGill’s books, research and information so highly as do many respected practitioners all over the world. I encourage you to get a copy of his Back Mechanic book as it is a very easy book to read and contains many illustrations and basic explanations of what can be a complex topic to explain.
I hope you have enjoyed this article and it gives you some knowledge you didn’t have before.
About The Author
Nick Jack is owner of No Regrets Personal Training and has over 20 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specializes in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.
References
•Gift Of Injury – By Stuart McGill
•Low Back Disorders – by Stuart McGill
•Back Pain Mechanic – by Stuart McGill
•Ultimate Back Pain Fitness – by Dr Stuart McGill
•Motor Learning and Performance – By Richard A Schmidt and Timothy D Lee
•Assessment & Treatment Of Muscle Imbalance – By Vladimir Janda
•Scientific Core Conditioning Correspondence Course – By Paul Chek
•Scientific Back Training – By Paul Chek