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Stuart McGill was our guest on 2017 and left a big impression on the audience by talking low back pain causes and treatments.
Transcript:
[00:00:23] I can’t thank you enough for taking a listen to the show for another year in 2017 and as we come to a close and get ready to start another season of Peetie pie and cast we take a look back and give you the top eight episodes of 2018. Aaron no particular order. Again one thank you for sticking with us and listening to us and most of all for telling a friend the show is and will be always free for you to listen to and the best way you can show your appreciation is just by telling a friend Sharon episode on social media or sending an email to a colleague. So thank you for telling a friend. So take a listen and enjoy one of our top 8 episodes of 2013. Whether
[00:01:05] you want to escape the snow or planted Arias Medical has you covered. Try a rewarding travel assignment during the holiday season with Arias medical group call Arias at 1 800 3 4 0 26 19 or visit Boreas medical com that’s AUREUS Medical dot com. This is the mind gas. Like gas that talks about physical therapy. Over here bringing together clinicians researchers informed thinking PT’s in a show that is anything.
[00:01:40] But boring. Here’s your host Jimmy McKay.
[00:01:48] Here we go the next episode of my guest starts right now. The best conversations haven’t had a happy hour. Welcome to OURS. Our guest tonight he’s a professor of spying biomechanics at the University of Waterloo where he has a laboratory that.
[00:02:02] Explores low back mechanics injury mechanisms for goals and performance enhancement. He’s been author of over 240 scientific journal papers. And is a major over 40 graduate students during his scientific journey as a consultant. He has provided expertise and low back injury of various government agencies many corporations and legal firms handed professional international police teams. He has regularly referred to special occasion cases from the international medical community for pain.
[00:02:33] My guest tonight Dr. Stuart MacGill during the show. Thank you very much Tumi. Appreciate you taking the time out as a recent graduate and as a person going through school.
[00:02:43] Your name comes up a lot in the realm of LDP low back pain. So it’s cool to be able to actually put a voice to a name I’ve seen on line so many times. So first I want to start. Let’s start from the from the bottom or start from the very bottom the back we said there’s no such thing as non-specific back pain. But you say there’s three injury or pain mechanisms that you can show that it shows where this comes from. What does that mean.
[00:03:10] I absolutely stand by the statement there is no such thing as non-specific back pain. There’s no such thing as Lundbohm say cross-trained even degenerative disease I think does us all a great disservice. All this shows is that the person hasn’t had a thorough assessment that will render a precise diagnosis of their pain a full understanding of their pain mechanism. Pain isn’t normal. It’s there. There’s something causing it. The great clinicians sort it all out. You know I just get so dismayed at these current trends. The pain isn’t the patients head and things like that. The most distraught psycho psychological lead disturbed back patients are the ones that have been told that the pain is in their head. I honestly thought this was a video podcast so I had models prepared based on what we have documented as the various tissues sensitized pain trigger mechanisms. And
[00:04:21] I was going to show them to you. And there’s there’s many more than three but I just had three prepare.
[00:04:30] Well I mean the cool thing about the Internet is what we can do is we can put those those models up on our Web site if you want to talk through those that people want to check it out along and have a little bit of visual we can do that.
[00:04:41] There are videos of these things that are associated with my books and that kind of thing that are that are already there. But you know if we just took a disc bulge for example and I hear students argue about oh there are papers that show disc Bolger’s aren’t related to pain because some people have them and they’re asymptomatic and some people don’t have them and they have back pain. But these are radiological confirmations usually and the fly in the ointment in all of this is the radiologist never sees a patient. So they have no context for what they report seeing in terms of the patient presentation nor are they trained in the injury mechanisms. I mean we’ve created I think it would be fair to say this I think we’ve created more disc herniation than any other laboratory ever. Basically you need a certain amount of load on the spine you have to bend it cyclically over and over again in the college and fibres the ground substance that holds them together gets soft with each repeated cycle of sand and slowly with pressure the nucleus works its way through these dilemma and nations in the in the college. Well there’s so much more to this. Can you imagine if you had a slender rod like a willow branch you could bend that Rod back and forth and it would never break very resilient to bend. And yet you took a much thicker branch and bent it just a few times to the same level of and it would shatter. And the reason is the stress in that raw is a function of its thickness or diameter.
[00:06:33] So then we get into all of the variance in biology that caused some people to be very injury resilient and yet others are really in injury waiting to happen and it’s no one’s fault that’s just the way that their anatomy and mechanics conspire together to to allow these these cumulative stresses to eventually cause changes in their tissues and pain. Others have different shapes of disk that really modulate the ability to resist damage. Anyway the radiologists don’t seem to know about all of this and it’s very clear when we go through a patient’s MRI scans for example the fact that they have a disc bulge or not you can see there might be an open fissure there or a disc tear that causes the disc bulge to change shape as a function of posture. So when the patient lays in the MRI scanner there’s a certain appearance to the disc bulge. And yet if you were a physical therapist and you set them on a chair had them sit up right pull up on the seat of the stool to add some load the patient might say you know I don’t have any pain and yet they have a disc Boge there. But you could put them into different bending postures and quite rapidly within two or three minutes change the shape of that disc bulge and then they say you know my right toe is on fire. Well again you know it took a few minutes for the mechanical changes to take place. Now all of a sudden you have a very precise diagnosis and a direct link between the pain trigger the tissue insult and what the patient reports.
[00:08:27] You also have a very clear approach now as to what you need to do to avoid that cause and then to create a foundation for pain free movement. So there just might be one very small example. It’s quite a failure in our current practice. While
[00:08:43] I say this as a recent graduate somebody who was just in physiotherapy school not long ago there are so many different ways to think we’re being pulled in so many different directions and we’ve talked about this previously on this show not to say a low back pain but other pathologies or other schools of thought typically it’s the person who screams the loudest or who toss the most in social media. Unfortunately students or clinicians wind up listening to you more. It’s just so difficult to sort through it all especially as a student when you don’t have much to base it on.
[00:09:14] Well here’s a rule of thumb the more time the expert spends on Facebook the less time that never never true words of nervous.
[00:09:25] So I just want to give a nod to your new book and it’s called back mechanic you can check out more information about McGill’s work on his Web site which is back pro dot Kolonits backflip pro dot com a new book out shows that patients how to self assess their pain triggers and then what to do and what not to do. The first Trivett this jumped out to me the first movie is not exercise but to alleviate the pain. Let’s give a little tease to it to give people a reason to want to read more. What are you talking about there.
[00:09:55] Well I get hundreds of e-mails every day from patients and clinicians alike. Undismayed when a clinician will say well without exercise how many reps should we do. And I thought oh my god the answer to those questions are always it depends on the assessment and what you’ve just learned about the patient what are their current pain triggers what you need to do to avoid the cause.
[00:10:20] When a patient gets 10 minutes or even half an hour it’s very difficult to come up with a precise diagnosis in that time. I mean to be frank I spent three hours assessing back to go through the Neurology the biomechanics the joints and then I go through the psychology how does the patient learn what are their perceptions to really and then their social situations I can just think of a patient a couple of weeks ago who said you know I can’t go outside and go for a walk it’s not safe for me to do that in my neighborhood. So if you don’t know that you can’t prescribe interval walking as an intervention because the patient don’t do it. So to really understand a patient it takes me three hours but what the book does is it guides the patient through nine self assessment tests. It places them into different postures through different motions and under different loads.
[00:11:28] Almost all of the time motions postures and loads modulate their pain either for better or for worse. If it doesn’t that is a red flag. There is something else causing their pain and we’ve found tumors and all sorts of nasty sinister things by people who don’t respond and cannot find more comfort or more pain in these provocative tests. The patients are then able to say well you know extension with compression causes my pain a little bit of shear load causes my pain and then we guide them through a little bit of an algorithm that if extension causes their pain. It doesn’t mean flexion is okay. It just means avoid that particular trigger whichever it is. Now you get into pain science avoiding the trigger avoiding picking the scab allows the sensitivity to reduce. That’s why it’s so important not to add corrective and therapeutic exercises.
[00:12:36] Miserere. That you have to do that in the next to response. The one area or area area just removing levels and allowing needs a full schedule so are so special.
[00:12:52] There’s tons of research and study in the Journal of Bone and Joint Surgery based on the total cause of low back pain and just over a U.S. total between 39 and 78 billion dollars in the year 2014. We’re not that great at trying to visualize how big of a number that is. So I imagine there’s no way to think about it. That’s the 62 billion dollars around if you spend a hundred dollars every second it would take 20 years to spend that money that the US economy loses an indirect cause of low back pain every single year so you’ve definitely found one area of focus on because it seems to be the most prevalent. Why do we have so many back injuries for these animals that are supposed to be under loaded flex and move. Why does it happen.
[00:13:35] That is a terrific question. You know I was trying to write a piece just the other day someone asked me to put together a prevention program to address that very question. There’s so many things I would blame.
[00:13:51] Computers and the amount of time that so many people see it as being a prime cause. The perfect storm may be sitting at a computer for eight or nine hours and then going to the gym for 1 hour. Isn’t that so unfair that people who then go to the gym for an hour hoping that this will help them actually end up coming more intolerant to sitting than ever by going to the gym. I’m not criticizing going to the gym at all but it is the routines that they are performing that adds to what’s going on sitting in the computer rather than counterbalancing what’s going on at the computer. So this whole idea of program design is not keeping pace with the changes that people are experiencing in mechanical load.
[00:14:50] So that would be one that goes back to what you talked about there get lots and make sure you know what they’re doing for those those eight hours so you know what to prescribe next.
[00:14:58] Yeah. And then my next line of logic would go to the answer. Well you know it depends. Some people are just soft. They are not resilient enough to bear much mechanical or mental stress in their lives and it manifests in pain. Others overdo it. They think that they have to strive for a personal best. They’ve met one and instead of letting that settle their off now at the gym trying to get the next one. And we all know it’s it’s well documented that the one of the times of greatest risk is a step input in load. These are all reasons explanations for the spread of back pain. And then I think the inadequacy of treatment we all carry a lot of treatment tools in our toolbox. There aren’t let me use an analogy of a car mechanic of which there’s got to be thousands tens of thousands throughout the United States but how many of them know what tools to pull out of their tool box to build a car that they know is going to win at Indy.
[00:16:17] Very few of those car mechanics. So we can do that with any fashion but let’s choose those clinicians who deal with bad backs. How many of them have a good skill level with many different tools in their toolbox and can pull out the most appropriate tool for that individual person who’s in front of them to stop their pain cause and build the foundation that that individual needs. It’s not you know this approach is better than that approach it’s only what is the approach that is most suited for that individual.
[00:16:55] How do we get there. I just graduated. How do I get there without. I guess just you know family so many people fail. You know the first 300 cars that I tried to get to any I want to make sure so they’re a little faster. I’m not looking for a secret or an easy way out but what’s a great way to get there a little faster. Well
[00:17:16] I wish I had a lot of wisdom on that night. I know my own career path. It’s very untraditional. I don’t know if I would recommend it to anyone else only that it worked for me and there was. I can tell you Jimmy there was no plan to my life whatsoever. I started my Ph.D. in this fine biomechanics lab and I would obviously dedicate myself to doing experiments to investigate how the spine worked and how it became injured so I would have done that probably for a dozen years or so and then different. I’d be invited to different medical meetings say in Neurology meeting or in orthopedics meeting and the docs would say you know that’s a very interesting way to view that particular pain pathway it’s one that we’ve never thought of before would you come and see a patient with us. And my answer would be well no I’m not trained as a clinician and they said well don’t worry about it we’ll do that. Just come and see a patient. And then I found very quickly that I wasn’t tainted with traditional medical training and I could see a patient and read all sorts of syndromes that were so overt and easy to see that the docs were totally missing.
[00:18:38] And I would explain to them and I’d say well look let’s coach the patient not to do that but to do this and the patient would say Oh Doctor you’re magical. My thing has gone missing. Well not really all we did was stiffen your S.I. joint if you know that particular lunge was triggering your pain or let’s lay on your tummy for a little bit. Let’s see if we can position your head take a little bit of tense I’ll stress off your spinal cord relieve the femoral nerve root. Oh yeah the the anterior thigh pain just went away or the you know the tickle in my toe or whatever happened to be. And these guys were they could look at it as if you’re conjuring them and that magical show or something but no it was just an understanding of how the thing works.
[00:19:28] And then I guess the word got out and there’s been some days where I’ve had a couple hundred requests in a single day to see patients from around the world and some as you can imagine are very high profile athletes and politicians and whatnot. That’s what I spend my time now.
[00:19:52] I can’t stay home for for privacy reasons. But I had a patient come into a clinic my very first clinic at a beauty school and he had been a patient at that particular clinic on and off for a couple of years and had good results but he just hasn’t back issues and he walked in and he was talking to my boss and said I just want to see this guy up in Waterloo throw your name down and I said I heard that guy flew all the way up there to see it.
[00:20:19] Well geez I’m glad I helped him because I don’t help everybody that’s for sure. That’s that’s how this craziness came about.
[00:20:29] And I should say that in your training I’m sure you heard the names like Vladimir yonder the great urologist Shirley Solomon the fantastic physical therapist from St. Louis Dick Ehrhart was another great clinical mentor of mine when I was younger and he would see patients with me and teach the magic of what he had in his hands. Clayton Skaggs one of the he’s still practicing now. He originally trained as a chiropractor but then became a medical director of some very powerful sports organizations. And so I’ve been able to work with these great people. It’s my nature not only to try and learn from them but I study what it is they do then I’m able to go back to the University of Waterloo and oh and play with some of the concepts that I’ve learned from them. And once in a while I’ve been able to to make them a little bit better and been able to give them back to them and in a more modified form that’s a whole fun of it. And can I suggest that you do that is see I really can’t. But perhaps I could encourage anyone don’t follow Garou go out and try and get the audience and work with someone who has a bit of a reputation someone who isn’t on Facebook work with them and see if you patience with them then go to someone else and see what you can learn from them. Someone very different someone who you may not even agree with but if they’re good and they get a few patients better there’s something that they are able to do for that particular patient.
[00:22:15] You know some people work on psychological interventions others on purely mechanical others on you know might be a directional mechanical like Marchesa.
[00:22:27] And yet none of these are highly effective with large numbers of people. They work for the right person in the right amount. And then you move on to something else as the person progresses so anyway sorry for the long winded answer but now I like that I like you a lot.
[00:22:48] I really do take a quick break with Dr. Sterman when we come back we’ll talk about another where we can reduce the pain which is changing the way we set back in 60 seconds the peaty forecast.
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[00:23:16] The effective clinical practice is grounded in effective research and that is what the foundation for physical therapy does for over 35 years now. The foundation for physical therapy has made it its mission to fund and publicize physical therapy research over the years. Their researchers had helped introduce movement in babies with cerebral palsy to great dancing to relieve the ailment in patients with Parkinson’s and to develop video games to implement physical rehabilitation. The work of their recipients would not be possible without the support of donors like you your support can help us continue the therapy and work towards creating a world that thrives on it and you have the power to make a difference. Join the power of one and contribute today. That foundation for peaty for donation number 4 paid for and. Donate today and experience the power of one for the foundation for physical therapy online at Foundation. The number for peaty dot org.
[00:24:20] Considering a travel assignment over the holidays or ready to escape the cold weather for some winter sunshine. Various medical group is the leading healthcare staffing agency offering travel and full time career opportunities for Petey’s nationwide call Orpheus at 1 800 3 4 0 26 19 or visit Arius medical dot com that’s AQR EU s medical dot com give given to the back.
[00:24:51] It’s great to see you.
[00:24:53] Let’s get back to the show now. We’re back from the cast with Dr. Stuart MacGill professor of spy biomechanics at the University of Waterloo. We want to get into three questions three questions powered by our sponsors at Aria’s medical staffing. First question you can do what you do anywhere in the U.S. whereas someplace you’d like to visit and spend some time.
[00:25:14] I’ve been so lucky that I been able to travel your country so I’m trying to think of somewhere that I haven’t been yet and I might say Santa Fe would be one only because of what I’ve heard about it.
[00:25:32] My mother’s favorite town is New Orleans and I’ve never been there yet so there might be two two good spots right there.
[00:25:39] Same question three questions. What is something you’re either currently reading or maybe just read that really inspired. It could be physical therapy or non-physical therapy.
[00:25:49] I was listening to our National Public Radio a little while ago. I’m very concerned with what’s going on in your country politically. You may have heard of Ralph Nader who has run for your presidency. But in my view he’s he’s got a very just good common sense understanding of how things works and he has written the book to guide the rest of the world on how to handle this new USA.
[00:26:18] So there’s one third question on three questions. Who is so in any physical therapy or or maybe we’ll go with you someone in the back pain or the back biomechanics world that we should be paying more attention to maybe someone who’s doing some good work at flying under the radar.
[00:26:35] Yeah I don’t know if I would say back biomechanics because you know sometimes I get painted as this professor of spine biomechanics as if that is the only thing that we do and we you know there are very strong links between say personality and the mechanical response of a person. So that would be led by Professor Bill merece at Ohio State University.
[00:27:06] But there are some clinicians that oh I wish they could teach every physical therapist.
[00:27:12] I mentioned Clayton SCEGGS who’s based out of St. Louis who I think was a wonderful blend of having very gifted hands for soft tissue work and also a terrific understanding of corrective movement and exercise and programming and all the rest of it. I love what’s going on in the pain science area. As long as people truly understand what it is and it’s not a dismissal of all mechanical techniques then it’s all now just become this intervention where you assure the patient that it’s alright. Take that into moving. No that’s not what they’re saying. In my view you know I know. Lorimer Moseley and paedos Solomon in Australia really well I think people are taking some of their points way out of context. So anyway these are all interesting thoughts you’ve got some terrific clinicians in your military by the way I think a lot of Daja taken. I think she should be your next president.
[00:28:30] Like the campaign right now. Well I appreciate that’s a great answer will have some people to look up. Last topic I really wanted to get into some that I found your website reduce the pain may setting a dynamic task the ideal sitting posture is one that continually changes. Is that why people have begun and it can feel didn’t fight it figured out.
[00:28:51] Try to sit on an exercise ball or at a more dynamic service if you’re going to be sitting for a long time and if so why does not completely solve the prob well sitting on an exercise ball is fantastic for a very short period of time sitting in a traditional office chair is a great way to sit for a short period of time. So you’re starting to get the idea. Now stress builds up when you don’t move. So a frequent posture change migrates the stress from one tissue to another and it really stops or thwarts the accumulation. But generally speaking the problem with most people sitting it is the loss of Florida OSIS and the cumulative disc strain. So if you were to measure the strain in their discs as some people do that accumulates with the longer period that they said.
[00:29:52] But if you were to put a support in the low back and we happened to have a pneumatic one that you inflate and deflate you tonight with the amount of air that sent it to support the lower back that will measurably reduce the stresses on the college’s fibres that will eventually loosen up with a little bit of training at the gym and a little bit of prolonged sitting etc. As I was describing before. So anyway don’t sit too long. You know you’ve heard the saying that sitting is the new smoking. It certainly is. And last but not least it should be for a host of physical ailments cardiac conditions hormonal and of course the biomechanical influences on the spine and the hips.
[00:30:46] It is that is milking the analogy it the last thing we do on every episode is we some shots instead of a we do shots parting shots of wisdom. This is a party.
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[00:31:25] If there’s one thought or one little nugget that you want everybody out there to kind of take with them out of this episode and onto their careers next time I see a patient. What’s what’s a parting shot of wisdom. Like to impart.
[00:31:36] Treat every patients as they were your mother. They deserve a hundred percent of your full attention. They deserve your empathy every little ounce of training that you’ve had and attention I will ring the neck of a clinician when I see them in front of a patient. The patient is struggling and they’re sitting down writing notes or just not paying attention. So pay bloody attention and be a good professional professional at your job.
[00:32:07] I like that a lot. Dr. Stuart MacGill you could find out more information on how to connect with him and his teachings in his new book Back fit Frode dot com the new book is called back mechanic.
[00:32:17] Dr. McGill appreciate your time and sharing your wisdom with you. Thanks so much Jimmy and I get your professionalism behind the mike. Good for you sir. Thank you very much. This isn’t the last time we we talk. And again thanks for being on the show.
[00:32:32] Oh thank you. The B.G. by chance is intended for educational purposes only. Clinical decision making should be based solely on one source. Care is taken to ensure accuracy. Actual errors can be present. Our lawyers made us read that.