The Thinking Practitioner Podcast:

Episode 145: Can Discs Heal? (with Stuart McGill) 

Til Luchau  

The Thinking Practitioner podcast is proudly supported by ABMP, Associated Bodywork and Massage Professionals, the premier association for dedicated massage and bodywork practitioners like you. When you join ABMP, you're not just getting industry-leading liability insurance, you're gaining practical resources designed to support your career, from free top tier continuing education and quick reference apps like pocket pathology and five minute muscles, ABMP equips you with the tools you need to succeed and grow your practice,

 

Whitney Lowe  

and ABMP is committed to elevating the profession with expert voices,fresh perspectives, and invaluable insights through CE courses, the ABMP podcast and massage and bodywork magazine featuring industry leaders like Til, my partner and myself, Thinking Practitioner, listeners like you can get exclusive savings on ABMP membership at abmp.com/thinking. So join the best and expect more from your professional association. So welcome everyone to the Thinking Practitioner, and we are delighted today to have, for the third time around, a wonderful guest with us here, Dr Stuart McGill. Dr McGill, thanks very much for being with us, and let me just briefly introduce you. For those who may not be aware of your esteemed background here, Dr McGill is a distinguished professor emeritus at the University of Waterloo, where he was a professor for over 30 years, and works with high performance professionals and patients from all over the world who seek out his help for musculoskeletal back pain issues. And he has produced over 245 peer reviewed scientific journal papers, several textbooks and many and won many prestigious international awards as well, including the Order of Canada in 2020 for leadership in back pain, 

Til Luchau  

he gets pegged a little bit as the anti-motion guy. And you might have clients who have come to you with back pain and said, Hey, my PT told me never to flex or never to rotate. Sometimes those never prescriptions get traced back to Stuart McGill's work. He wrote a very influential book called The Back Mechanic, a self help book for people with back pain, and I know it's helped a lot of my clients. And sometimes people oversimplify the message from that. Dr McGill would say be, don't move. He'll clarify his views on that sum in the conversation, and then recap those a bit at the end. 

 

Whitney Lowe  

So Dr McGill, thank you again for being with us. Great to have you here.

 

Stuart McGill  

Thanks, Whitney and Til I always enjoy the time we spend together.

 

Whitney Lowe  

All right, wonderful. Well, we got a wide variety of things that we want to jump in today, of course, talking focusing predominantly on back pain. And Dr McGill, you've been working on some things for some other lectures around disc healing issues. And we have some special things we want to do for a podcast. Today, we're going to do a bit more visual-oriented thing for those of us who are following on the YouTube. So let's just start off with this. Looking at this tell us a little bit about what your experience in the current research tell us about the ability of discs to heal. Or, you know, I hear a lot, especially all the way back to the early days of Robin McKenzie's work about you can do exercises and push discs back into a more normal condition, if they had herniated in just one. See what you can share with us about where we are on this currently.

 

Stuart McGill  

Well, I can certainly talk about McKenzie's work. I had great discussions with Robin on this many years ago, but it's become much more of an important topic, I think, because of social media, with some people claiming that you can heal a disc, or at least adapt it simply by exposing it to the activity that you want to eventually be able to do, it may work for some, but I can assure people, it pushes a lot of people over the edge. So because of this, I've been asked to give lectures a number to a number of different places on whether discs heal, or do they adapt? Or is it simply up to us to guide the client or patient in how to best manage it and enable biology? Biology, the well, the biological processes to proceed. So I have a bit of a lecture, and if you would like, I can. Switch to a PowerPoint, and with about 20 minutes or so, I think I can create a basis for clinicians to make the best decisions on how to guide people on this.

 

Speaker 1  

And if you're listening on the audio version of the podcast, we'll do our best to describe the slides as we go along and put references et cetera into the show notes for you.

 

Whitney Lowe  

Okay, then you may want to go back and watch the videos later without out walking your dog or driving your car or whatever. So yeah,

 

Stuart McGill  

like hit Share, Okay, and there we go. And so first slide, can a disc heal, adapt, or simply be managed? I've set the stage a little bit. A couple of years ago, I really started to scour the literature on what science, current science says about discs being able to adapt to mechanical stimuli. And then I found this review paper by refilling colleagues in 2023 and I thought they did a really fair review, at least from a disc cellular level. It doesn't appear that degenerated discs can adapt, however non degenerated, what I would call a young virgin disc, can adapt to the applied load, but only if the loads are very modest. So to get anabolic change to the nucleus cells, you can apply modest load, which is just a bit higher than gravitational influences. So having said that, the argument is, can you, through mobility, adapt? And there is evidence for adapting the collagen matrix. But if you're trying to adapt load bearing, the adaptations require stronger end plates and stronger bone and a collagen matrix. In other words, there are two different processes, and there seems to be restrictions on you can't do both. You must choose one if you want really substantial load bearing ability or really substantial mobility, if you want an extreme of one that comes at a cost of the other, or if you just want to be middle of the road, the implication is you can just have modest load bearing ability, and lot of modest did I say load bearing and then modest mobility? I know I get pegged a little bit as the anti motion guy, anti flexion. And that's not it at all. If the person has pain, I care about spinal motion and mobility and posture. If there isn't pain, I don't care if a person wants to touch their toes. I have no context to judge whether that's good or bad. But if the person has pain, and if we provoke their pain by exposing them to a load or a posture. In this case, we might have the client sit on a stool, sit upright, neutral spine, and pull up on the chair. So just apply a compressive load, and let's say that creates an ache in their back. Okay, we've just determined that the ache in their back comes from compressive load, and then we get them to slouch or flex their spine, and their left small toes start to become symptomatic. Now we've defined posture as driving their pain.

Til Luchau  

Let me catch up a little bit on the pic. On the picture. Here we have our having our clients slouch over on a stool, and he said, pulling up on the seat of the stool. If that provokes pain, let's say in the left foot. You're saying that's a posture key trigger as a postural related trigger. 

 

Stuart McGill  

If they are right forward and the left toes become symptomatic, either painful or numb, then yes, that's posturally driven, versus just having them sit upright. And let's assume there's no symptom, and then they grab the stool and pull up, say, 20 pounds per arm, and if that creates an ache in their back, then you could say, well, that's load driven. Or if they became a peacock and lifted their chest, you could say, That's load plus extension posture driven. You see? Okay. Now let me switch topics a little bit and look at the basic architecture of the disc, because some people treat a disc like a ball and socket joint. Well, the hip is a ball and socket joint designed to create power that is high joint. Forces and torque through a range of motion. It doesn't create local stresses, doing so until the very end range a disc, however, is this adaptable fabric of concentric layers of collagen. Now let's look at the collagen matrix in the collagen fibers in a disc, about 80% is type one, collagen, which gives strength and stiffness. Stiffness not being a negative term, stiffness, simply being a property of a material like a like it has mass. It has stiffness, which determines its elastic behavior. Type Two collagen is the elastic collagen. It's about 20% in a disc. But what is important when we have a discussion of adaptation is collagen type X, types three through 10, that bind collagens one and two together and prevent it from delaminating. So the type X collagen is follows a spectrum, like everything in biology and influenced by who the parents were of the person their training past exposure to disease, various substances, performance enhancing drugs, etc, tend to influence the behavior of type X collagen. Well, now let's look at some of the collagen science. And we look at Professor Jill Cook's work from Australia, very good scientist, showing how in a Achilles tendon. When you expose it to load, it adapts quite often positively, if the exposure is of the correct volume, etc

 

Til Luchau  

 She was on the show recently talking about this, the ability of tendons to adapt, right, please.

 

Stuart McGill  

Yeah, it's very good work. But here's the the rub, the applied load is parallel to the collagen fibers of the tendon. There are no delaminating stresses. But now let's look at the architecture of the disc, which, as I said, is concentric lying rings of collagen where each ring has a different orientation to the collagen. So if you move the disc back and forth and apply compressive load, you're creating tensile stresses that eventually turn into delaminating stresses. In other words, the applied loads are not parallel to every fiber, because every fiber has a different orientation. So when you look at the work of my colleague at the University of Waterloo, Jack Callaghan, and his students, he's shown at a micro structural level. The you can see in the lower right how the collagen fibers of the disc start to separate and delaminate with repeated motion and load opposite to the effect that Jill Cook found in the parallel orientation of

 

Til Luchau  

the Achilles tendon. Yeah, so that's if

 

Whitney Lowe  

there's any difference in this being compressive loading versus tensile loading on the on the collagen fibers in the Achilles tendon.

 

Stuart McGill  

Well, yes and no. Consider now that when you squeeze a disc, the nucleus increases pressure. In order to contain that pressure, the annular fibers are in tension.

 

Whitney Lowe  

Yeah, that's right. If the

 

Stuart McGill  

I didn't think we would get into this level of discussion, but it's so interesting, when you look at a person who's done excessive weight lifting, and they have a posterior disc bulge, and when they bend forward, the pressurized nucleus works its way through the delaminated collagen posteriorly, in other words, flexion almost always drives the posterior disc bulge under compression. But now let's take a person who didn't delaminate their collagen through weight training, but they did excessive mobility training when they bend forward, the posterior aspect of the disc doesn't bulge the anterior part of the disc bulges in compression. It buckles because it's a softer kind of collagen. So do you see how a mobility-adapted person's disc behaves very differently than a weight trained person who is excessive in that exposure? Is this very different?

 

Whitney Lowe  

Is this a genetic thing in terms of the way that disc would respond differently, or is it because of this type of training?

 

Stuart McGill  

I'm getting to that the answer everything matters and both of these things, that's why it's a lecture. Yeah, okay, I'm going to talk about genetics and exposure here in just a sec. So when we go back to our work, this is about 20 years old now, with orthopedic surgeon Claudio Tampier, who did his graduate work with us, the way that the load exposure is created matters as well. In other words, if we flex the disc and then added repeated twisting because of the concentric layers of the collagen fibers in the annulus, the delaminating stresses form between the layers. So you can now see in the bottom right, we dyed the nucleus a chromium blue, so the gel now works its way between the layers of concentric collagen and between the layers. So it works between the layers with repeated flexion or extension, and sorry, did I say between the layers? I meant between the fibers, but we see the delamination between the layers in repeated twisting because we are one layer, the collagen fibers run in a counterclockwise versus the clockwise of the other. So if I turn to the left, one layer is approximated, the other layer is distracted. So you see the competing delaminating stresses between layers with twisting, and that's what we're showing with the delamination between layers in the lower right that you can see. So does exposure to a particular load heal? And this isn't only from our work. Now I'm showing several authors who have all agreed on this, that the discs don't heal. You can manage them, shall we say, to subclinical levels, but there's really no evidence that you can heal a disc. So to summarize,

 

Speaker 1  

can I, go ahead,  so exposure to load, just to translate that into everyday language, that could be actually a weight bearing load, but you're saying could also be a bending load or a mobility challenge. This is also, does that apply in those cases, too? In other words, can we stretch our way into healing. Or is it, or is this irrelevant, just the weight bearing.

 

Stuart McGill  

I'm hedging on this, because the magnitude of the exposure really matters, and it's managed by the tipping point. So if the person wants to stretch and they don't need stiff X-type collagen to hold the fibers together when they're weight bearing with heavy load, then yes, they will adapt more mobility to their spine, but the volume must be underneath the tipping point. Okay, it's sufficient mobility, but the compromise now is they're giving up the ability to work in the in the weight room, for example, where they will need much stiffer collagen to stop the fibers from delaminating, meaning that they can't have as much motion, repeated motion ability. So when they would say squat with good form, meaning that they use the hips, the knees, the ankles, don't bend the spine very much. But if they want to bend the spine, they can't bear much load. This is the trade off.

 

Whitney Lowe  

So if we're saying, for example, that the disc, there's not a lot of strong evidence the disc can actually heal. But can it, for example, maybe you don't heal the the delamination, but can it sort of get pushed back into less herniation, for example, is there a feasibility to show

 

Stuart McGill  

evidence on that again in a couple more slides, and eventually it will gristle. So you look at like my self, who's almost 70, I had delaminated collagen in my 30s and 40s and discogenic back pain. I don't have it now. The discs have stiffened. They've lost height. I can't move my spine as much. However, I can also bear a lot more load, so time will cause adaptations. But if I tried to do it through strength training earlier, I only would have softened the collagen more. In other words, leave it alone, let it settle, let biology do the stiffening, and it will regain. You know, with many of. Your clients, they will say, Yeah, I had repeated episodes, very acute episodes in my 30s, 40s, perhaps early 50s. But once I hit 62-63 I never had another acute episode of back pain. But now the game changes. Maybe they have a little bit of central stenosis with thickened facet joints and some of these other issues. But this, this particular slide. Now I'm just giving a case study of this. Is a super athlete, a client I had a little while ago, and the massage and body workers were working on him to get more spinal extension. Well, I hope you can see in the right. CT, scan, he has an anomaly in one of the facet joints where they're hooked, that joint will not extend. And do you see it? The joint below there is a hook on the anterior part of the labrum of the disc, showing that that is the joint of instability, or a lot of sheer micromovements occurring because the joint above and the joint above that will not glide and move. So the mobility clinicians were pushing rope on this and actually making him worse, and they couldn't understand why. So, you know, I don't see the successes. I only see the patients who aren't responding. And okay, now to get to answering some of your previous questions, people who know me, they'll say, Well, what is the secret to lifelong disc health? And I'll say one of them is to keep your end plates healthy. And they look at me as though I'm from Mars. So let me tell you the reason for looking after your end plates for long life, annulus and nucleus, disc health. We took spines from animals, and you can see the spinal on the left being a virgin spine, and then we loaded it to simulate a one times body weight, deadlift, and you see the broken trabeculae and the broken end plate from an excess of compression. You will hear many people say, my discogenic back pain started with an excess of deadlift, or they slipped and fell on ice and pile drive their spinal In other words, it was a compression exposure, which people don't think that causes disc herniation, which directly it usually doesn't. But here's what happens, because of the cascade now being initiated with heavy compression. Once the end plate is damaged, the disc loses a little bit of height the nucleus pressure needs to be high because blood vessels, nerves are always trying to grow into the nucleus of the disc, but the high pressure kills them. So you'll see some studies that say, oh, only the outer part of the disc is innovated. I can tell you, those are young people that the cadavers were obtained from. And if they look at the next study says, oh, no, the nerves go all the way through into the, say, the outer third of the disc, or all the way through the disc. Well, they were harvested from older people who had uh, end plate, uh damage. So now I can, from that step, go on to talk about a disc bulge, uh, interestingly enough, I think we were the first to really test Robin McKenzie's theories that some of the extension protocols that he advocated actually vacuumed in extruded, posteriorly extruded nucleus. So if you look at the Xray on the left, we loaded up the nucleus. This is of a virgin disc now with a barium or a radio opaque material, and you can see it's contained inside the nucleus. And then we squeezed the spine, and you see in the right panel the nucleus has now left the disc, gone through the fracture or crack in the end plate, and it resides up inside the vertebral body, so that will create what's, you know, a modic change. If the person has had an MR. For example,

 

Whitney Lowe  

isn't that also referred to as a schmorl's node? It again this, can I interrupt you for just a second and ask pain related here, what is the level of innervation of those end plates? Because I know you know, like so, many of our bones are covered with periosteum that is super pain-sensitive, and so like when you have those minor fractures in the end plates, is that something that might be the pain generator itself?

 

Stuart McGill  

can, it can be a schmorl's node. If the fracture is small, like a little it looks like a little bomb crater. Or actually on purpose of the end plate, but it could also be a crack, or it could be underlying trabecular bone fracture as well different types of fractures, and by the way, the spectrum appears to be more hereditary than anything when it comes to what type of bone fracture is the end plate going to sustain? I'll talk about that in just a second as well. But what's interesting, this is from our own work and some of our own patients. If you look on the very left, do you see the edema underneath the end plate of the sacral plateau, you can see the little fracture and the damage to the end plate. Interestingly enough, when you harvest the extruded nucleus in surgery and perform an assay on it, most of the time, you will find fragments of cartilaginous end plate. In other words, prior to that disc bulge, the end plate fractured, broke, and as the nucleus worked its way through the delaminated collagen, it pulled with it little fragments of end plate, proving that the end plate was already pre damaged. Well, then this group came along, Rajasekaran's group, who won the issels Prize in 2013 and once again in 2024 last year. Originally, they found that when you harvested the nucleus of herniated discs, 65% of them contained fractured end plate. That's a that's an incredible statistic. And our work, and Robertson's and Brooms work from New Zealand, all then showed it. All showed that if you had the end plate damage, and then you repeatedly flex the spine, the disc is very potent pathway for posterior disc herniation. Then we look at Well, I can speak from personal experience, because I've had three of them, and I can tell you that one was in my neck in c4 I finished the game. It was in a hockey game. I finished the game and then it got a bit cranky. But really, however, on CT and MRI, I've got a flattened c4 desk two years ago, you're gonna laugh at my stupidity here. You might know I have a fatal personality flaw in that I love hot, high powered snowmobiles. I hit a rock at 100 miles an hour two winters ago and fractured T 10. Knocked the window to myself. I knew exactly what I did at the time, but you know, after I collected myself, I still rode my sled home, and I actually had more pain over the following year, and I can still feel it if I go into heavy extension, right? But at the time, no, not much pain. So it's the tissues around the joint that quite often trigger the pain. I did one in my in my lumbar spine in my 20s as well, and immediately I heard the fracture, and I heard the pop. I didn't really get the pain until the following day, and then I think it was from other tissues, nerve compression and that kind of thing.

 

Whitney Lowe  

And I would assume maybe some of that might be the chemical inflammatory soup caused by the fracture, too.

 

Stuart McGill  

I think you're dead on with that. Yeah, absolutely okay, so this may or may not help the listening audience, but Jerome fryer created some models based on our early work of disc herniation, and I'm just going to show that in order to create the hydraulics to get The nucleus to push posteriorly, you apply compressive load together with anterior flexion, bending, and that creates hydraulic pressure, and you can see the nucleus being pushed out. But in this next cycle, we don't allow flexion, you can see the whole disc deforming and flattening, but the hydraulic. Necks are not biased posteriorly. So if this person who had this particular delamination in their their posterior annulus, if they flexed over with a hip hinge, there wouldn't be any nerve compression. But if they flex their spine, you can see there would be direct nerve impingement there. So having stated that, this was the machine that we used for a number of years to create these dynamic disc bulges caused by flexion and compression, and we would then document how with each cycle of flexion, the nucleus would be literally pumped through the annulus until we saw a frank posterior herniation. And at that point, we could get together with Robin McKenzie and say, do your techniques truly work to vacuum in and reverse the posterior disc bulge. And the answer, here's some of the evidence. This comes from my work with Joan Scanal, one of our our PhD students, and she was a McKenzie-trained therapist. There would be the disc bulge shown on the left with the radio opaque contrast well on its way, working through the delaminated collagen posteriorly, and then she was able to prove McKenzie was right, that he could reverse the pressures pushing The nucleus posteriorly and vacuum them back in again with the what is known today probably as the floppy push up. Okay, a lot of clinicians use the floppy push up, but here's what we have seen clinically. There will be a client comes in and we review their history of back pain with them, and they say, Yes, well, I had a frank posterior disc herniation. I went to a clinician who prescribed floppy push ups, and I've been doing them every morning when I get out of bed for the past year. And now, extension triggers my pain. It's a whole new pain. And we say, well, yes, no wonder. We now look at the changes that have been induced to the facet joints in the neural arch because of the repeated extension. So the next question became, was there a mechanical correlate of the floppy push up and extension that that achieved the same vacuuming result. I should also say that not every spine responded to floppy push ups, just like you find, clinically some people, it's poison that makes them worse. And what Joan found was that if a person had retained 70% in other words, they lost 30% of their disk height or more, it wouldn't work. It would just rub the facet joints that were already compressed. So what we were learning was for the McKenzie protocols to work, only a little bit of disk height could be lost. Well, then we tried static postures that were not so irritating of the facet joints, and we in our first 16 specimens, we found that just simply laying in a static, extended posture, vacuumed in the disc bulge every bit as well as the dynamic, repeated floppy push up extension with the same restriction, and that being that 70% of the disc height had to be remaining or more. Well, that was work that we did quite a number of years ago. And interestingly enough, a very recent paper has just come out showing that a person standing in an arching backwards, once again, statically created this improvement in their clinical pain. So there seems to be some justification. Well, first McKenzie was on to something, but it may be that simple isometric postures are good enough. Well,

 

Whitney Lowe  

if I can, I interrupt you for a moment. There's something I want to the thing we were talking about with the compression loading versus the compression loading plus forward flexion. That then seemed to indicate some protrusion of the disc. This is something that has always bothered me, and I'd love to hear your take on this is like, how much is that disc actually protruding? Uh, let's say it's relatively close to nerve, you know, nerve roots that are coming out of that region we know all over the rest of the body that nerves can take, you know, moderate amounts of pressure and get pushed and prodded and poked all the time without being symptomatic. So how much does that disc really actually move in a protrusion, and is that nerve so taut that there's no like give or no slack at all in it to be able to absorb any of that force? Yeah,

 

Stuart McGill  

it's a fabulous question. Whitney, again, I'm not avoiding the question, but a thorough assessment should give you the answer. For example, say, the person has a little bit of a disc bulge at t9 that has already pre tensioned the whole central nerve, so that a minor compression or touching of the nerve at l4 or l5 is enhanced because there's already, in other words, you're holding the rope, pinning it down now, and giving it friction at two points rather than one. There might be a cyst on that nerve root. There might be a tissue adhesion somewhere along that tract. And then the other thought that's coming to mind is, when I work with radiologists, we will put a client into an MR. Scanner on their back, and we'll measure the size of the disc bulge. Then we'll get them out, and then for 10 minutes, they will sit slouched, and then we put them back in the scanner, and you will see a much bigger disc bulge. Or you could put them in and lay them on their tummy, and the disc bulge has probably greatly reduced. In other words, the motion of the nuclear material through the open fissure of the delaminated collagen responds quite quickly. And those are the people who report, oh, if I sit on a soft couch for 15 minutes watching the TV, the radiating fire down my leg just lights up. However, if I sit on a kitchen stool or on a chair like I'm sitting on now, a very firm chair with a pretty aggressive lumbar support. I have zero symptoms. So you can see how quickly the geometry of that disc bulge can change, and it can change from a friction into a compression, etc. So there's just a little bit of a riff on that, but the assessment will always show you what the variable is that's offending the disc, whether it's whether it's a compression induced friction or a posturally induced friction, and then try and decompress the disc. All right, have them do a prone lay, maybe they're a little older now and they cannot tolerate any McKenzie like extension. But if you were to ask them, Well, put your hands palms up under your belt line. In other words, we're biasing the spine into a little bit of flexion. Now they'll say, oh, yeah, that's reducing the symptom. Good. Now pull on their legs a little bit and they'll say, oh, that's removed all the radiation out of my legs. Good. That, by the way, was the most potent combination we found to vacuum in most disc bulges that being a prone lay, nuancing the curve of the lumbar spine and adding a little bit of traction on the legs. And then, if we really want to get expert on that, we can internally rotate or externally rotate the feet as we're applying traction to either add some controlling stiffness or take some controlling stiffness away, or you're even changing the path of the nerve. We know, as we externally rotate the hips, we're pulling the l5 root more in detention than we are the l4 root as an example, you're making the path of travel a bit longer. So the amount of you know, we call it playing jazz to see what is the magic combination that reduces the person's symptoms.

 

Speaker 1  

Improvising, experimenting, trying these different variables. You're giving me some ideas of things to try. You're describing almost a reverse McKenzie, where there's actually a bit of flexion as well, and a different place of pivoting. Well,

 

Stuart McGill  

while we might if we find that, you know, if we were to do what we call a short stop squat, you know, where we have the person. Uh, I'm having my my hands wide open here, and I'm going to place my kneecap between my thumb and my fingers as if I was playing shortstop, and then while people are watching, so they will get this big hands. I slide them down. I grab my knees hard, and now I'm going to play with the curve of my back

 

Speaker 2  

in flexing, extending your lower back. 

 

Stuart McGill  

Yeah, yeah, until I make it as comfortable as I can. Now, I found the magical geometry that the symptoms are reduced. Now I'm going to push my toes down and lean into it, which adds a controlling co contraction now and then we coach the person not to lift with their spine, but to pull their hips through. And now, all of a sudden, that movement, which is a very controlled hip hinge, has taken all their pain triggers away.

 

Speaker 1  

You have so many of those stories and some of those examples of these magic, little jazz combinations that relieve particular people's pain has been inspiring to me to be more experimental and to really use the in the moment, experience of the client as the guiding indicator of what we're going after. Are there other takeaways that you would like to give manual therapists about we've covered so far, you've made a really clear case for the existence of physical damage or the limitations of the disc to adapt. How would that impact how we work as manual therapists, or hands on therapists?

 

Stuart McGill  

Well, my last two points are really adding a base knowledge. So I was just going to give a bit more evidence on what leads to the ability of a disc to instantaneously resorb but I'll skip that. I'm going to go to Michael Adams work, who I consider to be one of the all time best disc biomechanists, and we both retired about the same time, and it was at that time he put forth this idea of the phenotypes of discs, and I've really come to appreciate that in the last 10 years. In my own work,

 

Speaker 1  

there's another slide for this. Still. Is there a slide that,

 

Stuart McGill  

yeah, there is, it's, it's, it's coming, um, there is a biological spectrum of every single variable and trait that define all of us. When we look at the bone type of damage that I talked about, end plate damage that seems to follow families. It's passed on. It tends to be hereditary. So you know, if your mother developed a really pronounced kyphosis as she aged, it really increases the chance that you may do that as well. However, the collagen type of damage that I was talking about with delamination seems to be more mechanical. It's the exposure to those mechanics of repeated cycles of load with flexion motion. Now, even there, there is a biological spectrum, and we know that the thicker your spine. And I'll just go back to bending a willow branch. You can bend a willow branch back and forth, and it doesn't create stress because it's thin, but it's the property of a round rod or tube that it if it's thicker, the larger the radial thickness, the higher the stress in the convex side and the concave side between compression and tension. So a thicker spine is suited for load bearing, not for bending. You don't see too many strong men or big power lifters who do a lot of bendy twisty sit ups, that kind of thing. They're usually people with finer frames that gravitate to those kinds of activities. Their joint conformations being slender, naturally develop less stress. You know, you can't take a St Bernard and train it like a greyhound and expect it to win it that the dog racing track, it won't happen. You'll end up with a broken dog. And you know, there's a lot of wisdom in that for body workers to consider, who is it that they're really working with? The

 

Speaker 1  

other you're not trying to make, maybe not trying to make everybody move the same or feel the same under our hands. Or is that? Is that the one of the takeaways?

 

Stuart McGill  

Yeah, it's not possible, for sure. And I've had, you know enough of my friends, my good friends, who are fabulous body workers, I've been the benefactor of their work. And I know there's a great difference among them some, you know, and I, prior to my getting hip replacement, I fractured my hip. It was absolutely brutal being worked on by some general massage people say, Oh, well, we'll loosen up your hip. For me, I couldn't walk for a week after. And then I I come to another just such a masterful body worker, and it's such a different experience. They know what to work on, what to release, what to leave alone. And you know the names I could throw at names like Clayton Skaggs. If I saw Clayton Skaggs every three months, I didn't need hip replacement. It. You know, he was absolutely fabulous.

 

Til Luchau  

Do you shout out to Clayton

 

Stuart McGill  

Skaggs? Yeah. Does the name Baron Spatos mean anything to you? I don't know that any. Yeah. He's he's sort of a really well known unknown, at least in the professional sport world, the hockey players, the baseball players, the NFL ers that they know who Baron Spatos is. And he's another one of these guys with just the magic hands. But it goes so much far beyond that you know, he knows how to stimulate a reflex and leave something else alone. It's, it's quite magical what he can do with his understanding of this biological spectrum that we're we're talking about.

 

Til Luchau  

You've made really clear case for all of us about why we don't want to just mash everything and give me everything floppy or soft? Why the the important role of stiffness or resilience and the understanding that there may be physical damage and limitations to adaptation when there's been an injury like that?

 

Stuart McGill  

I think the concept that I'm trying to use to answer your question with your audience has to do with tuning of the body, and sometimes to get an effect, stiffness is required in some places of the body. So if I want to throw something, for example, if I have proximal stiffness in my core, whatever power I can create in my hip, then transfers through my core, through to my shoulder, and then I can whip my arm to throw a ball, or, you know, a tennis racket, or whatever it happens to be, so that strategic whip, for example, is unleashed through the combination of proximal stiffness And then distal timed mobility. And when a therapist understands that unleashing of the performance, they know what to leave alone and even encourage perhaps a co contraction to lock it down and then mobilize something a bit more distally. Or, you know, I gave the example of that athlete who the therapists have been pushing him into extension because he his his sport requires him to rapidly extend the spine. It's not going to happen. They had to do a more thorough assessment to learn that they're only going to make him worse. And and do you really want to mobilize the joint below? Not really. It's already suffering and showing the signs of being too mobile with the bone spurs that are now growing at the joint below. So here you have a joint that's locked because of anatomy, and now the joint below is becoming so lax because it has to move for the three above segments that aren't moving, that isn't going to end very well if that's continued to be pushed however, a little higher up, I know what We did, a little bit more general thoracic extension mobility really helped. A little bit of hip mobility and the training of the new movement to utilize the strategic tuning of his body. A bit more mobility here, a bit more. Controlling stiffness there. We did a study. Jan Morehouse, she was a PhD clinician at the time. We took hockey players, and she did three dimensional mobility work on their hips? Well, if you know hockey players as a collective, they have stiff hips. They're in the fifth, or, you know, very low pro distribution of hip mobility. And it's just the nature of the sport. It stiffens their hips, pulling all their heavy skates and equipment through in this in the striding skating motion. She was so successful and such a good clinician in taking those hockey players from the fifth percentile on average of mobility through to the 75th percentile. So she was an extraordinary, successfully stretcher. Do you think the hockey players then used the new mobility, walking, getting out of a chair, just in daily activities? And the answer is not, because if you give a person mobility and you want them to use it, you have to change the engram or the movement tape. Sure that that was the big finding of that particular study. So there's another take home for perhaps your audience, if you really want to change movement, simply strategically stiffening and strategically mobilizing may not give you the movement you want until you've grooved in that desired movement for whatever reason, whether it's to avoid further injury or movement efficiency or speed or whatever.

 

Whitney Lowe  

Yeah, I think the same thing is true. You know, I certainly have kind of changed a lot of my tune on this over the years, of thinking that we could make very significant sort of structural kinds of changes with people's backs necks or whatever, with the one hour session that we do with them. And I just, I think that same sort of thing is so true that so much of this is going to have a whole lot more to do with the way in which they move once they leave then, then what I might be doing within my my confines of my 60 minute time with them.

 

Stuart McGill  

Do you want to comment from a guy who doesn't have the skills that you two have, but I've got quite a number of years of back pain, people, of course, you know, we got to know one another at the international fashion meetings, and in my lecture there, I admitted I'm a newcomer to this whole fascial area. Shall we say. And it wasn't until I learned that don't stretch locally that all of a sudden I became to appreciate what you did, but it also made me better. For example, say we have someone who who has had quite a history of hip pain or back pain, and we know the neurogenic loops they will they may have neurogenic facilitation of the psoas muscle, neurogenic inhibition of the gluteal muscles. And if we can rebalance those, we've restored performance and some pain free function, all right, but what I learned from working with your group was that that psoas muscle, we could say, well, that's a hip flexor, and you can stretch the hip flexors. Well, wait a second. What I learned was that if I now appreciate the whole anterior line, and the might be the spiral line, if I can push my arm strictly overhead, and not only that, but if I push the heel of my hand to the ceiling, and I internally and externally rotate my shoulder, I can monitor the change in psoas tension and how that whole fascia linkage now determined the success of releasing that psoas. In other words, how many articular linkages in the skeleton. Did I have to think through to get where I needed the effect? So that's what I learned from I'm calling it your group, your area of expertise, and and that was, you know, you had. Ask me, what is the implication for the body workers and the fascia expert? So I'm giving you an implication of what it has done for helping me, and then I can add our mechanical assessments to now appreciate the full linkage to retune the body. I don't know if I'm not arch,

 

Til Luchau  

that's helpful. You're saying you're talking about the big picture perspective, the fat. And this has really been emphasized in the fashion world, how these long connections are important to consider, not just the named parts we think about conventionally, but then how thinking in bigger linkages, bigger lines, bigger connections, can really open up different possibilities for pain relief or control or change the proprioception, the relationship between span Whitney,

 

Stuart McGill  

you asked me earlier about, does there have to be a big disc bulge to get compression of the nerve and pain. Well, we will see, sometimes say, we do a a pull on the femoral nerve root so the the person might be prone on a table, and we will bend the knee, bringing the heel towards the buttock. We might see a little bit of Eli's sign so we know that something is tight. But they'll say, Oh yeah, that is my upper lumbar back pain. You have just replicated the pain that I came to see you about. All right? It's a fetal nerve root. And then I grab their arm and I pull it up overhead. I pull the heel of the hand into full extension, and they'll say, Oh, you just took my pain away. What did you do? Well, I didn't do anything to the disc bulge. I changed the position of the nerve. And for some reason, I don't understand that that time, the mechanic of the interaction between the nerve and the disc bulge, but I just found the medicine to take the pain away. So does it really matter? Okay, well, then let's use a little bit of what we know about reducing the disc bulge. We'll try that for 20 minutes, and now Let's retest that very offensive femoral nerve root irritation that I just described. And I'll say, oh, yeah, no, I my symptoms now gone. So we may not know the description and the mechanism right at the offense, but does it matter when we've just discovered how to take it away.

 

Whitney Lowe  

Were there? Yeah. And I would, you know, certainly make the argument that it matters to a certain degree to figure out what's happening eventually. So we can apply this to other places and apply it to other people, if we can do that at all, but certainly for that one individual, we found a solution for them, right? And

 

Speaker 1  

the principle that, again, I get reinforced every time I talk to you, Stu is the jazz one. It's knowing my instrument, knowing the territory, but being willing to adapt and experiment and find out. What is that combination that makes a difference for someone in that moment?

 

Stuart McGill  

Well, that's why it's so much fun when we can have a patient together and share ideas.

 

Whitney Lowe  

Wonderful. Well, no one other thing I wanted to kind of add we've been talking a little bit about some of the other things from the perspective of how this influences and impacts other soft tissue manual therapists. So I get this a lot, hearing from people we have a big problem. You may be aware of this in our profession, with longevity of people staying around for a long time, mainly because it's a very physically demanding occupation that people do. So lots of folks doing this work bend and reach all day. So which spinal stressors Do you see most often in those kind of practitioners, and how might they kind of focus on the things that they can do to improve their mechanics, or do things that will decrease the detrimental aspects of those loads?

 

Stuart McGill  

What's going through my mind as you're asking that question? It's it's not only body workers. It's dentists. It's, you know, I'm trying to think of a trade like, say, a plumber, yeah,

 

Whitney Lowe  

dog washers, you know, yeah,

 

Stuart McGill  

yeah. I can tell you that that the if you take in the American Dentistry Association. I did a keynote lecture for them a few years ago, and I thought they got the wrong guy. And I said, Well, I'm a back pain guy, and the President says to me, yes. He says the number one reason for unwanted retirement of American dentists is back pain, and I suspect it's for your profession. Yeah. As well. So it's a big deal. And I would say, even when I get an athlete here, you know, some of them are pretty magnificent names, and I wonder, why are they here? And it starts with an underperforming core. So for whatever exposure it is in their sport or their occupation, you are an occupational athlete, and your colleagues, the core is not up to the task, so your members are getting pain. So now to be a bit more specific about that, because we have to guide an intervention. First, we think about what we call as being external mechanics, so external to the body, a body worker will apply a force in a posture to a client. If I push my hand through my core, I'm creating a thrust line. It does not well. I'm trying to figure out where my camera is. There it is. So I'm creating a thrust line that goes through my core. But if I create a thrust line off center, it's pulling my core. So there's an example of if you can apply a force, whether it's a push or a pull or a traction, and direct it through your center, through your center of mass, or through your spine. Shall we say, there's very little impact on your spine, so that thrust line, as it's called, try and drive it through the joint that you're trying to save. So there would be a beginning principle. Postures matter to joints, but the spine is a flexible rod. If the spine is in a highly deviated position, and then you have to apply a load. The passive tissues of the curve rod take the load. But if you can neutralize the spine, you know, I can flex and extend my spine through the range of motion under muscular control, but it's at the end range of motion where either the facets are jammed together in extension or the discs are taking the load and the ligaments in full flexion, whatever the case may be, if I can create a neutral spine posture, meaning that I have to set that up with a different hip confirmation, a different knee conformation, different shoulder conformation, but those joints are made to be mobile. They're ball and socket joints. So there's a there's another principle, I would say, things like the simple stuff that everybody knows, try and get the person's neck or shoulder or thigh, whatever you're working on, close to you. That's that's all very simple. So these are all external mechanics to think about. Now comes the internal mechanics. The curvature of the spine determines which structures bear load, just as I showed before. If I fully flex and I pull the fascia and the nerves a certain way, or think of a nerve flossing movement, for example, if I open up the hand, extend the wrist, extend the shoulder and look the other way, that's a nerve traction, but I've now released the nerve by changing different positions in the linkage to affect the tissue that's bearing the load. So these are all internal mechanics. Now, the assessment of the person's pain will guide you as to what is it that you need to spare, and now you've unlocked what is it that that clinician has to do now to either retune their body to handle the stresses in a distributed way so no single tissue crosses their tipping point, etc. So does that answer your question?

 

Whitney Lowe  

Sure. Yeah, very well, thanks.

 

Stuart McGill  

Yeah. I wish it was a simple answer, but every single person will be a bit different. You got to spare them that have a low tipping point.

 

Til Luchau  

Yeah, and you're painting a picture of finding the sparing combination of factors, not and this is one that I want to just name for myself, it isn't to repair necessarily some damage, as much as help people find a way to adapt to what limitations they might be dealing with in the physics. That's what I'm always impressed with talking to is. Is the detailed picture of the physics you paint for me and the different perspectives into it, and you talk about limitations, but it's in service of what you're giving us, which is this possibility of less pain, more function, finding a way through these different puzzles you construct for us, for our patients. Is that a fair summary?

 

Stuart McGill  

Yeah, what was going through my mind, listening to that logic, is chronic pain. So many clients say, Oh, I've got chronic pain. And then when I assess them, I find out they don't have chronic pain. I know I define chronicity, not by the duration of the symptoms. So someone will say, Well, I've had pain longer than three months, therefore I suffer from chronic pain. And I'll say, wait a second, let's do an assessment and find out with precision what offends your pain. And let's say it's Oh, every time you sit on a floppy couch watching the television now, I've you know your leg goes numb, or has terrible sciatic or whatever it happens to be these. So the chronic pain that occurs every day was actually the result of a mini acute offense that was repeated throughout the day, unbeknownst to them, stop repeating the insult that we've just defined, and guess what? Their pain goes away so they no longer have chronic pain. And then they realize that, oh, I have this bogeyman of chronic pain. No, you don't. You know, with precision, now, what was that mini insult that you kept doing unbeknownst to you before, throughout the day, keeping you chronic now, your chronic pain has gone away, so the next time you get the pain, you realize, ah, I just offended my pain mechanism. I know exactly what I did. I won't do that again. And now pain shifts from this terrible bogeyman to a tutor. It teaches them, oh, I shouldn't have done that, and now you're powering or empowering behavior change and a very solid way to

 

Til Luchau  

what a fantastic way to think about does it pay

 

Stuart McGill  

completely transforms their concept of pain?

 

Speaker 1  

Sure. Listen, I would love to keep talking to you. I always get so much from our conversations and takes me many places we should wrap it up for today. What thought o you want to leave us with on our way out? I

 

Stuart McGill  

don't have any other than to keep doing what you're doing.

 

Speaker 1  

How would people find out more about what you do? Dr McGill, they'd like to know more. Well,

 

Stuart McGill  

I'm not much on social media, I'm afraid. So we just have our website, backfitpro.com and we have a few of our books there, and some of our clinicians that have been trained in what it is we do and that's about that's about it,

 

Whitney Lowe  

all right. Well, we certainly thank you again for wonderful, stimulating conversation. I always end up with more questions than I came in with here. But again, thank you so much for taking some time with us today to look into these things. And we would also like to thank our sponsor, books of discovery, who has been part of the massage therapy and body work world for over 25 years. Nearly 3000 schools around the globe teach with their textbooks, and digital resources. Books of Discovery likes to say that learning adventures start here, and they find that same spirit here on the thinking practitioner podcast, and are proud to support our work, knowing that we share the mission to bring the massage and body work community thought provoking and enlivening content that advances our profession.

 

Speaker 1  

Instructors of manual therapy education programs can request complimentary copies of books of discoveries, textbooks for review, for use in your programs. Listeners like you can explore their collection of learning resources for anatomy, pathology, kinesiology, physiology, ethics and business mastery at books of books of discovery.com. Where you as a thinking practitioner, listener, can save 15% by entering thinking at checkout. And we

 

Whitney Lowe  

would again like to say thank you to all of our listeners and to all our sponsors. You can stop by our sites for the video, show notes, videos, lots of stuff on there, the good pictures to take a look at on this episode, for sure, transcripts and any extras and all kinds of stuff there. Over on my site, you can find that academyofclinicalmassage.com and Til where can they find that for you.

 

Til Luchau  

 Advanced-trainings.com? We want to hear from you, your ideas or input about the show, about guests you'd like to hear from about subjects you'd like us to explore. Email us at info, at the thinking practitioner.com. Or look for. Us on social media and YouTube under our names, my name Til Lucau, Whitney, what's your name, and

 

Whitney Lowe  

you can find us over there under my name, Whitney Lowe on those channels as well. We'd really appreciate it if you would also take a moment to rate us on Apple podcast or your podcast player of choice, as it does help other people find the show, and you can hear us wherever you happen to listen to your podcast. So please share the word, tell a friend, and thanks again, so much for listening. And thank again, Dr Stuart McGill for being with us here today. Well,

 

Stuart McGill  

thanks to both of you, Til and Whitney, I enjoyed that, and I look forward to the next time. Hopefully we can meet in person. And All right, seem to have a lot of fun.

 

Whitney Lowe  

Yeah, we'll do it. Thank you again.

 

Speaker 2  

Thanks for joining us. Dr McGill, okay, so that was our conversation. After we had the call. Dr McGill wrote and thanked us for the time and offered this summary, which I thought was helpful too. He said the notion that trying to return to the activity that caused the problems in the first place, replicating the same technique, dose, training, cycles, et cetera, will probably produce the same result. But with the best science, the discs can become resilient again in most people, and we've proved that over and over again in restoring athletic performance to the highest levels in strength sports and in mobility, elastic athletics. But each person was considered as an individual and not simply exposed to the activity while hoping for the best. So there you have Dr McGill's summary of that extended conversation and the details he offered us, always some interesting tidbits along the ways and sparks for our own creativity, imagination and better understanding. Thanks again to Dr McGill.